Coronary care networks in the resource-limited setting : systems of care in South Africa

BACKGROUND: Owing to an epidemiological transition observed throughout Sub- Saharan Africa, South Africa is experiencing an increase in the incidence of myocardial infarction. ST-elevation myocardial infarction (STEMI) occurs commonly in South Africa and at much younger ages than observed elsewhere in the world. Emergent treatment in the form of coronary reperfusion is required to reduce morbidity and mortality following STEMI. Political and socio-economic factors have led to large disparities in emergency healthcare access for many South Africans. Well organised networks of care (coronary care networks, CCNs) that seamlessly integrate prehospital care, in-hospital assessment and percutaneous coronary intervention is recommended to reduce mortality for these patients. CCNs are underdeveloped and under-studied in South Africa. To this end, the aims of this project was to examine the current state of Coronary Care Networks in South Africa, a low- to middle income country and to provide recommendations for future development of such networks.

METHODS: This project was comprised of four studies. Study I was a cross-sectional descriptive study that aimed at determining the current PCI-capable facilities in South Africa and sought correlations between the resources, population, poverty and insurance status using Spearman’s Rho. Study II utilised proximity analysis to determine the average drive times of South African municipal wards (geopolitical subdivisions used for electoral purposes) to the closest PCI-capable facility for each South African province. It further determined the proportion of South Africans living within one and two hours respectively, from such a facility. Study III combined data obtained from Studies I and II with network optimisation modelling to propose an optimised reperfusion strategy for patients with STEMI, based on proximity, using the North West province as a case study. Finally, Study IV employed qualitative methodology to determine the barriers and facilitators to developing CCNs in South Africa by performing interviews with individuals working with the South African contexts of coronary care.

RESULTS: South Africa has 62 PCI-capable facilities, with most PCI-facilities (n=48; 77%) owned by the private healthcare sector. A disparity exists between the number of private and state-owned PCI-facilities when compared to the poverty (r=0.01; p=0.17) and insurance status of individuals (r=-0.4; p=0.27) (Study I). This means that reperfusion by PCI is likely inaccessible to many despite approximately, 53.8% and 71.53% of the South African population living within 60 and 120 minutes of a PCI facility (Study II). Yet, we provide an efficient and swift model that provides a recommendation for the best reperfusion strategy even in the instance of a large amount of ward data with these additional constraints. This model can be run in realtime and can guide reperfusion decisions at the bedside or form the basis of regional reperfusion guidelines, and CCN development priorities (Study III). When considering the local CCN, we found an under-resourced CCN that is not prioritised by policymakers and displays considerable variation in performance based on time of day and geographic locale. Specific barriers to the development of CCNs in South Africa included poor recognition and diagnosis of STEMI, inappropriate transport and treatment decisions, and delays. Facilitators to the development of CCNs were regionalised STEMI treatment guidelines, further research and prehospital thrombolysis programmes (Study IV).

CONCLUSION: South Africa has a shortage of PCI facilities. Even in areas with high concentrations of PCI facilities. In addition, many patients may not be able to access care due to socio-economic status. When considering proximity alone, most South Africans are able to access PCI within guideline timeframes. Despite this, prehospital thrombolysis should still be considered in some areas – as demonstrated by a novel approach that combines geospatial analysis and network optimisation modelling. This approach is able to efficiently determine the optimum reperfusion strategy for each geographic locale of South Africa. Current CCNs in South Africa are under-resourced, over-burdened and not prioritised. Future efforts should aim at improving STEMI recognition and diagnosis to decrease delays to reperfusion. The findings described should be considered and integrated into a future model of CCNs within South Africa, towards improving reperfusion times and finally morbidity and mortality.

List of scientific papers

I. Stassen W, Wallis LA, Vincent-Lambert C, Castren M, Kurland L. Percutaneous coronary intervention still not accessible for many South Africans. Afr J Emerg Med. 2017;7:105-7.
https://doi.org/10.1016/j.afjem.2017.04.009

II. Stassen W, Wallis LA, Vincent-Lambert C, Castren M, Kurland L. The proportion of South Africans living within 60 and 120 minutes of a percutaneous coronary intervention facility. Cardiovasc J Afr. 2018;29(1):6-11.
https://doi.org/10.5830/CVJA-2018-004

III. Stassen W, Olsson L, Kurland L. A coronary care network model for patients requiring reperfusion in the North West province of South Africa : recommendations based on optimisation modelling and geospatial analysis. 2018. [Manuscript]

IV. Stassen W, Kurland L, Wallis LA, Castren M, Vincent-Lambert C. Barriers and facilitators to implementing coronary care networks in South Africa : a qualitative study. 2018. [Manuscript]