All ETDs from UAB

Advisory Committee Chair

Marie A Bakitas

Advisory Committee Members

Anne W Alexandrov

E Kristi'ina Hyrkäs

Rita A Jablonski-Jaudon

Erica R Pryor

Henry E Wang

Document Type


Date of Award


Degree Name by School

Doctor of Philosophy (PhD) School of Nursing


Introduction: Acute coronary syndrome is the most common cause of death in the U.S. and the world; ST segment elevated myocardial infarction is the most acute form. The preferred reperfusion therapy is immediate primary percutaneous coronary intervention at an interventional cardiology center. It is intuitive, but not known, whether delay in receipt of reperfusion therapy because of geographic distance is associated with increased coronary mortality. Even so, clinical practice guidelines recommend organizing coronary care in each community in regional systems. Hub-and-spoke has been proposed as a regionalized coronary care model. Article synthesis: The first article in this dissertation, titled Effectiveness of Regionalized Systems for Stroke and Myocardial Infarction, is a narrative review of the studies that examine the effectiveness of model systems in myocardial infarction and a decade of societal experience with Joint Commission certification of United States stroke centers. The review was complicated by a lack of an explicit definition of a regionalized coronary care system. Without an explicit definition, coronary care stakeholders cannot interpret or generate evidence to support or refute assertions that regionalization should be the standard of care. The second article, titled Hub-and-Spoke: A Concept Analysis, is a proposal of an explicit definition of regionalization. A documented formal statement of hub-and-spoke system governance is proposed as the missing link between regionalization recommendations and an adequate evidence base. The third article, titled Geographic Access to Interventional Cardiology Services in Maine, is an exploration of the effect of delayed geographic access to care in a largely rural state with high quality rural hospital care. Key findings: (1) Gaps in the evidence supporting the recommendation for regionalized coronary care are the result of lack of an explicit definition of such systems; (2) documentation of a formal system-wide governance agreement is a promising candidate definition; and (3) in a largely rural setting without formal system-wide governance, delayed geographic access is not associated with age-adjusted coronary mortality. Extension of the study is justified to overcome limitations resulting from lack of clinical data, relatively small sample size, and survival bias.

Included in

Nursing Commons



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