Distance Doesn't Make the Heart Grow Stronger for 50 Million Americans

Despite a modest upswing in the number of hospitals equipped to perform angioplasty, a life-saving procedure for heart disease that should be carried out promptly, nearly 50 million residents of the continental United States face travel times of more than one hour to reach them, according to a new study.

Angioplasty, also known as percutaneous coronary intervention, is a procedure in which a balloon is delivered via catheter to blocked coronary arteries. It is then inflated to open the arteries and restore blood flow to heart muscle.

The American Heart Association and the American College of Cardiology recommend that no more than 120 minutes elapse from a heart attack patient’s first medical contact to inflation of the balloon in a cardiac artery. The longer travel times uncovered in the study may lead to worse recoveries for many patients, said senior author Renee Hsia, MD, professor of emergency medicine and health policy at UC San Francisco.

“While our results show that the 84 percent of the continental U.S. population live within 60 minutes of a hospital with an angioplasty facility, we have to recognize that the remaining 16 percent do not have timely access to these centers, which should be reflected in pre-hospital treatment protocols to optimize other methods of management,” Hsia said, noting that the median travel time for the latter group was 81 minutes.

In the study, published July 13, in Health Services Research, the demographic and geographical distribution of hospitals with angioplasty facilities was examined by Hsia and Yu-Chu Shen, PhD, of the Naval Postgraduate School in Monterey, Calif., and the National Bureau of Economic Research in Cambridge, Mass.

Hsia and Shen assessed how long it would take residents in more than 32,000 ZIP codes, covering the communities of 306 million individuals, to reach the closest of 1,738 angioplasty centers. Actual driving times were obtained using Google Maps and Stata, a statistical software package. Alaska and Hawaii were excluded from the study, since the topography, climate and roadway limitations in those states would distort timing calculations.

The researchers found that the median time of arrival to a U.S. angioplasty center was 33 minutes. But for 16.3 percent of the population, or approximately 50 million people, it took more than 60 minutes to reach an angioplasty center.

Angioplasty is indicated for some patients with coronary artery disease, including acute myocardial infarction, or heart attack, one of the leading causes of death. For patients with STEMI, the deadliest type of acute myocardial infarction affecting half-a-million Americans every year, swift access to an angioplasty center is vital. But only 37 percent of all acute care adult hospitals in the nation have an angioplasty center and less than 12 percent are capable of handling a high volume of patients with STEMI.

Additionally the researchers discovered that low-income and Hispanic populations had greater odds of poorer access to angioplasty centers, independent of rural or urban residence. Patients from low-income and Hispanic communities were found, respectively, to be three times and two-and-a-half times more likely to reach an angioplasty center more than 60 minutes after making medical contact. “This is especially significant given well-documented disparities in interventions and outcomes for minority and socio-economically disadvantaged patients with acute myocardial infarction,” said Hsia, an emergency physician at San Francisco General Hospital and Trauma Center.

In 2000 the median distance to an angioplasty center was 7.9 miles and 79 percent of the population lived within one hour of a center. In 2011 these figures improved to 7.4 miles and 84 percent respectively. While this shift suggests a trend toward better accessibility, the researchers write that many new centers are opening where need may be lowest – “in competitive markets, often with high private insurance penetration” – and where angioplasty services may already exist.

To expedite treatment for patients in rural, low-income and Hispanic communities, Hsia proposed establishing new guidelines. 

“A system should be implemented that recognizes these limitations and provides alternative treatments,” she said.

“This might include protocols for prompt administration of clot-busting fibrinolytic therapy in the pre-hospital setting for those patients who are too far away from their closest angioplasty facility.”

This study was supported by a grant from the National Heart, Blood, and Lung Institute of the National Institutes of Health.

UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy, a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences, as well as a preeminent biomedical research enterprise and two top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospital San Francisco.