In ST-segment elevation myocardial infarction (STEMI), reperfusion with primary percutaneous coronary intervention (PCI) is a time-sensitive process. Time from arrival at hospital to first balloon inflation during PCI, door-to-balloon time (DTBT), has become a process core measure of quality of care. Timely reperfusion may be hampered due to travel times (TT) and, even in presence of short DTBT, these gaps may contribute to worse outcomes [Figure 1]. Current guidelines recommend, as health care system goal for treatment with PCI, a time windows within 90 minutes from first medical contact (FMC). THE EFFECT OF HOME TO HOSPITAL TRAVEL TIME ON 30-DAYS MORTALITY AFTER PCI IN STEMI PATIENTS IN THE LAZIO REGION (ITALY) INTRODUCTION Riccardo Di Domenicantonio, MSc; Giovanna Cappai, MSc; Paolo Sciattella, MSc; Francesca Mataloni, MSc; Valeria Belleudi, MSc; Nera Agabiti, MD; Mirko Di Martino, PhD; Carlo Alberto Perucci, MD; Marina Davoli, MD; Danilo Fusco, MSc. OBJECTIVES • To evaluate the effect of TT on 30-days mortality of STEMI patients who undergone PCI within 90 minutes of system delay (defined as sum of TT and DTBT) • To evaluate the role of TT as effect modifier of the relationship between DTBT and 30-days mortality on STEMI patients who undergone PCI within 120 minutes of DTBT METHODS We carried out a retrospective cohort study in Lazio Region, Italy, using the regional health information systems. We selected patients aged 35–100 years, discharged with a diagnosis of STEMI (ICD-9-CM: 410.1–410.6, 410.8) between 1th January 2009 and 30th November 2013 who underwent PCI (ICD-9-CM: 00.66, 36.01, 36.02, 36.05-36.07) with DTBT less than 2 hours. Minimum driving travel time from each census block to hospitals with PCI facilities were calculated using geographic information system. DTBT was measured from first hospital access to first balloon inflation. System delay (SD) was defined as sum of TT and DTB. The travel time and DTBT were categorized into two classes according to their median values. We defined two cohorts including A) patients with SD ≤ 90 minutes B) patients with DTBT ≤ 120 minutes Multivariate logistic regression model was performed to estimate the effect of travel time on mortality adjusting for demographic and clinical characteristics. Correspondence: r.didomenicantonio@deplazio.it Via di Santa Costanza, 53 00198 - Roma tel. 06.83060461 - www.deplazio.net RESULTS This study included 1,735 and 3,327 patients respectively for cohort A and cohort B. Patients with higher TT were characterized by a higher prevalence of males, younger age, lower frequency of systolic pressure lower than 100 mmHG and higher frequency of presentation throughout emergency medical service. Median values for TT and DTBT were respectively 14 and 72 minutes (data not reported). Travel time above the median resulted positively associated with 30–days mortality (OR=2.46; P=0.0093) [Table 1]. DTBT below the median resulted negatively associated with 30–days mortality (OR=0.39; p=0.013) among early presenters. Interaction term estimate (OR=2.36; p=0.076) shows that the effect of DTBT is modified by travel time and resulted strongly reduced among patients with TT above the median (OR=0.92; p=0.798, data non reported) [Table 2]. Figure 2 reports the mortality odds ratio for DTBT (under the median versus above the median) for increasing values of TT. CONCLUSIONS We measured the effect of TT on mortality after PCI. In STEMI patients who received PCI within 90 minutes of system delay, TT affects 30-days survival. Travel time plays an important role, even in the presence of health care system able to comply with current guidelines. Moreover, in patients with DTBT ≤ 120 minutes, TT resulted to modify the effect of DTBT, leading to reduced benefit of short DTBT on late presenters. Efforts of health care system should be focused on the reduction of pre-hospital delay. Our findings allow also including travel time as a confounding factor in hospital health care quality indicator already used in the context of comparative outcome evaluation programs. Table 1: Adjusted 30-days mortality odds ratio. Cohort A Figure 2: Adjusted 30 days mortality odds ratio for DTBT for increasing values of TT Figure 1: Delays from symptom onset to PCI in patients with STEMI EMS: Emergency Medical Service Modified from Terkelsen et al. 2010 0.1 1 10 1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 OR for DTBT (under the median versus above the median) Travel time (minutes) Effect Estimate 95% CI P Travel time > 14 minutes vs. 0-14 minutes 2.46 1.25 4.86 0.01 Gender Male vs. Female 0.68 0.35 1.31 0.25 Age class 65-84 years vs 35-64 years 4.81 2.05 11.26 <0.0001 > 84 years vs 35-64 years 19.62 6.42 59.92 <0.0001 Systolic blood pressure <=100 mmHg vs. >100 mmHg 4.21 2.19 8.1 <0.0001 Presentation E.M.S* vs. Direct 1.14 0.57 2.27 0.71 Hour of admission 22.00-23.59 vs 08.00-21.59 1.81 0.51 6.45 0.37 24.00-07.59 vs 08.00-21.59 1.11 0.43 2.85 0.83 Comorbidities Other heart conditions 7.65 1.76 33.17 0.01 * Emergency Medical Service ** Index admission Table 2: Adjusted 30-days mortality odds ratio. Cohort B Effect Estimate 95% CI P Travel time > 14 minutes vs. 0-14 minutes 1.15 0.63 2.1 0.662 Door to balloon time 0-72 minutes vs. >72 minutes 0.39 0.16 0.82 0.013 Interaction Terms Travel time * Door to balloon time 2.36 0.91 6.1 0.076 Gender Male vs. Female 0.71 0.45 1.14 0.154 Age class 65-84 years vs 35-64 years 3.2 1.83 5.6 <0.0001 > 84 years vs 35-64 years 9.78 4.65 20.55 <0.0001 Systolic blood pressure <=100 mmHg vs. >100 mmHg 3.57 2.22 5.73 <0.0001 Presentation E.M.S* vs. Direct 1.55 0.95 2.52 0.077 Hour of admission 22.00-23.59 vs 08.00-21.59 1.21 0.45 3.21 0.709 24.00-07.59 vs 08.00-21.59 1.04 0.56 1.93 0.898 Comorbidities Other heart conditions 5.3 1.61 17.43 0.006 Diabetes ** 1.98 1.22 3.21 0.006 Cerebrovascular diseases 2.56 1.23 5.35 0.012 Cancer 2.15 0.98 4.73 0.057 * Emergency Medical Service ** Index admission - - - OR ∙∙∙∙∙∙ 95% C. I.