Despite encouraging declines in the death rates due to coronary heart disease (CHD) over the past two decades in the United States, the natural history of CHD is characterized by the large number of individuals who die prior to receiving medical care and by the considerable percentage of patients who present to the hospital with signs and symptoms of acute CHD after a prolonged delay. Patient associated delay in seeking medical care in the setting of evolving acute myocardial infarction (AMI) is particularly vexing given the availability of thrombolytic therapy which has been shown to be associated with up to a 25 percent reduction in in- hospital case fatality rates following AMI. A multi-site community-based randomized controlled trial is proposed to evaluate the impact of community educational interventions on patient delay time from the onset of signs and symptoms suggestive of AMI to seeking care for treatment. This trial will be accomplished through a cooperative multi-center research program. The primary objective of this trial is to design and conduct community-based interventions that will result in a reduction on patient delay time to hospital arrival and receipt of medical treatment in those with evolving AMI. The secondary objectives of this study are to examine the impact of the community educational interventions on the use of emergency medical services and emergency departments, use of thrombolytic therapy, and on in-hospital case-fatality rates associated with AMI. To this end, we are proposing to study the effects of community-wide educational interventions on these primary and secondary trial endpoints in two sets of matched community pairs from Massachusetts. These pairs include the cities of Haverhill and Pittsfield, MA, and the cities of Fitchburg/Leominster and Worcester, MA. The intervention protocol will consist of a core of standardized strategies which will be utilized in all intervention communities as well as the consideration of other intervention strategies which could be tailored to the needs of individual communities. The full-scale intervention will be implemented for 24 months through a variety of intervention channels; middle-aged and elderly males and females, patients with previous and current AMI and their families, and the general public will be specifically targeted for the various interventions. Health care providers will be of key importance in delivering selected intervention approaches. A community board will be formed to plan and coordinate the community-wide intervention efforts which will ensure a partnership between the community and local investigators in the design and implementation of the intervention efforts. Baseline (pre) and follow-up (post) cross-sectional interviews of patients presenting with signs and symptoms of acute CHD to eight hospitals in the two matched community pairs will be conducted to determine the effects of the educational program on patient delay time to hospital treatment and secondary outcome measures. The enthusiasm and support of the community organizations, public health agencies, and health care institutions at the proposed sites as well as of several state-wide organizations make this project feasible.
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