Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease - The Rapid Early Action for Coronary Treatment (REACT) trial

Context Delayed access to medical care in patients with acute myocardial in farction (AMI) is common and increases myocardial damage and mortality. Objective To evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical serv ice (EMS) use. Design and Setting The Rapid Early Action for Coronary Treatment Trial, a r andomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pai rs; population range, 55777-238912) in 10 states. Participants A total of 59944 adults aged 30 years or older presenting to h ospital emergency departments (EDs) with chest pain, of whom 20364 met the primary population criteria of suspected acute coronary heart disease on ad mission and were discharged with a coronary heart disease-related diagnosis . Intervention One city in each pair was randomly assigned to an 18-month int ervention that targeted mass media, community organizations, and profession al, public, and patient education to increase appropriate patient actions f or AMI symptoms (primary population, n = 10563). The other city in each pai r was randomly assigned to reference status (primary population, n = 9801). Main Outcome Measures Time from symptom onset to ED arrival and EMS use, co mpared between intervention and reference city pairs. Results General population surveys provided evidence of increased public aw areness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in interventi on communities by -4.7% per year (95% confidence interval [CI], -8.6% to -0 .6%), but the change did not differ significantly from that observed in ref erence communities (-6.8% per year; 95% CI, -14.5% to 1.6%; P = .54). EMS u se by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% ( 95% CI, 7%-34%; P < .005), Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use am ong patients with chest pain released from the ED, did not change significa ntly. Conclusions in this study, despite an Is-month intervention, time from symp tom onset to hospital arrival for patients with chest pain did not change d ifferentially between groups, although increased appropriate EMS use occurr ed in intervention communities. New strategies are needed if delay time fro m symptom onset to hospital presentation is to be decreased further in pati ents with suspected AMI.