394 Abstracts

the 10,711 OHCA cases, 2881 were transported to CCMCs and7502 were transported to NCCHs. The primary endpoint was“neurologically favorable outcome” defined by Cerebral Perfor-mance Categories score. Among patients with return of sponta-neous circulation (ROSC) in the field, the authors found thatneurologically favorable outcome was similar between theCCMC and NCCH groups (43% vs. 41%, respectively, adjustedodds ratio [OR] 1.09, 95% confidence interval [CI] 0.82e1.45;p = 0.554). Among patients without ROSC in the field, neurolog-ically favorable outcome was very unlikely overall, however,slightlymore likely in theCCMCgroup (1.7%vs. 0.5%, adjustedOR 3.39, 95% CI 2.17e5.29; p < 0.001) compared to the NCCHgroup. The authors conclude that patients without ROSC benefitfrom transfer to a CCMC. Factors such as cooling protocols,rapid access to percutaneous coronary intervention, and subspe-cialty support may be responsible for these differences.

[Charles M Reynolds, MD

Denver Health Medical Center, Denver, CO]

Comment: This study suggests that outcomes of OHCAwith-out ROSC are dependent upon in-hospital factors. If true, thiscould have implications for the transport of patients withoutROSC after OHCA. However, there are several important limita-tions to the article, including the observational nature of the study,lack of randomization, andpotential for selection bias amongpre-hospital providers (EmergencyMedical Services personnel chosetheir destination without support from a decision-makingprotocol) that necessitate caution in interpreting the results.

, HEALTH CARE INSURANCE, FINANCIAL CON-CERNS IN ACCESSING CARE, AND DELAYS TO HOS-PITAL PRESENTATION IN ACUTE MYOCARDIALINFARCTION. Smolderen KG, Spertus JA, Nallamothu BK,et al. JAMA 2010;303:1392e400.

This was a prospective observational study that examined theassociations between health insurance status and financial con-cerns related to accessing health care with delayed presentationto the hospital in patients with acute myocardial infarction. Par-ticipants were consecutively enrolled from the TRIUMPH studypatient population from 24 urban hospitals within the UnitedStates. Patients older than 18 years who had elevated cardiacenzymes within 24 h of admission and other supporting evidenceof acute myocardial infarction were considered for inclusion.Patients were excluded if they were incarcerated, refused toparticipate, were unable to consent, did not speak Spanish orEnglish, transferred to the participating hospital more than24 h after initial presentation, if they died, or if they were dis-charged before being contacted by researchers. Data were col-lected by chart abstraction and from interviews that wereperformed within 24e72 h of admission from 3271 includedpatients. Insurance status was divided into three categories: noinsurance, insurancewith financial concerns, and insurancewith-out financial concerns. Patients were classified as havingfinancial concerns if cost had caused them to avoid care in thepast year, to be non-adherent to medications in the past year,or to have difficulty obtaining health care services. These datawere compared to the time from symptom onset to hospital pre-sentation, which was grouped into one of three categories:# 2 h,

2e6 h, or > 6 h. Time to presentation was compared to insurancestatus using multivariable hierarchical cumulative-logit models.To adjust for missing time data across all insurance categories,a non-parsimonious model was created and the reciprocal ofthe associations were used to weight the hierarchical cumula-tive-logit model. A secondary analysis was performed to analyzethe association between delayed presentation and lower rates oftreatment with percutaneous coronary intervention or thrombo-lytic therapy. Multiple differences were found in the baselinecharacteristics of patients with insurance without financial con-cerns, those with insurance with financial concerns, and thosewithout insurance. Compared to patients with insurance and nofinancial concerns, patients who were uninsured or insuredwith financial concerns were more likely to be younger, non-white, single, and less likely to have completed high school.There were also significant differences between the groupswith regard to pre-hospital delays to care. Among those with in-surance without financial concerns, 36.6% presented within 2 h,as compared to 33.5% of insured patients with financial concernsand 27.5% of uninsured patients. Of patients with insurancewithout financial concerns, 39.3% presented > 6 h after symptomonset, as compared to 44.6% with insurance with financialconcerns and 48.6% of uninsured patients. After adjustmentfor demographics, baseline health status, social factors, and psy-chiatric variables, insured patients with financial concerns werefound to be more likely to delay care (odds ratio 1.21, 95% con-fidence interval 1.12e1.51). Among patients with ST elevationmyocardial infarction, those with pre-hospital delays > 6 hwere less likely to receive primary reperfusion therapy (83.9%of those with delays > 6 h, 92.5% for those with > 2e6-h delays,and 93.5% in thosewith < 2-h delays). The authors conclude thatfinancial concerns or a lack of health insurance are importantcauses of delays to accessing care for patients with myocardialinfarction. Unless the financial aspect of access to health careis addressed, patients may continue to delay care.

[Colleen Foster, MD PGY-2Denver Health Medical Center Emergency Medicine

Residency Program, Denver, CO]

Comments: The authors provide a compelling argumentabout the influence of financial concerns for patients in access-ing health care when they need it most. What could not be an-swered by this study was whether or not that delay resulted inworse outcomes. Nonetheless, if the desire is to have patientspresent as early as possible in the course of a myocardial infarc-tion, the financial barriers, or at least the perceptions of them,must be addressed.

, ACUTE PERIORBITAL INFECTIONS: WHO NEEDSEMERGENT IMAGING? Rudloe TF, Harper MB, Prabhu SP,Rahbar R, Vanderveen D, Kimia AA. Pediatrics2010;125:e719e26.

With the emphasis on reducing pediatric exposure to radia-tion, providers often find themselves debating whether theirpatient needs a computed tomography (CT) scan. This study ex-amined factors that identified those children with signs or symp-toms of periorbital infection who were candidates for earlyimaging of the orbit. Included were all children presenting to