Variation in access to primary percutaneous coronary intervention in 120 european regions: why do inequalities persist?

Purpose: Prompt reperfusion optimizes outcome of ST-elevation myocardial infarction (STEMI). Although programmes for delivering timely primary percutaneous coronary intervention (PPCI) in experienced centres have been implemented large inequality in the use of PPCI for STEMI across Europe is evident. We performed a comparative study looking to quantify variation in access to PPCI and factors associated with these observed differences at a national as well at a regional level. Knowledge on such factors hampering patients having access to PPCI, would be the first step in reducing inequality in access to life-saving treatment in Europe.

Methods: An ecological study based on aggregated data from available national and international registries in Austria, Belgium, England, Germany, Italy, Portugal, Scotland, Sweden, Northern Ireland and Wales. Main outcome was number of PPCI per 1 million inhabitants, collected for the years 2003-2008.

The individual country's yearly regional increase in implementation of PPCI was investigated by use of linear regression. We applied mixed effects regression models to study the relation between usage of PPCI and a set of health care-associated, economic and demographic regional-level parameters.

Results: We detected a large variation in the absolute numbers of PPCI per million inhabitants between the different regions. Regional-level rates varied from 0.74 (95% CI 0.42, 1.30) to 1.90 (95% CI 1.01, 3.55) per million inhabitants per year. Regional inequalities were largest in Italy, Spain and Sweden. Significant positive associations with PPCI utilisation were number of physicians per 100,000 inhabitants; number of nurses and midwifes per 100,000 inhabitants; and the proportion of the regions population aged 50 to 70 years.

Conclusions: Between 2003 and 2008, PPCI utilisation increased significantly in all European countries, but there was great variation within country regions. Regional variation in PPCI rates was associated with both demographic and supply factors. Implementation strategies focusing on these factors would most likely hasten PPCI uptake in the communities, and thereby be the first step in securing equal access to evidence-based treatment regardless of residency.