Family Practice Vol. 18, No. 5, 537-539
© Oxford University Press 2001
Health Services Research |
Impact of community-based education on health care evaluation in patients with acute chest pain syndromes: the Wabasha Heart Attack Team (WHAT) project
Division of Cardiovascular Diseases and the Mayo Physician Alliance for Clinical Trials (MPACT) Coordinating Center, Mayo Clinic and Mayo Foundation, Rochester, MN,
a Mayo Health System and
b Wabasha County Public Health, Wabasha, MN and
c Foundation for Health Care Evaluation, Minneapolis, MN, USA.
R Scott Wright, MD, Division of Cardiology and the Coronary Care Unit, The Mayo Physician Alliance for Clinical Trials (MPACT) Coordinating Center, Mayo Clinic and Mayo Foundation, 150 Third Street SW, Rochester, MN 55902, USA.
Wright RS, Kopecky SL, Timm M, Pflaum DD, Carr C, Evers K and Bell J. Impact of community-based education on health care evaluation in patients with acute chest pain syndromes: the Wabasha Heart Attack Team (WHAT) project. Family Practice 2001; 18: 537–539.
Received 31 October 2000; Revised 2 March 2001; Accepted 4 May 2001.
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Abstract |
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Background. Community education programmes focused on raising public awareness of the symptomatology of acute coronary syndromes have had mixed results.
Objectives. The Wabasha Heart Attack Team project, a unique multidisciplinary public education effort in Minnesota, sought to educate area citizens about signs and symptoms of acute myocardial infarction (MI).
Methods. After an intensive 1-month education period, we compared presentations for emergency evaluation of chest pain during the study period with baseline data from the same seasonal period of the preceding year.
Results. Visits to the Emergency Room for symptomatic heart disease increased significantly during the study period (56 patients versus 46 patients during the baseline period), as did the percentage of patients presenting with acute MI (18% versus 12%, P < 0.05). Use of emergency medical sevices for pre-hospital evaluation was significantly increased (41% versus 27%, P < 0.05).
Conclusion. A community education campaign can significantly increase use of pre-hospital emergency medical service resources and may increase the number of patients presenting with acute chest pain symptoms, including MI.
Keywords. Community medicine, health education, myocardial infarction.
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Introduction |
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Acute myocardial infarction (MI) afflicts 1.3 million Americans every year and results in 500 000 deaths.1,2 Significant advances over the last 15 years have enhanced its treatment;3 in particular, intravenous fibrinolytic therapy has reduced mortality in patients with acute MI by >30%, with greatest benefit seen in patients treated very early in the MI course.4
Despite these advances, delays in treatment—both pre-hospital and in-hospital—contribute significantly to patient mortality and morbidity in acute MI, delaying initiation of treatment by >3 hours after onset of symptoms. Pre-hospital delay, accounting for some 65% of the interval between symptom onset and initiation of treatment, can stem from patient misperception about the severity of chest pain justifying emergency presentation.5–7 In-hospital delays may be related to inefficient systems within hospital emergency departments and protracted decision-making processes.
Community education programmes seeking to increase public awareness of the signs and symptoms of acute chest pain (ACS) hold promise for reducing pre-hospital delay and encouraging appropriate use of emergency transport systems, but previous programmes of this kind have met with mixed results.
The Wabasha Heart Attack Team (WHAT) project, a multidisciplinary public education effort in Wabasha County, Minnesota, sought to improve public awareness of the symptoms of MI; increase use of 911 emergency medical transport services; reduce delay between onset of chest pain symptoms and arrival at the Emergency Room (ER); and increase the percentage of patients who seek ER evaluation for acute MI.
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Methods |
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The WHAT education effort
A collaborative endeavour between public health departments, hospitals, the American Heart Association and area cardiologists, our intensive 1-month community education effort stressed recognition of the warning signs of ACS, and outlined appropriate steps for individuals experiencing these symptoms. Strategies included quick 911 activation, initiation of cardiopulmonary resuscitation (CPR), immediate transport to the nearest emergency cardiac care facility and use of aspirin. Presentations and informational displays (with questions fielded by a programme representative) were held at 18 sites. Six news releases, six print advertisements and two public service announcements were deployed, in addition to cable television announcements and various non-traditional teaching tools.
The programme also provided continuing medical education for local physicians and medical personnel, including a review of AHCPR guidelines for management of unstable angina, and development of teaching tools that encouraged critical pathway use of reperfusion strategies in acute MI. The cost of the project (excluding volunteer time) was under $3000.
Data collection and analysis
Data pertaining to presentations for emergency evaluation of chest pain during the study period (the 1-month education period and the 3 months following) were collected from area hospitals. Retrospective data collection was carried out for similar ER visits during the same months (February–May) of the preceding year for baseline comparison.
Key definitions were as follows:
- myocardial infarction, characterized by fulfilment of the World Health Organization (WHO) criteria8 for either acute ST-elevation MI or non-ST-elevation MI.
- unstable angina: symptoms suggestive of ACS, with electrocardiographic changes, without CK and MB isoenzyme elevation, or failure to meet WHO criteria for MI;
- sudden cardiac death within 1 hour of hospital arrival in the setting of ACS;
- heart failure: new-onset shortness of breath, fatigue or peripheral oedema, with impaired left ventricular systolic or diastolic function and radiographic evidence of fluid overload or cardiomegaly;
- cardiac dysrhythmia: alteration in cardiac rhythm with potential to produce symptoms of ACS or of dyspnoea, lightheadedness or syncope resulting in treatment.
Biostatistical support was provided by the Foundation for Health Care Evaluation. Contiguous variables were compared using t-tests, and demographic and non-linear variables were compared by means of chi-square analyses.
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Results |
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Patient demographic variables are outlined in Table 1
. ER visits for symptomatic heart disease were increased in the WHAT period (n = 52) versus the baseline period (n = 46), with no differences seen in gender distribution and median age. Most patients in both study groups were female and elderly; chest pain and heaviness was the most common primary symptom, followed by dyspnoea, arm numbness, back and/or shoulder arm pain and tachycardia.
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Median time interval from symptom onset to ER arrival was 1.58 hours for both periods, and mean time interval did not differ significantly (2.38 hours WHAT versus 2.32 hours baseline, P = NS).
Table 2 shows a significant increase in ER visits for acute MI (12% baseline versus 18% WHAT, P < 0.05), an increase that extended at least 3 months beyond the educational effort. Presentations for congestive heart failure and unstable angina showed no significant change between periods. During the study period, the number of patients transported by ambulance to the hospital for acute chest pain increased significantly (47% WHAT versus 27% baseline, P < 0.05).
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Figure 1
illustrates the final disposition of patients who presented for evaluation of ACS.
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Discussion |
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The WHAT project demonstrates that a community-based public education campaign can have a significant impact on patient presentation for emergency evaluation of symptoms of ACS.
Our study is strengthened by the inclusion of an above-average percentage of elderly citizens (a group known to delay seeking treatment for acute MI9–11), and by its use of a collaborative model with a decentralized leadership structure. This model can be replicated easily in other communities, as reliance on state or federal grants or non-local expertise was minimal.
Long-term longitudinal follow-up in the studied population is unavailable, and the study is of narrow scope. Initial data fail to demonstrate a significant reduction in overall mortality, but longitudinal follow-up might identify a long-term effect. In addition, we did not demonstrate that public awareness of the symptoms and signs of heart disease was increased long-term.
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Conclusions |
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The WHAT project demonstrates that a community-based collaboration can be valuable in increasing use of emergency medical services for evaluation of acute chest pain symptoms. Long-term studies to ascertain the effectiveness of community-based interventions on outcome are needed.
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Acknowledgments |
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The authors wish to thank Judith Morton for her critical assistance and editorial guidance, and Amy Oeltjen for her expertise in manuscript preparation. We are grateful to all WHAT project participants.
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References |
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1 WHO–MONICA Project. Myocardial infarction and coronary deaths in the World Health Organization Monica Project: registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation 1994; 90: 583.
2 American Heart Association. Heart and Stroke Facts: 1995 Statistical Supplement. Dallas: American Heart Association, 1994.
3 Yusuf S, Collins R, Peto R et al. Intravenous and intracoronary fibrinolytic therapy in acute myocardial infarction: overview of results on mortality, reinfarction and side-effects from 33 randomized controlled trials. Eur Heart Jl 1985; 6: 556–585.
4 Weaver WD, Cerqueira M, Hallstron AP et al. Pre-hospital-initiated vs. hospital-initiated thrombolytic therapy (The Myocardial Infarction Triage and Intervention Trial). J Am Med Assoc 1993; 270: 1211–1216.[Abstract]
5 Schmidt SB, Borsch MA. Multivariate analysis of pre-hospital delay during acute myocardial infarction in the thrombolytic era. Circulation 1989; 80 (Suppl II): 637.
6 Alonzo AA. The impact of family and lay others on care-seeking during life-threatening episodes of suspected coronary artery disease. Soc Sci Med 1986; 22: 1297–1311.
7 Hackett TP, Cassem NH. Factors contributing to delay in responding to the signs and symptoms of acute myocardial infarction. Am J Cardiol 1969; 24: 651–658.[ISI][Medline]
8 Gillum RF, Fortmann SP, Prineas RJ, Kottke TE. WHO criteria for diagnosis of acute myocardial infarction. Am Heart J 1984; 108: 150–158.[ISI][Medline]
9 Turi ZG, Stone PH, Muller JE et al. Implications for acute intervention related to time of hospital arrival in acute myocardial infarction. Am J Cardiol 1986; 58: 203–209.[ISI][Medline]
10 Maynard C, Althouse R, Olsufka M et al. Early versus late hospital arrival for acute myocardial infarction in the Western Washington thrombolytic therapy trials. Am J Cardiol 1989; 63: 1296–1300.[ISI][Medline]
11 Rawles JM, Haites NE. Patient and general practitioner delays in acute myocardial infarction. Br Med J 1988; 296: 882–884.
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