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Improving access to treatment for
coronary heart diseases: overcoming
barriers, addressing inequalities
Cross-border access to primary angioplasty in the European
Union – opportunities, challenges, recommendations
Funded by the
Brussels, October 10 2013
Improving cross-border access to primary angioplasty in the EU:
Opportunities, challenges and recommendations
“This document has been prepared for the European Commission however it
reflects the views only of the authors, and the Commission cannot be held
responsible for any use which may be made of the information contained
therein.
Contents
Executive Summary ........................................................................................................................................................ 2
Aims and objectives of the report ................................................................................................................................. 5
Methodology ....................................................................................................................................................................... 5
Cross-border healthcare: Background and literature review ................................................................................. 6
Health and economic impacts of cardiovascular diseases ..................................................................................... 9
Best practice treatment for acute heart attacks ........................................................................................................ 10
The case for cross-border collaboration as a means of improving outcomes for STEMI patients .......... 12
Survey findings ................................................................................................................................................................ 12
Conclusions ....................................................................................................................................................................... 23
Recommendations ........................................................................................................................................................... 23
References ......................................................................................................................................................................... 25
Annexe I: Interview transcripts ............................................................................................................................... 29
Austria: Professor Kurt Huber, Vienna. ............................................................................................................ 29
Greece: Dr. John Kanakakis, Athens ................................................................................................................... 34
Latvia:Professor Andrejs Ergils, Riga ................................................................................................................ 37
Lithuania: Dr. Gintas Bieliauskas, Vilnius. ....................................................................................................... 38
Northern Ireland: Dr. Patrick Donnelly, Belfast. ........................................................................................... 42
Poland: Dr. Zbigniew Siudak, Krakow............................................................................................................... 46
Portugal: Dr. Helder Pereira, Almada ................................................................................................................ 49
Slovenia:Dr. Marco Noç, Ljubljana...................................................................................................................... 52
Spain: Dr. Ander Regueiro, Barcelona ............................................................................................................... 55
Sweden: Professor Stefan James, Uppsala. ...................................................................................................... 59
Acknowledgements
This report would not have been possible without the assistance of Kristina Laut and the Department
of Cardiology at Aarhus Unviersity Hospital, Skejby, the Stent for Life Initiative and the contributions
of the participating cardiologists. Opinions expressed in this report are those of the European Critical
Care Foundation and report participants, and do not represent the DG SANCO’s official position.
1
Executive Summary
Diseases of the heart and circulatory system (cardiovascular disease or CVD) are the single most
common cause of death in the EU, accounting for some 1.9m deaths in EU member states each year.
One of the main forms of CVD, Coronary Heart Disease (CHD) costs the EU economy some €60bn
and is the single most common cause of death. Over 681,000 European citizens die each year from
coronary heart disease, of which acute heart attacks (specifically, acute myocardial infarction with STelevations, or STEMI) is the most severe manifestation.
The main goal of treatment in STEMI patients is to restore reperfusion of the heart tissue. European
Society of Cardiology (ESC) guidelines recommend primary percutaneous coronary intervention
(pPCI, also known as primary angioplasty) as the most effective method of opening blocked blood
vessels that cause heart attacks when available within 90-120 minutes of first medical contact. Since
relative mortality after one year increases by approximately 1 per cent for every three minute delay in
receiving treatment, optimal organisation of systems and processes to minimize time delays, and the
availability of pPCI as the recommended reperfusion therapy, is key to improving outcomes for
STEMI patients.
However, access to primary angioplasty can be difficult in national periphery regions where the
nearest catheterisation laboratory may be located across the border. The problem is not only a function
of geographical remoteness, but also due to differences between reimbursement systems, emergency
transport systems, professional training and qualifications of healthcare staff and language – to
mention a few. Therefore, if outcomes for acute heart attack patients in border areas are to be
improved, all stakeholders involved in the delivery of healthcare on either side of the border need to
collaborate, and political will is required in order to resolve these differences through bilateral
agreements and protocols.
The October 2013 deadline for the transposition of the Patients’ Rights Directive on Cross-border
Healthcare into national legislation is a timely opportunity to look at how organisational factors, in
particular through sharing best practices and making more efficient use of existing resources can
2
improve timeliness, quality and cost-effectiveness of care delivery. This study was commissioned by
DG SANCO to look at the opportunities and challenges of improving access to primary angioplasty to
treat acute heart attack patients across the EU, as part of the Commission’s on-going work in cross
border cooperation in the field of healthcare and does not reflect any position or view of the European
Commission.
The report provides a snapshot of the current situation regarding cross-border arrangements for STEMI
patients in 10 member states of the European Union (EU). The Member States studied are Austria,
Greece, Latvia, Lithuania, Northern Ireland, Poland, Portugal, Slovenia, Spain, and Sweden. It is based
on interviews with leading interventional cardiologists in those countries, and is not intended to be an
exhaustive account of STEMI management in border areas in Europe nor a formal review of the
administrative agreements between Member States of the EU.
The study revealed that apparently there are no formal cross-border arrangements regarding the
management of acute heart attack patients in the countries studied – at least, not to the best knowledge
of the experts interviewed. The findings also suggest that despite the ESC guidelines, there are
continuing, major variations in treatment utilization. A significant proportion of eligible patients are
not receiving any treatment at all, and an estimated 40-50% of European STEMI patients are not
currently treated with primary angioplasty. Given the prevalence of acute heart attacks as a cause of
death and morbidity in the EU this situation needs to be urgently addressed.
Opportunities: The best interpretation of the report’s findings is that there is a major opportunity to
improve outcomes for acute heart attack patients not only in border areas, but also within countries,
between regions. The findings also suggests that a coherent, comprehensive approach to the creation of
networks for delivering treatment across border areas would improve outcomes for patients, whilst
remaining cost effective for healthcare systems. These efficiencies would arise through sharing best
practices and providing standards of excellence which could be achieved within the framework of the
Cross-border Healthcare Directive. This report addresses the specific topic of acute heart attacks,
however establishing a European Network for a broader group of cardiovascular diseases (eg including
stroke) may also bring benefits to patients and reduce the economic burden on health systems.
3
Challenges: The study also revealed a number of challenges in the treatment of STEMI patients
across borders. The most commonly mentioned challenges were differing reimbursement systems, the
need for joint training programs for healthcare professionals, consistent data registries and the
organisation of Emergency Medical Systems (EMS). In relation to the last point, the use of the 112
European emergency number is a key area where more action is required to encourage its use. And
although there is anecdotal evidence of border populations that might benefit from greater
collaboration, there is a little data about which criteria or variables should be used to identify priority
areas for action.
Finally, while the cardiologists interviewed were overwhelmingly open to the idea of greater
collaboration, many drew attention to the longstanding need to overcome challenges and barriers
between regions in their own countries to implement best practice. Many felt that political action at
national and EU level would be helpful in overcoming internal as well as cross-border barriers to
collaboration.
Recommendations: Cross-border cooperation provides an opportunity for a new approach to the
organisation and delivery of timely reperfusion to all eligible patients with severe heart diseases.
Implementation of the following aspects would ensure long term solutions and wide-scale progress:
1. Establish STEMI European Reference Networks adapted to local and regional circumstances
2. Secure reimbursement of treatment and transportation across borders: given that reimbursement
of Emergency Services is covered by Regulation 1408/71/EEC, it is important to harmonise
efforts to address existing barriers which arise as a result of the different organisation of
healthcare systems and related payment systems.
3. Optimise Emergency Medical Systems across borders
4. Accelerate the use of the common EU-wide emergency number (112) and develop awarenessraising campaigns to increase public knowledge on the symptoms of acute heart attacks
5. Establish common datasets and registries for benchmarking purposes
6. Define indicators for use in quality and safety standards related to pPCI delivery
7. Encourage the exchange of information and experiences between countries and regions –
sharing best practices
4
8. Develop shared treatment protocols in order to ensure consistent and coherent information
streams between healthcare systems when moving patients across borders
9. Promote joint training programs on acute heart care earmarked for healthcare professionals
10. Generate a series of decision points that contribute to the development of appropriate models of
service organization and delivery.
Aims and objectives of the report
The aim of this study is to review the extent of cross-border collaboration in the delivery of primary
angioplasty across Europe to treat acute heart attack patients. It seeks to identify best practices and
state of the art in the delivery of primary angioplasty and examines the main barriers to collaboration
(for example technical, legal, cultural, administrative, clinical issues). Recommendations are
developed which if implemented, would increase access to evidence-based treatment, decrease time
delays and thereby improve outcomes for patients with STEMI.
Methodology
Following a review of the literature on cross-border cooperation in the field of healthcare, the report
briefly outlines the health and economic impacts of cardiovascular diseases, describes best practice
treatment for acute heart attack patients and presents the case for cross-border collaboration as a means
of improving outcomes for patients through more efficient use of available resources.
5
ECCF invited the following 16 countries to participate in the study (Austria, Czech Republic, Finland,
France, Germany, Greece, Netherlands, Northern Ireland, Italy, Latvia, Lithuania, Slovenia, Spain,
Sweden, Poland and Portugal). 10 countries were able to participate. Experts from those countries
were identified to be interviewed on the current reperfusion strategy, knowledge of existing crossborder collaborations as well as perception of existing barriers and facilitators to implementation of
cross-border collaborations. The interviewees were all medical doctors with extensive knowledge of
STEMI treatment in their country.
Cross-border healthcare: Background and literature review
Cross-border healthcare has become an important topic of discussion in Europe in recent years. Patient
mobility in Europe as well as cross-border use of health services has become reality and is likely to
increase. In tandem with this, there is a need to facilitate greater mobility of the healthcare
professionals themselves. EU member states are therefore facing a new healthcare landscape would
benefit from joint courses of action with neighbouring countries to resolve the challenges that this
presents. In February 2011 The Patients’ Rights Directive in Cross-border Healthcare was adopted by
the European Council. The aim of the Directive is to facilitate access to safe and high-quality crossborder healthcare and provide reliable information to patients regarding access and reimbursement for
healthcare received in another European Union (EU) member country.
There are already a number of cross-border healthcare-related projects, which have been or are being
carried out at internal and external borders of EU member states, often with funding from the EU.
Under these projects, a wide range of solutions have been developed to address the practical problems
of cross-border cooperation. Cross-border healthcare is not just a question of patient choice and
mobility. Medical doctors and nurses cross borders for training or to provide temporary services, and
increasingly data is exchanged. Therefore cross-border cooperation requires that authorities and
institutions work together, to address the needs of both patients, healthcare professionals and providers.
Cross-border cooperation has great potential for improving patient outcomes, and is a route towards
facilitating the transfer of expertise and knowledge, and enabling greater efficiency in providing
healthcare. Studies show that the majority of cross border arrangements are concentrated in just a
handful of countries, namely Belgium, France, Germany and the Netherlands. Here, there is a long
6
tradition of cross-border cooperation in healthcare which is firmly embedded within relevant
institutions. Most cooperation is bilateral however, and the involvement of more countries and actors
in a single cooperation arrangement is rare. A number of cross-border arrangements developed as a
response to waiting-list problems (1).
A well-known cooperation arrangement is the Euregio. Euregio means “European Region” and the
establishment of this cross-border cooperation was established for the first time in 1958. The most
active Euregios are in the north-west of Europe the Rhine-Wall and Meuse-Rhine Euregios as well as
the Euregio located on the German-Dutch and on the German-Dutch-Belgian border with many years
of experience in cross-border cooperation. Within the project HealthACCESS, 132 different crossborder arrangements were identified in relation to the 10 countries studied (Austria, Belgium, France,
Germany, Hungary, Ireland, Italy, Netherlands, Poland, and the UK), showing again that the DutchBelgian border is among the most active European borders in terms of cross-border contracting in the
EU. The European Observatory on Health Systems and Policy has also studied cross-border healthcare
and has published a number of reports on the subject (www.euro.who.int/en/who-weare/partners/observatory).2 The oldest cross-border arrangements are those which relate to planning for
major disasters in border areas. For instance, an agreement of this type has been in place between
France and Germany since 1977. These arrangements involve the shared use of emergency and
ambulances services.1
Cross-border projects have covered a wide variety of thematic areas. The most frequent topics include
education and further training, joint use of resources, out- and in-patient treatment, as well as
prevention and health promotion activities. Cross-border arrangements take a wide variety of forms,
but despite this, there are a number of common features that can be considered to be key characteristics.
In an evaluation of 122 cross-border projects published in 20073 the main barriers for these types of
collaborations were administrative work and bureaucratic application procedures, financial problems
and legal issues. The main facilitators were the commitment of the project actors, proximity to the
border, the visibility of the benefit of cooperation to the population, and political support.3 Other
positive factors and barriers to implementation of cross-border cooperation include the following:
Positive factors:
7

Public knowledge about the projects

Political support at the local and national level

Experience with cross-border collaborations

Equal benefit for all countries

Familiarity of the partners with the structures on the other side of the border

Support through the Euregio office or similar cross-border structures

Existence of local agencies which are able to initiate activities at local level (rather than central
planning of cross-border arrangements)

Stakeholder support and patients’ willingness to be treated in another country
Barriers:

Geographical remoteness

Density of care providers vs patients (- are there enough patients to justify having certain
technologies available?)

Size of the country

Distance from the national border

Lack of knowledge on the volume of services moving across borders

Comparability of data across countries

Preferences and socioeconomic characteristics of the patient population

Reimbursement systems

Proportion of privately funded systems vs publicly funded systems

Differences in the quality of care

Problems with referrals between hospitals

Language differences
Despite a growing number of projects, data on cross-border healthcare in general seems to be scarce
and incomplete. The report published by the European Observatory on Health Systems and Policy in
2011 concludes that documentation of cross-border cooperation projects is of varying quality and data
is often not comparable between countries.2 Moreover, there is very little information about which
quality control mechanisms are being implemented in terms of cross-border collaborations, and which
8
party is responsible for quality and safety.2 Furthermore, acute care has not been a focus of activities,
and little is known about how access to appropriate medical services is facilitated between European
countries.
Access to emergency medical services, in particular acute care, is not covered by the Patients’ Rights
Directive, but falls under the remit of Regulation 1408/71/EEC which ensures access to care for
citizens who are temporarily abroad. That said, the implementation of the Directive is directly relevant
to improve standards and access to acute heart care through the establishment of dedicated STEMI
European Reference Networks (ERNs).
Little research exists on cross-border collaborations in respect of acute heart attack patients or Primary
Percutaneous Coronary Intervention (pPCI) treatment. The only project in existence within the field of
cardiovascular diseases is the so-called EURHOBOP project (EURopean HOspital Benchmarking by
Outcomes in acute coronary syndrome Processes) which was originally based on the EUPHORIC
(www.euphoric-project.eu) cardiovascular pilot study. EURHOBOP seeks to provide European
hospitals with a validated set of indicators for benchmarking the quality of cardiovascular disease
management, including invasive procedures like pPCI. At the moment, 11 countries are participating
in the project (Belgium, Bulgaria, Finland, France, Germany, Greece, Italy, Poland, Portugal, Spain
and Sweden).
Finally, there little is known about transferability of quality and safety strategies in cross-border
healthcare and no research was found covering an acute care setting.
Health and economic impacts of cardiovascular diseases
Diseases of the heart and circulatory system – cardiovascular diseases - are the main cause of death in
Europe, with very significant differences in mortality rates between countries.4 Each year they cause
over 1.9 million deaths in the European Union (EU), with Coronary Heart Disease (CHD) as the
leading cause in both men and women, followed by stroke and other cardiovascular diseases. Death
rates from CHD are generally higher in Central and Eastern Europe than in Northern, Southern and
Western Europe.
9
New data shows that mortality from CVD is declining in some countries.4 However, the cost of CVD
to the EU economy is unchanged, mainly due to its large contribution to morbidity. Overall CVD is
estimated to cost the EU economy almost €196 billion a year.5 This includes around €46 billion
estimated production losses due to mortality and morbidity associated with CVD in patients of
working age. The total cost of coronary heart disease to the EU economy is € 60 billion. This
significant burden needs to be addressed by improving the delivery of care.
Best practice treatment for acute heart attacks
Acute heart attacks (STEMI) are the most severe manifestation of coronary heart disease, and are
caused by blockages of the cardiac arteries. Evidence shows that minimally invasive modern
reperfusion therapies can restore oxygen and blood flow quickly, thus preventing cardiovascular
events like death and recurrent infarction. When acute heart attacks occur, timely, effective
intervention is key to improving patient outcomes and therefore reducing the risk of further
cardiovascular events. For each 30 minutes delay, the relative risk of 1 year mortality increases by
7.5%.6 This means that ensuring optimal patient outcomes depends on timely emergency response
systems and care.
According to the European Society of Cardiology and the American College of Cardiology/American
Heart Association guidelines7, 8, primary percutaneous coronary intervention (pPCI) is the most
effective method for opening blocked blood vessels that cause heart attacks. pPCI is a catheter-based,
minimally invasive surgical technique, which involves dilating the blocked artery. In 2003,
implementation of pPCI accelerated in Europe, following the publication of two large, randomized
trials demonstrating superior clinical outcomes with pPCI.9, 10 Since then, a growing body of scientific
knowledge favouring this mechanical reperfusion strategy over the alternative pharmacological
approach has accumulated. Despite these recommendations, large variations in pPCI utilization have
10
been observed between countries as well as within countries11-14 (Figure 1), and it is estimated that
only 50-60% of European STEMI patients are currently treated with pPCI.14
Figure 1. Variation in the use of different reperfusion therapies in selected European countries in 2008
Widimsky et al, Eur Heart J 2009
In 2011 a new survey on variations in reperfusion therapies in Europe was conducted by The Stent for
Life Initiative1. Results from this survey are expected to be published in early 2013, but it is likely to
reveal continuing, major variations in treatment utilization and a large proportion of eligible patients
who are not receiving any treatment at all. Earlier studies have estimated that 25% to 30%15, 16 of heart
attack patients appear to be eligible for reperfusion therapy but receive no specific treatment, which
highlights a major opportunity to improve the care of this group.
1
The Stent for Life Initiative is a unique European platform for interventional cardiologists, government representatives, industry partners,
patient groups and patients to work together to help shape healthcare systems and medical practices and ensure that the majority of ST elevation
myocardial infarction (STEMI) patients have equal access to the life-saving indication of p-PCI.
11
The Guidelines recommend that the time from first contact with the healthcare system to treatment
with pPCI should be no more than 90-120 minutes.8 This time from symptom onset to treatment can be
significantly reduced through reorganisation and optimization of the STEMI treatment system.
The case for cross-border collaboration as a means of improving outcomes for STEMI
patients
The Patients’ Rights Directive in Cross-border Healthcare gives patients complete freedom on the
choice of the healthcare provider for treatment abroad. However, pPCI treatment is an emergency
service, where patients are often unable to express their preferences. In this situation, medical opinion
plus the organisation of national health service systems (including for example emergency transport,
hospital opening hours and reimbursement structures), rather than patient preference tends to dominate
the choice of hospital or treatment. The result of these influences on time-to-treatment, and therefore
preservation of heart muscle, lead to sub-optimal outcomes. It can be surmised that most patients,
offered the choice, would prefer to go as quickly as possible to the most appropriate hospital facility to
receive the recommended best treatment.
Given that time is of the essence in reducing risks of mortality and morbidity, collaboration across
borders provides an obvious opportunity to deploy rapid and potentially life-saving services with pPCI
in areas where patients can reach cath lab facilities more rapidly in a neighbouring country than within
their domestic borders.
Survey findings
Many countries in the EU are in the process of adapting their STEMI management programs to meet
the goal of providing pPCI treatment to the majority of their acute heart attack patients. Some
countries have already established an effective system and are ready to take on new tasks such as
cross-border collaboration. Other countries still have major challenges to overcome with various
internal barriers impeding access to pPCI. Overall, large variations across countries in implementation
of evidence-based practice are still common, and much work still needs to be done to urge member
12
states to implement best practice guidelines in STEMI treatment. The cardiologists interviewed were
overwhelmingly open to the idea of greater collaboration, and believe that political action at national
and EU level is now necessary to overcome internal as well as cross-border barriers to collaboration
Critical success factors for cross -border collaboration: The most commonly mentioned
issues be addressed for cross-border collaboration in STEMI treatment to be operable were
reimbursement agreements, organisation of Emergency Medical Systems, training and exchange of
expertise and maintenance of pPCI and STEMI data registries.

Reimbursement: The survey showed that reimbursement schemes both for physicians and
hospitals are a significant factor for cross-border collaboration. This finding supports the
literature reviewed on cross-border collaboration in general. Most project actors highlight
financial issues as the most hindering factor.1,
2, 19
This reinforces the need to establish
agreements on payment methods. In practice, the financial coverage of health care by social
security schemes generally stops at the border of national jurisdictions. Moreover, current
funding systems in some European countries could create structural barriers and disincentives
to implementation across borders. One can speculate that non-PCI-capable hospitals would
resist the loss of revenue sources and ‘desirable patients’ with the implementation of crossborder pPCI. Losses for the individual hospital would have to be weighed against the benefits
in terms of reduced mortality and morbidity and the potential long-term savings for the
healthcare system. A related point is that protocols for return of patients to referral hospitals
after treatment are needed in order to accommodate concerns regarding limited bed capacity
and ensuring patient flow.

Emergency Medical Systems: Speed of reperfusion is a major determinant of outcome in
STEMI, and healthcare system delay (first medical contact to initiation of reperfusion therapy)
is a key component of contemporary guidelines.8 Evidence indicates that the focus should be
on activities that reduce healthcare system delay, so the need for well-functioning regional prehospital systems for early diagnosis and immediate transport to a pPCI centre is crucial.20
13
When a patient with chest pain contacts the healthcare system, an optimal strategy would be for
an ambulance to be dispatched to the patient immediately, rather than waiting for a primarycare physician to evaluate the patient. When the ambulance services arrive at the scene,
carrying out a pre-hospital electrocardiography (ECG) should be mandatory. If emergency
vehicles are not staffed with physicians or paramedics trained to establish a pre-hospital
diagnosis of STEMI, transmitting the ECG recordings to a hospital-based physician for further
analysis
is
recommended.21-23
Previous
studies
have
shown
that
performing
electrocardiography en route to the hospital can reduce the time delays. The hospitals can then
activate the catheterization laboratories while the patient is being transported. When a
diagnosis of STEMI is confirmed, patients should be directed to the nearest interventional
hospital for pPCI. In this setting, initial admission to a local hospital has been associated with a
30–50 min extra delay before transfer to the interventional hospital and, therefore, should be
avoided. In this model the role of EMS is significantly expanded and might require more
training for ambulance staff than they currently receive. The EMS has to deliver rapid
diagnosis and transfer to the nearest pPCI centre and plays a crucial role in timely delivery of
STEMI.24 A strategy of pre-hospital diagnosis of STEMI and field triage directly to
interventional centres is associated with improved outcome and ensures that the majority of
patients with STEMI can be transported directly to a PCI centre.21,
25
Written agreements
covering the logistics associated with the transfer of patients to pPCI-capable centres, the
movement back and forth of ambulances and the activation from one system to another is a
prerequisite for implementation of cross-border pPCI.

Exchange of expertise: Many of the countries highlighted the need for specialized and
experienced staff to maintain pPCI competencies. The literature shows that STEMI outcomes
are related to appropriate staff education and specialization, as well as a sufficient volume of
procedures. A lack of interventional cardiologists, cardiac nurses, technicians and other
appropriately trained staff could threaten the sustainability of pPCI in some locations. For
example, in a sparsely populated country like Sweden, cardiologists are hard pressed to
maintain cath labs when the volume of procedures in established centres is low. Cardiologists
and allied health professionals therefore need to maintain their clinical skills training and
14
knowledge, in order to continue to provide appropriate treatment for heart attack patients.
Fortunately, the national cardiology societies have a long tradition of collaboration, and most
participants favoured increased international cooperation for education and training. Thus,
specific training programs and increased staff mobility across borders might offer a solution to
the future challenges of an aging population and potential shortages of suitably qualified
healthcare professionals.

Registry data: One significant obstacle to pPCI delivery across borders is the availability of
and access to data. Most of the participating countries have no existing national registries on
pPCI or STEMI. The general aggregated indicators cannot capture the more specific variations
in access to healthcare and be used for benchmarking and quality comparisons. Some national
and regional registries and initiatives have been established to register pPCI activities where
the relevant Ministry of Health is responsible for collecting national indicators of
cardiovascular diseases. Registries are however, often voluntary and often lapse because of the
lack of time and funding. At the same time, participation from countries and hospitals is often
voluntary and frequently lacks sufficient coverage, so is not necessarily representative of the
population-wide medical system targeting cardiac disease. Use of data from existing registries
is further hampered by the variety of data collection methods, as well as absence of consensus
on data definition for collected variables. National and international collaboration on the
establishment of minimum aggregated datasets is needed in order to compare treatment quality
and outcoms across countries. This is the cornerstone of benchmarking and quality
comparisons and thereby a prerequisite for cross-border collaboration, as well as the basis for
the redirection of resources to different parts of the healthcare system. The EU has already
established projects to support EU member states in developing comparable and interoperable
patient registries, two examples are the EURHOBOP and cross-border PAtient REgistries
iNiTiative (PARENT) projects. Collaboration with and support for these projects will facilitate
cross-country comparisons, benchmarking and, in the long-term, treatment quality and patient
outcomes. Despite their regional differences, cross-border regions in Europe often share similar
problems and needs in the health sector. New projects can learn from the experiences of
existing and completed projects. Moreover, it is necessary for procedures to be compatible if
15
patients are to be assured that the care they receive is safe, of adequate quality, and capable of
providing continuity where some parts of the complete process are provided in different
Member States.
Organisation of STEMI networks as an example of transferable, replicable, good
practice: Establishment of STEMI networks is recommended by the latest European as well as
American heart attack treatment guidelines.7, 8 These networks have shown impressive reductions in
case fatality rates, have shown to actually increase the percentage of patients treated by any
reperfusion strategy, as well as increasing the percentage of patients receiving treatment within the
recommended time frames.16
Timely delivery and administration of reperfusion strategies to all eligible patients remains challenging
in a number of the countries surveyed. Several have established STEMI networks in which hospitals
are organised in a rotational system, ensuring that patients bypass local hospitals, or are transferred
immediately from them to specialised PCI centres 24 hours seven days a week.20 Examples of wellestablished STEMI networks include the Vienna STEMI network, The Lille and Paris STEMI
networks and South East Scotland STEMI Network,16 demonstrating that STEMI networks can been
established in a variety of healthcare systems in the EU. Those experiences could be replicated in
cross-border settings, for example through establishing European Reference Networks for STEMI
management.
Other successful models establishing STEMI networks can be found in the Stent for Life Initiative
countries. The Stent for Life Initiative was launched in 2008 and supports the implementation of local
STEMI treatment guidelines, helps to identify specific barriers to implementation of guidelines and
defines actions to make sure that the majority of STEMI patient have access to pPCI. Ten countries are
currently included and show very promising results.20, 26
An important point is that a strategy of developing STEMI networks could be implemented with
existing resources.21, 24 simply by making better use of them. Thus, new models of care delivery could
save lives, by making it possible to provide faster treatment to patients in border regions through
collaboration with cardiology and emergency physicians.
16
Organisation of campaigns to raise awareness of heart attack symptoms as an example
of transferable, replicable best practice: Across Europe the majority of STEMI patients present
to community hospitals without pPCI facilities. The anecdotal evidence arising from our survey
indicated that this happens ranging from 30-80 per cent of cases. Therefore strategies to encourage
patients to call the EMS as soon as possible after the onset of symptoms are urgently needed. 20 This is
heavily dependent on patients’ ability to recognize heart attack symptoms and act quickly.
Examples of successful campaigns include the ACT NOW. SAVE A LIFE campaign introduced by the
Stent for Life Initiative, where for example in Romania, 85% of respondents recognized chest pain as a
heart
attack
symptom
compared
to
54%
before
the
campaign
(see
http://www.stentforlife.com/2013/07/act-now-save-a-life-think-globally-act-locally/).
Need for a concerted effort to implement the unique EU emergency number (112): The
implementation of Directive 2009/136/EC has been rather patchy in Europe. A recent oral question
supported by a significant number of Members of the European Parliament has pointed out that no
criteria for caller location have been defined as required in Article 26(5) of Directive 2009/136/EC2
and that more information is needed to increase public awareness of 112.
Throughout Europe there are different emergency phone numbers in each country, and sometimes
there are several different emergency numbers within the same country. For example in France
alongside the 112, there are 7 other emergency numbers available3. In Italy there are three emergency
numbers available besides the 1124 . Reinforcing the use of a common EU emergency number and
securing wide public knowledge of that number will help patients and consequently reduce time to
treatment, thereby saving heart muscle. Protocols for return of patients to referral hospitals after
treatment are needed in order to accommodate concerns regarding limited bed capacity and ensuring
patient flow. Following the ACT NOW. SAVE A LIFE campaign introduced by the Stent for Life
For further information, the oral question is available here:
http://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//TEXT+OQ+O-2013000064+0+DOC+XML+V0//EN
2
3
4
More information is available at http://ec.europa.eu/digital-agenda/en/112-france
More information is available at http://ec.europa.eu/digital-agenda/en/112-italy
17
Initiative in Catalonia, Spain, the number of calls to 112, which was promoted by the campaign,
increased by 61% over the course of a year.
Criteria for the identification of geographical areas for action in this field: All
respondents named a range of elements which would need to be brought together for cross border
collaboration to be successful, as described above. However there was little feedback about which
criteria or variables should be used to identify priority areas for action. Further research, based on the
experience of establishing cross border healthcare activities elsewhere, (for example the EUREGIOs),
might help develop those criteria. Such criteria might include demographic variables, mapping and
quantifying populations falling outside the recommended time to treatment parameters, health-specific
criteria, existing inventory of health capacities, opportunities for sharing resources, and demonstrable
health gains.
Examples of areas close to national borders where certain populations might benefit
from greater collaboration: As already mentioned, this report has been compiled from the
responses of a single respondent in each country, and is therefore not necessarily comprehensive.
However, respondents were selected on the basis of their international reputation as the person most
familiar with the STEMI treatment activities in each country. The following areas were suggested
during the course of the interviews (see annex 1 for interview transcripts).

Slovenia – border areas with Austria might benefit from collaboration with centres in Villach
and Klagenfurt

Slovenia – Sezana and border areas with Italy might benefit from collaboration with centres in
Trieste

Southern Germany - border areas with Austria might benefit from collaboration with centres in
Salzburg

Lithuania - border areas with Latvia might benefit from collaboration with centres in Liepaja,
Riga and Daugavpils

Northern Poland - border areas with Lithuania might benefit from collaboration with centres in
Vilnius and Kaunas
18

Republic of Ireland - border areas with Northern Ireland might benefit from collaboration with
centres in Derry/Londonderry and Craigavon

Portugal - border areas with Spain might benefit from collaboration with centres in Badajoz
and Vigo
19
Country Responses - summary
COUNTRY
CATHETERISATION
LABORATORIES
ESTIMATED
PATIENTS
TREATED WITH
pPCI
ESTIMATED
PATIENTS
TREATED WITH
THROMBOLYSIS
DOORTOBALLOON
TIME
Austria
34
70%
30%
90-120
Mins.
Greece
9
50%
na
Latvia
4
73%
14%
Lithuania
6
>50%
20%
Northern
Ireland
4
10%
na
Poland
149
>90%
1%
Portugal
18
90%
na
Slovenia
5
>93%
na
Spain
76
50%
40%
Sweden
79
73%
Gotland, Norrland
and Aland Islands
1
2
90-120
Mins.
90-120
Mins.
90-120
Mins.
na
90-120
Mins.
90-120
Mins.
90-120
Mins.
90-120
Mins.
90-120
Mins.
pPCI
Service
24/7
CROSS-BORDER
COLLABORATION
FOR STEMI
National
Registries
pPCI/STEMI
√
No
√/No
na
No
No/No
√
No
No/√
√
No
No/No
9 am -5 pm
Some discussion
No/No
na
No
√/√
√
No
√/√
√
Some discussion
No/No
na
No
√/√
√
No
√/√
na = no response
Full text of interviews avaiable in annexe 1
22
Conclusions
Prompt treatment increases the likelihood of survival for patients who have STEMI. Hospitals can
therefore influence the outcomes for such patients by developing and implementing systems and
processes that minimize the interval between the time from first medical contact to the arrival at the
hospital and the administration of reperfusion therapy. The importance of reducing time from first
medical contact to initiation of reperfusion therapy called ‘system delay’ is highlighted17, 18 and is
therefore included as one of the core quality measures in the existing STEMI treatment guidelines.8
Despite local differences, cross-border regions in Europe often share similar problems and needs in the
healthcare sector. Thus, introducing cross-border collaboration might be an effective route to overcome
the difficulty of providing timely access to pPCI in border regions. However implementation of such
programs would demand support from multiple partners within the medical system, as well as the
political system. Opportunities for, and restrictions to cross-border healthcare must be addressed in the
light of the domestic situations of the Member State concerned. In other words cross-border
cooperation is only one element of a broader set of actions that are needed to improve access to pPCI
treatment across all of Europe. In some EU border regions, cooperation in the health sector is based on
many years of experience, whereas other regions have only just started to explore the opportunities and
issues this presents. The exchange of successfully tested solutions, and knowledge of facilitating and
hindering factors provide an important contribution to the success of collaboration activities.19
Recommendations
This study reports preliminary findings from 10 European countries relating to cross border
cooperation to reduce time to treatment for acute heart attack patients. More research is needed to
better understand the organisational and cultural barriers preventing cross-border cooperation for this
critical condition, and to establish criteria for determining priority areas for action. Experience shows
that STEMI Networks are replicable in different healthcare systems in the EU. In the implementation
23
process of cross-border collaboration, that experience might offer learning tools and gold standards in
setting up cross-border European Reference Networks for STEMI, and perhaps other coronary heart
diseases.
Whilst we found significant barriers to the development of cross-border acute healthcare services, they
can be addressed through organisational changes at minimal cost. However, legislative, administrative,
reimbursement and cultural changes are required to ensure long term solutions and wide-scale progress.
The European Union’s cross-border healthcare directive provides the opportunity for a new approach to
the organisation and delivery of timely reperfusion to all eligible patients with severe heart diseases.
1. Establish STEMI European Reference Networks adapted to local and regional circumstances
2. Secure reimbursement of treatment and transportation across borders through adopting a
common approach to reimbursement practices
3. Optimise Emergency Medical Systems across borders
4. Accelerate the use of the common EU-wide emergency number (112) and develop awarenessraising campaigns to increase public knowledge on the symptoms of acute heart attacks
5. Establish common datasets and registries for benchmarking purposes
6. Define indicators for use in quality and safety standards related to pPCI delivery
7. Encourage the exchange of information and experiences between countries and regions –
sharing best practices
8. Develop shared treatment protocols in order to ensure consistent and coherent information
streams between healthcare systems when moving patients across borders
9. Promote joint training programs on acute heart care earmarked for healthcare professionals
10. Generate a series of decision points that contribute to the development of appropriate models of
service organization and delivery.
The implementation of the patients’ rights directive in cross-border healthcare provides a unique
opportunity to encourage cooperation between Member States in order to address a significant health
24
inequality. It would allow standards to be raised to the levels of the best performing countries, in order
to deliver timely reperfusion to all eligible patients with severe heart diseases.
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28
Annexe I: Interview transcripts
Austria: Professor Kurt Huber, Vienna.
Kritina Laut: What is the current situation with STEMI treatment in Austria?
Prof Huber: Since 2003 Austria has worked on establishing a well-functioning STEMI organisation.
STEMI treatment in Austria is organised in STEMI networks where pPCI service is coordinated
through collaborations between the different invasive centres in one area. These networks can help to
reduce transport time from first contact, guide transport to the most appropriate hospital, activate the
catheterization laboratory at the time of pre-hospital diagnosis, and reduce inter-hospital transfer delays
as well as door-to-balloon times at pPCI centres.16 Furthermore, STEMI networks ensure a sufficient
number of patients for each operator in order to maintain their competences.
Kristina Laut: What is the time delay to treatment in Austria?
Prof Huber: Since the establishment of STEMI networks, internal barriers between Austrian regions
no longer exist. About 70% of the STEMI patients are offered pPCI within the recommended
timeframe. If a time delay of longer than 90-120 minutes is expected, for example due to weather
conditions or traffic problems, pre-hospital thrombolysis is given, and the patient is immediately
transferred to the nearest hospital with an active catheterisation laboratory. The mountainous areas can
be difficult to reach within the recommended timeframe and here, helicopters are available. Around
70% of patients arrive at hospital transported by the EMS.
Kristina Laut: What is the balance between the reperfusion treatments offered in Austria?
29
Prof Huber: On average, thrombolysis is offered to about 30% of the STEMI patients. In the Vienna
network, 95% of patients receive pPCI and only a small percentage are still treated with thrombolysis.
Kristina Laut: Is there are STEMI registry in Austria?
Prof Huber: Austria has an existing national PCI registry called the Austrian PCI registry. However,
no national STEMI registry exists.
Kristina Laut: Tell me about the organisation of STEMI networks in Austria
Austria has a total of 34 catheterisation laboratories. In some cities there are more than one
catheterisation laboratory that participate in 24/7 pPCI service, e.g. in Vienna: 6, in Linz; 3 and in
Graz; 2 (Figure 1).
Some STEMI networks have collaborations between centres. They are all open during official
catheterisation times (day time), but at night they follow a rota system, e.g. Vienna, Linz, or the
Southern Lower Austria/Burgenland network consisting of Eisenstadt, Mödling and Weiner Neustadt.
Other centres like Innsbruck (Tyrol) or Feldkirch (Vorarlberg) serve the whole county. The number of
available catheterisation laboratories per centre differs, but it is guaranteed that STEMI patients within
these networks are treated within 2 hours of first medical contact.
Kristina Laut: Are there areas in Austria where patients might benefit from cross-border
collaboration?
Prof Huber: Patients living in the mountainous areas around Salzburg and Tirol are hard to reach
within the recommended timeframe in any direction. There are some types of collaborations with
southern Germany as well as Italy. These collaborations are local initiatives and reimbursement
arrangements are decided internally between regions/counties. However, I am not aware of any crossborder collaboration within the area of acute treatment for patients with heart attacks.
30
Collaboration used to exist between Switzerland (Sant Gallen) and Austria (Vorarlberg). However, for
the last two years or so Vorarlberg has had its own STEMI network and this collaboration was
therefore terminated.
Austria does potentially have the capacity to treat patients from other countries, as there is a wellestablished STEMI organisation and a lot of active catheterisation laboratories. The best potential
countries to benefit might be areas near the borders with Slovenia.
Kristina Laut: Do you think that cross-border collaboration would work?
Prof Huber: Yes, I think it would work in some areas. However, it has so far never been discussed. If
direction were to come from the political system in the EU it would surely be discussed. In my opinion
cardiologists are completely open to these things if it makes sense and if it would solve problems for
the patients.
Kristina Laut: in your opinion, what are the main barriers to implementation of cross-border pPCI
collaboration with Austria’s neighbours?
Prof Huber: Firstly, reimbursement systems - budgets are tight everywhere. Secondly, emergency
medical systems and transport across borders is extremely difficult. There need to be very clear
agreements, for example regarding accidents and insurance. Finally, specific, clear rules for
collaborations and reimbursement arrangements have to be discussed at a political level.
The Austrian government already reimburses treatment of people from other countries in an acute
situation if they are not insured in their own country. If you could develop a system like this where
reimbursement agreements were in place that would help cross-border collaborations. Regarding
31
language, patient information in Austria already exists in English, German, Hungarian and Serbo-Croat,
so the language barrier would not be a major problem. Austria is a multicultural country.
Kristina Laut: so what criteria do you think should be met to establish pPCI across borders?
Prof Huber: Firstly, political pressure and the involvement of the professional societies in discussions
is necessary. Also, there have to be very clear rules – politicians need to discuss this. But the main
barrier is financial constraints – this has to be decided upon at a political level. One example is the
situation in Braunau am Inn in Austria and Simbach am Inn in Germany. These are both small regions
with about 40-50,000 inhabitants each only separated by a river. Each region has an interventional
catheterisation laboratory since Germany did not want their patients to be treated in Austria. It is a
question of nationality and money!
Kristina Laut: The European Cross-border Health Directive idea includes specific provisions for the
development of European Reference Networks though which health experts across Europe will be
able to share best practices on healthcare and provide standards of excellence. Do you think that
this would be relevant to for STEMI networks?
Prof Huber: I am not familiar with this. In theory, but I would think it would work. We already have
numerous collaborations within the professional community. We meet our colleagues at numerous
meetings where we share experiences, so we know exactly what is going on. So I think the success of
these networks would depend on who is invited to such discussions. Clinicians know what is going on
in their own community but such a network should clearly include politicians, who unfortunately do
not always understand all of what is going on, and that is a real problem! Politicians change every two
years and then it is somebody else you have to discuss with which often makes implementation difficult.
Figure 2. Catheterization laboratories in Austria, 2013
32
AUSTRIAN primary PCI- CENTERS
– 24/7 STEMI Networks 2013
Linz
St. Pölten
Wels
Waidhofen/ Krems
Ybbs
Salzburg
Feldkirch
Mistelbach
Mödling Eisenstadt
Wr. Neustadt
Innsbruck
Schwarzach
Bruck
Lienz
Klagenfurt
Graz
Villach
Ground transporta on <90-120 min
Remote areas can be reached by helicopter within the
recommended melines
Primary PCI trans borders is unusal but occasionally done
K. Huber, Vienna, Austria
33
Greece: Dr. John Kanakakis, Athens
Kritina Laut: What is the current situation with STEMI treatment in Greece?
Dr Kanakakis: Greece has quite a lot of pPCI centres scattered around the country. There are two
well-functioning STEMI networks in Athens and Péloponnèse. Establishment of further STEMI
networks in the north of Greece in Veria, Thessaloniki and Ioannina as well as at the Greece Islands is
planned within the next year. At the moment there are a total of 9 government-owned catheterisation
laboratories (2 at Skyros and 2 at Rhodes) as well as 5 privately-owned catheterisation laboratories.
Kristina Laut: What is the time delay to treatment in Greece?
Dr Kanakakis: At present around 50% of the Greek STEMI patients can reach a pPCI centre within
the recommended timeframe. The mean transport time from onset of symptoms to treatment is 1 hour
and 38 minutes. Approximately 38% of the STEMI population arrive at Hospital with the EMS
Kristina Laut: What are the opportunities for collaboration between Greece and its neighbours?
Dr Kanakakis: At the moment there are no cross-border collaborations. There are no nearby
catheterisation laboratories in Albania and the situation in Bulgaria, Macedonia and Turkey is unknown.
The Greek system is the most developed compared to the neighbouring countries so Greece would be
able to help the surrounding countries. With the planned expansion of the pPCI treatment, Greece
would be interested in collaboration with the neighbouring Balkan countries all the way along the
borders. However, there are still problems internally in the country that have to be solved.
Kristina Laut: What sort of data registries exist in Greece?
Dr Kanakakis: Greece has no existing national registries on pPCI or STEMI. Greece has a regional
34
PCI Registry called the Hellenic PCI Registry, however this only covers around 15 % of the STEMI
population.
Kristina Laut: What in your view are the main barriers to implementation of cross-border pPCI
collaboration?
Dr Kanakakis: Firstly there are different political systems. This is especially problematic with
Macedonia. There are also different insurance systems and organisational structures, particularly within
the EMS system.
Kristina Laut: So what criteria do you believe should be met to establish pPCI networks across
borders?
Dr Kanakakis: Well, the first thing that has to be in place is an official agreement between the
countries. This has to be agreed at the political level. We also need to know where the catheterisation
laboratories are situated - at the moment, we have little knowledge of where the catheterisation
laboratories in other countries are located! This would then provide us with the necessary information
about distances and transfer times to the nearest catheterisation laboratories in other countries.
All in all, cross-border collaborations would be a good idea. However, at the moment the political
situation in Greece is difficult which might make implementation of new initiatives difficult too.
Kristina Laut: European Reference Networks are a potential mechanism within the European cross
border health directive for sharing best practice and standards of excellence. Do you think that STEMI
patients would benefit from this approach?
35
Dr. Kanakakis: Yes, collaboration within the Stent for Life Initiative5 has provided much experience
of how to organize STEMI treatment across countries. This has resulted in the establishment of two
very well-functioning STEMI networks in Athens and the Peloponnese Islands. We have also gained
valuable experience from well-functioning countries like Czech Republic, the Netherlands and
Denmark and those collaborations are very helpful. I am not aware of these European Reference
Networks, but they sound like they would be a very good idea. It would be helpful with experience
from other countries as well as how to organize such collaborations.
5
The Stent for Life Initiative is a unique European platform for interventional cardiologists, government representatives, industry partners,
patient groups and patients to work together to help shape healthcare systems and medical practices and ensure that the majority of ST elevation
myocardial infarction (STEMI) patients have equal access to the life-saving indication of p-PCI.
36
Latvia:Professor Andrejs Ergils, Riga
Kristina Laut: could you tell me about the organisation of STEMI networks in Latvia?
Prof Ergils: pPCI is the first choice treatment in patients with STEMI who are admitted within 12
hours of symptom onset. There are four catheterization laboratories in Latvia, two in Riga, where
primary PCI is available 24 hours a day, 7 days per week and two in the regional hospitals; Daugavpils
and Liepaja (Figure 3). At present pPCI is performed in approximately 73% of all STEMI patients and
thrombolysis is provided to 14%. At present 74% of STEMI patients arrive at the hospital transported
by the EMS.
Kristina Laut: What is the situation with data registries?
Prof Ergils: Latvia has no existing national PCI Registry, but it does have a national STEMI Registry
which covers around 90% of the STEMI population.
Kristina Laut: Is there any cross border collaboration with neighbouring countries? and are there areas
where you think patients might benefit from cross-border collaboration?
Prof Ergils: There is no cross-border collaboration because Latvia is able to provide pPCI to its entire
STEMI population. However, we would be interested to take part in the establishment of cross-border
collaborations and help neighbouring countries.
37
Figure 3. Catheterisation laboratories in Latvia, 2013
38
Lithuania: Dr. Gintas Bieliauskas, Vilnius.
Kristina Laut: dr Bielauskas, please tell me about current STEMI treatment practices in Lithuania?
Dr Bieliauskas: Lithuania (as well as the neighbouring countries, like Latvia, Poland or Belarus)
seems to have quite favourable geography to implement pPCI, being a small country with good
infrastructure - it is not difficult to reach most areas from a geographical standpoint. There are 6 PCI
centres in Lithuania, three of those offer 24/7 service (Figure 4). The 24/7 centres are situated in
Vilnius (Vilnius University Hospital), Kaunas and Klaipeda. Centres not offering 24/7 service are
situated in Siauliai, Panevėžys and Vilnius (Private Hospital Kardiolita) (Figure 4).
The majority of the population can therefore reach a pPCI centre within the recommended timeframe
(90-120 minutes), however, given that there are a number of PCI centres where pPCI service is not
available 24 hours a day, seven days a week, some patients are still treated with thrombolysis when
STEMI is diagnosed in remote areas of the country. I would say that around 20% are treated with
thrombolysis and the proportion of untreated patients is unknown. In 2011 around 92% of STEMI
patients were transported by EMS.
Kristina Laut: So what is the situation with data registries?
Dr Bieliauskas: Well, there is no PCI or STEMI registry in Lithuania, which makes it very difficult to
be precise about treatment numbers!
Kristina Laut: Do you think that there are areas in Latvia where patients might benefit from crossborder collaborations?
Dr Bieliauskas: Yes, I would say that patients diagnosed close to the Northern border with Latvia
might potentially benefit from cross-border therapy as the Latvian PCI centres in Riga are within reach.
39
Lithuania itself would also have the capacity to treat patients from other countries if a suitable
reimbursement system could be established. The best potential countries to benefit might be Belarus
(Vilnius is close to the border), Northern Poland (Vilnius and Kaunas are quite close) and Russia
(Klaipeda is not far away).
Kristina Laut: From your perspective then, what are the main barriers to implementation of crossborder pPCI collaboration?
Dr Bieliauskas: Different regional and state reimbursement policies are the main problem, as is the
absence of cross-border insurance coverage for medical staff and transportation. Another issue is
differences in standards of healthcare, including pPCI. Although less important, language can also be a
factor in certain cases. Finally, I would say that some in the medical community might oppose this idea
as well, because there might be a preference to treat patients in their home country simply for national
political reasons.
So, in order to implement cross-border PCI, discussions with colleagues in the neighbouring countries
would be required to assess the need, to identify the potential problems and the potential solutions.
Kristina Laut: What criteria do you think need to be met in order to establish pPCI across borders?
Dr Bieliauskas: Primarily, I would say the ability to establish fast transportation across borders. Then
reimbursement agreements need to be in place covering medical staff and transportation costs. Overall,
there needs to be agreement within medical communities and the neighbouring countries regarding
such treatment strategies.
Kristina Laut: Do you think that STEMI networks could be operated across borders, for example
through the development of a European Reference Network for STEMI?
40
Dr Bieliauskas: I am not too familiar with this idea, but overall I am positive about cross-border
collaboration. However, it is possible that some of my colleagues will continue to believe that
Lithuanian patients should be treated in Lithuania.
Figure 4. Catheterization Laboratories in Lithuania, 2013
PCI centers with
24/7 service
PCI centers without
24/7 service
41
Northern Ireland: Dr. Patrick Donnelly, Belfast.
Kristina Laut: So, Dr Donnelly, please could you tell me a little about STEMI treatment in Northern
Ireland?
Dr Donnelly: Yes, of course! Northern Ireland is a small country with a fairly unique geography with a
direct border to the Republic of Ireland. The majority of the population lives around Belfast. pPCI is
something that they have fought for a very considerable period of time to get up and running. They
have run quite an effective out-of-hospital thrombolysis service for a long time, and few patients were
transported to PCI facilities. However over the last two years, the National Department of Health has
issued a review of this situation. This was based on various position statements from the European
Society of Cardiology and the American Heart Association on pPCI as the first choice treatment on
patients admitted with STEMI. Since then, there has been a total overhaul in Northern Ireland where
they have looked at the logistics, the need and the number of centres that would be required to try to
deliver that service.
At the moment there is no real regional angioplasty service in Northern Ireland per se, and we are
lagging well behind other European countries. However there is an ad hoc pPCI service where, in
specific patient cases, consultants will arrange to have it performed. So, if you are admitted in a
hospital that has a catheterisation laboratory between the hours of 9am - 5pm there might be an
interventional cardiologist on duty who would be happy to deal with this STEMI case.
At present, I would say that probably less than 10% of STEMI patients are treated with pPCI and they
are predominantly treated during daytime – not ideal if you have your heart attack after opening hours!
Moreover, coverage very much depends on the operators in specific hospitals. The task in the years
ahead, is to work out internal STEMI organisation and logistics. The majority of patients are
hospitalized through the ambulance system and paramedics can already reach every area in Northern
Ireland. However within a year, the state of play should be different. There will be two regional centres
42
supported by the Northern Ireland ambulance service to deliver patients in timely fashion to two major
catheterisation laboratories that will be working 24 hours a day 7 days a week. It is a major over haul
and a huge investment for Northern Ireland at the moment!
Kristina Laut: …and what is the state of play with data registries?
Dr Donnelly: I’m sorry to say that there is no PCI and STEMI Registry in Northern Ireland!
Kristina Laut: Can you tell me a bit more about the catheterisation laboratories in Northern Ireland?
Dr Donnelly: Yes, there are currently four catheterisation laboratories in Northern Ireland (Figure 5).
However there is insufficient cardiology coverage to support a 24/7 primary angioplasty service, and
neither are there sufficient numbers of cases for operators in each of those centres to justify maintaining
that competency. Therefore the strategy has been to concentrate on delivery of pPCI in two centres
moving forward, one in Belfast and one in the North West.
Kristina Laut: How about areas where patients might benefit from cross-border cooperation?
Dr Donnelly: Overall, there is very little collaboration with the Republic of Ireland at the moment,
although some collaboration has begun with Dublin in the area of paediatric cardiology.
Options for greater cooperation for STEMI patients are being considered in a number of areas, for
example the north-west coast of Northern Ireland up towards Derry/Londonderry. Sometimes patients
on the Irish side of the border have to travel as far as to Dublin to have access to PCI so it is hoped that
patients in the northwest could be served primarily by a centre in the northern part of Northern Ireland
in order to deliver timely pPCI, and in fact, this has been taken into consideration in determining the
location of future pPCI centres. There will be a pPCI centre located very centrally within the region,
and then another centre up towards the northwest, both with 24/7 service, which will then open up the
43
possibility of cross-border work.
Another potential area would be the Craigavon area along the border area with the Republic of Ireland.
There seems to be much potential for cross-border work, but negotiation on this is barely in its infancy
as the current priority is simply to get regional pPCI centres up and running.
Kristina Laut: If that cross border collaboration could be established, what sort of criteria do you
think would need to be met?
Dr Donnelly: EMS logistics, that is, the movement back and forth of ambulances and the activation
from one system to another is central to this issue - there would have be to greater integration between
the two systems. Then, there would need to be agreements at inter-governmental level as to what the
system would look like and what the reimbursement strategies should be. One other important factor is
automatic rights of return – there needs to be a good system in place that ensures that the areas from
which those patients have come will be in a position to accept returning patients at the local hospital,
should that be necessary. There is currently a lack of beds and high bed occupancy rates!
I also reckon that there need to be protocols on transferrals between hospitals, in order to ensure patient
flow through the system and reduce loss of information between hospitals. Access to information
between hospitals, preferable electronically is really important. Treatment follow-up will most likely be
at the local hospital, so this would ensure continuity, reduce duplication and contribute to integrated
treatment strategies.
One further point that I want to make, is that an advantage in Northern Ireland is that we are part of the
UK National Health Service, so everything is coordinated through this system. In the Republic of
Ireland however, the vast majority of patients have some form of private health insurance, which
provides access to healthcare. Negotiations in the south over contracts and insurances might therefore
represent a barrier for cross-border healthcare, and which would have to be discussed with the Irish
44
government. Some hard decisions will probably have to be taken!
Finally, this cannot work without the buy-in of the cardiologists - so the endorsement of the local
cardiac society is also necessary. The Cardiology Society would probably be interested in cross-border
collaborations and particularly in mapping geographic locations where pPCI is not currently an option.
Figure 5. Catheterization Laboratories in Northern Ireland, 2013
45
Poland: Dr. Zbigniew Siudak, Krakow.
Kristina Laut: Dr Siudak, could you give me an overview of the provision of STEMI treatment in
Poland?
Dr Siudak: Yes, in fact there are currently no cross-borders collaborations between Poland and its
neighbours largely because Germany and the Czech Republic already have a high penetration of pPCI.
Poland itself has 149 catheterisation laboratories scattered around the country (Figure 6). In Poland
thrombolysis is used in less than 1% of STEMI patients, more than 90 % of STEMI patients can reach a
catheterization laboratory within the recommended timeframe and 56% are transported by the EMS.
Kristina Laut: Are there any regions which might benefit from collaborations across borders?
Dr Siudak: Firstly, I would say that in our country there is not a major need for cross-border
collaboration as there are already many catheterisation laboratories in Germany, Czech Republic and
Poland. There may be some regions, especially in the southern part of Poland, ie the mountainous
regions, where the delay might be longer, and which might benefit from cross-border collaboration.
This however, should be a joint decision based on discussion between countries to identify areas that
might benefit. Concerning our neighbours in Ukraine, Russia and Belarus, it would be difficult to
discuss the issue since they are not a part of the EU.
However I believe that Poland does potentially have the capacity to treat patients from other countries.
Kristina Laut: And what is the status with data registries in Poland?
Dr Siudak: Poland has established national registries on PCI and STEMI treatment.
Kristina Laut: What do you believe are the main barriers to implementation of cross-border pPCI
46
collaboration?
Dr Siudak: If cross-border cooperation were to start, and if there were tangible reasons that patients
could benefit from such cooperation, the first priority would have to be inter-governmental cooperation.
All governments have to decide to treat these patients and reimburse the treatment at the same time.
Language could be a problem, particularly for German patients coming to Poland (rather than for polish
patients going to Germany), and translators might then be required. I have wondered whether a
rotational system where doctors from Poland go to Germany for one week and vice versa might be a
solution?
Then there is the EMS system service - there are already difficulties crossing regional borders within
Poland. Moving this to an international level would be even more difficult, and is something that would
need to be resolved at a government level. If protocols on transport can be established at both the
national level as well as between countries then the Polish EMS system would no doubt be more than
happy to serve patients from neighbouring countries.
The professional society would probably be interested in such cooperation arrangements if the abovementioned barriers were resolved at government level. We are of course interested in such cooperation
if it were promoted by the ESC or any other organisation, but there are many issues which need to be
addressed first!
Kristina Laut: What do you think of the idea of establishing European Reference Networks for
STEMI?
Dr Siudak: It sounds like a good idea. We already have doctors from other countries coming here for
training, and we also collaborate with many centres abroad.
47
Figure 6. Catheterization Laboratories in Poland, 2013
ECG teletransmission in Poland in 2013
149 cathlabs
Do you have ECG teletransmission
available in your cathlab?
Yes, on site (101/149 cathlabs)
No (39/149 cathlabs)
Available, however located in
another department
(9/149 cathlab)
In another department
ECG teletransmission is available in 74 % of cathlabs in Poland
Data collected on 13th March 2013 by D. Dudek & AISN of the Polish Cardiac Society)
48
Portugal: Dr. Helder Pereira, Almada
Kristina Laut: Dr Pereira, could you give me a brief overview of STEMI treatment in Portugal?
Dr Pereira: Yes, Portugal by now has a very well established STEMI organisation with wellfunctioning STEMI networks. 90% of the STEMI population live closer than 90 km from a
catheterisation laboratory and can be treated within the recommended timeframe. However, still only
around 30% are transported by the EMS system! The central part of Portugal is made up of
mountainous areas where it can be a problem to reach a catheterisation laboratory within 2 hours. In
total, there are 18 catheterization laboratories in Portugal that are providing 24 hour service, 7 days a
week (Figure 7). In 2012, two catheterization laboratories were opened in Covilhã in order to serve this
population.
Kristina Laut: What about data registries?
Dr Pereira: Portugal has two different national registries on PCI and STEMI.
Kristina Laut: Are there areas you think could benefit from cross-border collaborations?
Dr Pereira: There are no existing cross-border collaborations between Portugal and Spain at present.
The areas that might benefit from this type of collaboration would be border areas with Galicia to the
north and with Badajoz in southern Spain. In the other direction, Portugal does have the capacity to
treat patients from Spain.
Kristina Laut: So what would be the main barriers to be overcome in establishing cross-border pPCI
collaboration?
Dr Pereira: The two principal obstacles are emergency transport systems and reimbursement
49
agreements. Language should not be problematic between Spain and Portugal.
Kristina Laut: What criteria do you believe should be met to establish pPCI across borders?
Dr Pereira: It should be possible to call the neighbouring countries directly to be able to transfer
patients. Then, it is important to know where the nearest catheterisation laboratory in the neighbouring
country is located. And finally the reimbursement agreements need to be in place.
STEMI?
Dr Pereira: I am not familiar with this concept, but find it a very interesting idea!
50
Figure 7. Catheterization laboratories in Portugal, 2013
51
Slovenia:Dr. Marco Noç, Ljubljana
Kristina Laut: Dr Noç, could you give me a brief overview of STEMI treatment in Slovenia?
Dr Noç: Slovenia is a small country with only 2 million people. Slovenia uses only pPCI and has a
very well established STEMI organisation including pre-hospital services and STEMI networks. The
population trusts the system and everybody knows one other within the cardiology community. It is
possible to reach a PCI centre within the recommended timeframe (90-120 minutes) from all parts of
Slovenia, and around 15% of patients arrive by helicopter. There are 5 catheterisation laboratories in
Slovenia, of which 2 (Ljubljana and Maribor) provide 24/7 service (Figure 8). In 2011, 93% of all
STEMI patients were treated in these two centres.
Kristina Laut: Could you tell me about data registries in Slovenia?
Dr Noç: Yes, Slovenia has no existing national PCI or STEMI Registry. However there are regional
registries in all areas of Slovenia.
Kristina Laut: Are there any cross border collaborations with neighbouring countries?
Dr Noç: There have already been discussions about cross-border collaboration in the Trieste/Sežana
area. The driving time from Sežana to Ljubljana is approximately 1 hour, whilst driving time to Trieste
is only 20 minutes. Trieste has a catheterisation laboratory working 24/7, so patients would reach
treatment faster if this collaboration was established. The pre-hospital system is keen to do this in order
to reduce transport times, however, no formal cooperation is yet in place.
Cross-border collaboration is a good idea, especially in areas where there are mixed nationalities. In the
area of Trieste/Sežana the majority of people speak Italian, so the pre-hospital system as well as the
hospitals will understand the information. Often, there will already be a personal link between the two.
52
The only problem is that Ljubljana is a high-volume centre and Trieste is not. Collaboration has not yet
been discussed anywhere else.
Kristina Laut: Are there potentially other border areas where collaboration could be beneficial?
Dr Noç: Yes, possibly the areas bordering with Austria where patients could go to Klagenfurt,
although this is a rural, mountainous area with poor infrastructure, so it would be important to verify
whether this solution would actually reduce transport times. Secondly, areas near the border with
Croatia may benefit from going to Zagreb and Karlovac, although this could be difficult due to
language barriers.
To date, there have been no discussions about patients from other countries getting treatment in
Slovenia, however it would be possible.
Kristina Laut: What sort of barriers might be encountered in establishing cross-border pPCI
collaborations?
Dr Noç: Firstly, it takes time to build up trust and it is important to know each other and each other’s
competences. Then there are insurance issues - who will pay for what? Agreements would have to be
established concerning the pre-hospital transport units – will they be permitted to drive across borders?
And finally there are patient preferences – is the patient population happy to be treated outside their
home country?
Kristina Laut: Do you think that the access to STEMI treatments could be improved for patients
through establishing European Reference Networks for STEMI?
Dr Noç: Overall, I am in favour of cross-border collaboration for STEMI, however, the main problem
is that the barriers to different treatments and organisations of (e.g. STEMI networks) are very different
53
across regions and countries. Problems are specific to each country. You can´t just copy and paste –
each situation is very different. However the Stent for Life Initiative as a good example of a way
forward.
Figure 8. Catheteriza on laboratories in Slovenia, 2013
PCI centers with
24/7 service
PCI centers without
24/7 service
54
Spain: Dr. Ander Regueiro, Barcelona
Kristina Laut: Dr Reguiero, could you tell me a little bit about STEMI treatment in Spain?
Dr Reguiero: yes, of course, you may know that each region in Spain is independent in regards to the
healthcare system, administration and resources. There is no comprehensive national PCI and Acute
Coronary Syndrome registry in Spain, which makes it very difficult to be precise about treatment
numbers. In Catalunya for example, 90% of the STEMI population is treated with pPCI and 60%
receive treatment within the recommended timeframe. However, throughout the entire country it is
thought that around 50% of patients admitted with STEMI are treated with pPCI and 40% with
thrombolysis. Only 30% are transported by the EMS system the rest are self-presenters.
Spain has a total of 76 pPCI centres with 10 STEMI networks scattered around the regions (Figure 9).
STEMI networks operate in Asturias, Cantabria, Baleares, Castilla la Mancha, Catalonia, Galicia,
Madrid, Murcia, Navarra and Valencia.
Kristina Laut: What is the situation with data registries in Spain?
Dr Reguiero: Spain has a national PCI and STEMI registry, but it covers less than 30% of the STEMI
population as reporting is voluntary. At the moment only data in Catalonia is consistent and regularly
updated.
Kristina Laut: Are there regions where patients might benefit from cross-border collaborations?
Dr Reguiero: There are a number of catheterisation laboratories close to the borders with Portugal in
the west and France in the east. In particular, patients close to the Spanish/French border might benefit
from cross-border collaborations since this area is mountainous. In other regions such as Galicia and
Andalucía which share borders with Portugal, they do not have the same problems, because they are
55
able to reach a catheterisation laboratory within the timeframe.
I should also mention a new cross-border collaboration running at the Hospital of Cerdanya situated in
the city of Puigcerdá in Spain. The region is thinly populated - there are only around 30,000 people but during holiday season, this number increases up to about 150,000 people. On the French side, the
next hospital for acute care is about 150 km away. The hospital will run under a joint Spanish/French
administration and management system. However, the hospital does not offer pPCI and so patients
from this region are currently treated at a centre in Catalonia. However, if they were transported by
helicopter it is possible to treat them within 2 hours. French patients could probably be treated faster in
Catalonia even though they live in France!
So yes, mountainous areas both in Spain and France, particularly the area around Andorra would be the
main areas to benefit.
Spain does have the capacity to treat patients from other countries. The number of Spanish patients is
not expected to increase significantly, so the available resources should be sufficient.
Kristina Laut: What are the main barriers to implementation of cross-border pPCI collaboration?
Dr Reguiero: At the moment I am not aware that the EMS system crosses borders as this would be
problematic. So for patients to be treated quickly, the EMS must be able to drive freely across borders.
Whilst this is largely an administrative problem, it would definitely need to be addressed.
Don’t forget that this is an issue which also needs to be addressed at regional level! At present, the
EMS system within Spain can only cross regional borders on inter-hospital drives. So even though you
are closer to a pPCI centre in another region, you will be transported to the closest centre in your own
region – this is not ideal!
56
So, EMS transportation needs clear instructions and protocols; reimbursement for treatment and
transportation needs to be agreed; and you need clear protocols for the return of patients to the referral
hospitals after pPCI treatment.
Kristina Laut: Could you suggest what criteria should be met to establish pPCI across borders?
Dr Reguiero: I think that the resources and equipment already exist in the hospitals, so it is primarily
political will and administrative agreements that are needed, covering rapid transportation across
borders, and reimbursement for medical staff and transport costs. There would also need to be
agreement within medical communities and the neighbouring countries regarding treatment strategies.
If we are able to explain the benefits to the cardiologists I don´t think it will be a problem, as long as it
does not increase the workload!
The way things operate at present, each region would have to make its own decisions and cross-border
agreements. National agreements will probably not be possible, since the regional borders and the
existing barriers are very region-specific, but at least language is not a major barrier.
STEMI?
Dr Reguiero: Spain has already some collaboration with other catheterisation laboratories in other
countries for training of interventional cardiologists.
57
Figure 9. Existing STEMI networks in Spain, 2013, all regions have catheterisation laboratories
58
Sweden: Professor Stefan James, Uppsala.
Kristina Laut: Professor James, what is the situation for STEMI treatment in Sweden?
Prof James: Sweden is a large, sparsely-populated country. Sweden treats patients primarily with pPCI,
however thrombolysis is used in remote areas, after which patients are transported to the nearest PCI
centre. 73% of STEMI patients receive reperfusion therapy within 90 minutes from first medical
contact to PCI. The mean delay is 60 minutes from first medical contact to pPCI, and eighty per cent of
the STEMI population are transported by the EMS. Patients are treated with thrombolysis in Gotland,
Norrland and Aland Islands and Sweden potentially has the capacity to treat more patients.
79 hospitals in Sweden offer pPCI, of which approximately half offer pPCI 24 hours a day 7 days a
week (Figure 10). The rest of the hospitals follow different protocols with some being opened only
during daytime (8-16) and some offering pPCI 24 hours a day but only Monday till Friday.
Kristina Laut: How about data registries?
Prof James: Sweden has a well-established national PCI and STEMI registry covering the entire
STEMI population.
Kristina Laut: Are there areas where patients might benefit from cross-border collaboration for
STEMI patients?
Dr James: Some cross-border collaboration already exists between Finland and Sweden at the Aland
Islands. Aland is the largest island in an archipelago of nearly 15,000 others. Aland is an autonomous,
self-governed territory of Finland, but the main population is Swedish. However, pPCI is not offered at
the Islands and so people have to be transported to Uppsala by helicopter. In fact, it is not always
possible to reach the islands by helicopter in the acute phase, so people are treated with thrombolysis
59
and later transported to Uppsala for PCI.
There are some collaborations for emergencies in the skiing areas, of which Åre is the largest. However,
that hospital does not offer pPCI, only angiography, and so patients have to be transported to Umeå or
Uppsala. Patients living in Åre and the Norrland region could also be transported to Trondheim in
Norway, although it would remain a challenging journey in this remote region regardless of the hospital
chosen!
The remote areas in Sweden are hard to reach, especially Gotland, which is a very sparsely populated
area with large distances to cover in any direction. Another possible area for discussion would be the
east coast of Sweden where some areas would be closer to Oslo than Gothenburg.
Kristina Laut: What in your view are the main obstacles to the implementation of cross-border pPCI
collaboration?
Dr James: For me, these are reimbursement of medical staff and treatment, and EMS systems and
transport across borders, so this is mainly a financial problem.
Kristina Laut: So what criteria should be met to establish pPCI across borders?
Dr James: STEMI protocols and pharmacological treatment should be similar. This will probably not
be a problem in the Nordic countries where treatment schemes are comparable.
I am sure that cardiologists in Sweden would be interested in looking into cross-border collaboration.
However, there would be competition between the hospitals in treating patients since all hospitals are
reimbursed “per treated patient” within their own county (Län). Healthcare services in other counties
would have to be reimbursed.
60
Kristina Laut: In your view would a European Reference Network for STEMI be a useful tool for
sharing best practices between countries?
Dr James: It seems like a good idea. The main problem in Sweden is that it is a large country with
some very sparsely populated areas. We have a lot of PCI centres with a low volume of patients, which
makes training of interventional cardiologists difficult. We already send doctors to other countries for
training, so increasing educational cooperation would be good.
Figure 10. Catheterization laboratories in Sweden, 2007
PCI-Sverige
2007
90 min
transport-radie
= 24/7
= övr
Kellerth 07
61

Here - European Critical Care Foundation

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