Distance, Delay, and Discontent

> Discontent is the first necessity of progress.> > —Thomas EdisonIn November of 1993, 3 reports that published simultaneously in the New England Journal of Medicine demonstrated the superiority of primary percutaneous coronary intervention (PCI) over thrombolytic therapy for treatment of patients with acute ST-segment–elevation myocardial infarction (STEMI).1–3 At that time, within my hospital system, the Johns Hopkins Health System, there were 2 acute care hospitals: the Johns Hopkins Hospital, a tertiary center with both PCI and cardiac surgery capability, and the Bayview Medical Center, a community hospital that could provide neither revascularization modality. In 1993, ≈20 patients with acute STEMI presented to our tertiary facility annually, whereas our community hospital admitted >5× that number. Because State healthcare regulation prohibited performance of PCI at hospitals without colocated cardiac surgery, the superior therapy could be applied at the hospital where the minority of patients presented, whereas at the hospital where the overwhelming majority of patients with STEMI presented primary PCI was not available.Article see p 797This situation was replicated in many areas around the country, essentially restricting access to the better form of therapy for many patients with STEMI. The rationalized solution to this dilemma offered 2 alternatives: (1) continue to simply offer the “community hospital standard of care,” thrombolytic therapy, to patients with STEMI presenting to non-PCI hospitals or (2) transfer patients from non-PCI–capable to PCI-capable facilities for primary PCI. We were not satisfied with these proposed solutions. In the first, an inferior therapy is offered to patients with STEMI simply because of an accident of geography: they presented to the “wrong” hospital. Furthermore, transfer was not practical. According to Goggle Maps, in the absence of traffic, the Hopkins tertiary and community hospitals are separated geographically by 3.1 miles and temporally by 11 minutes. Yet in …