REACT trial data indicates that public education about MI risks does not affect symptom-to-hospital time lapse

Shelley Wood

July 10, 2000

Chicago, IL - How, when, and why people call for ambulances when the think they may be having a heart attack are some of the questions raised in the Rapid Early Action for Coronary Treatment (REACT) trial. The major findings of the study, linking community education campaigns to the time lapse between onset of acute MI (AMI) symptoms and hospital-based care, appear in the July 4, 2000 issue of JAMA[1].


REACT was a five-center, randomized, controlled trial that looked at the effects of an 18-month-long education campaign, aimed at teaching people how to recognize CAD symptoms, and was conducted in 20 communities in 10 different states. Avenues for education included mass media - namely television, newspaper, and radio announcements - in addition to direct contact through mail-out brochures, posters, and community group seminars. Baseline data was collected 4 months prior to the education campaign. Campaign impact was assessed through random-digit dialed telephone surveys after the education period had ended, as well as by comparing the use of emergency medical services (EMS) in the 10 "intervention" communities to that in 10 matched "reference" communities in which campaigning did not take place.

Dr Russell Luepker (Division of Epidemiology, University of Minnesota, Minneapolis, MN) and colleagues found that the average delay-to-hospital time in all cities, prior to education campaign, was 2 hours, 21 minutes. Following the 18-month education period, the researchers saw no reduction in the amount of time people were taking from symptom onset to emergency room admission, regardless of whether they lived in an intervention or reference community. In other words, one and a half years of vigorous public education appeared to have no effect on reducing patient delay times.

"The lack of effect represents a failure of the intervention to achieve this goal under the conditions of the REACT design," the authors write. "The educational messages may have been flawed, lacked sufficient intensity, duration, or both, or were targeted to the wrong groups."

"The significant increase in the use of the EMS system by the primary study population in the intervention communities is an important positive result."

Luepker et al point out that the public already receives a steady stream of heart-smart advice and that future education attempts must be even more forceful. "Although the REACT campaign appeared quite intense, it must be viewed in the context of a constant barrage of information that virtually all citizens in communities throughout the United States receive," the authors observe. "It is conceivable that, given this intensity of background information, a longer duration of an even more intense intervention might have been more effective in lowering delay time."

A promising, if surprising finding to shake out in the REACT analysis was that the number of patients later diagnosed with CAD who actually called 911 to get to the hospital increased in certain areas, even though this rise did not seem to affect overall patient delay times. The increase of 16% per year was seen only in intervention communities, while rates of EMS use in reference communities remained unchanged.

Changes in patient delay time and EMS use per year following education campaign

Changes Intervention community (%) Reference community ( p value
Decrease in delay time −4.7%  −6.8 0.54
Increase/decrease in EMS use per year 16 −3 <0.005

The upsurge in EMS use within the intervention community is a good sign, say the researchers. "The significant increase in the use of the EMS system by the primary study population in the intervention communities is an important positive result," the authors write. They conclude that further assessment of education strategies and other tactics are necessary if patient delay times are going to be further reduced.

"Doc, surely it's not happening to me?!?"

Houston, TX - A separate REACT analysis, published in the July 11, 2000 issue of Circulation [2] looked specifically at factors that influence individuals' decisions to call an ambulance. The study indicates that factors such as geography, demographics, indecision, financial concerns, physician contact, and personal beliefs play an important role in distinguishing people who call for help from those who don't. Ironically, while almost 90% of people surveyed claim that they wouldn't hesitate to call 911 if they witnessed a cardiac event, the mean percentage of people using the service for themselves was only 23%. Dr Adam L Brown (Department of Emergency Medicine, Oregon Health Sciences University, Portland, OR) and colleagues, using REACT trial data, showed that patients who called for emergency assistance were more likely to be older, taking nitroglycerine, and/or be living in an area with a prepaid emergency medical services system. People who spoke first to their doctors, or who tried to get rid of the symptoms by taking aspirin or antacids, were less likely to call 911.

The fact that a call to a doctor appeared to decrease use of emergency services is "problematic," the authors write. "It is unclear if doctors were acting as managed care 'gatekeepers' to EMS care, or if they reduced patient anxiety in a way that made EMS transport seem optional." Either way, REACT survey data indicates that in more than 4 out of 5 cases, people who spoke first to their doctors before being admitted to hospital did not use EMS transport.

Overall, knowing the value of emergency services only partially solves the problem. As the authors observe, "People seem to understand the prudent actions to take when faced with a public cardiac event, but they may be unwilling to take the appropriate steps when facing a personal cardiac emergency."

- SW




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