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Differences in medical care between urban and rural regions concern both the availability of medical facilities and the quality and accessibility of care. This work aimed to investigate possible differences in prehospital care—an aspect inadequately examined to date—based on the clinical picture of acute coronary syndrome (ACS). Consecutive patients with a diagnosis of ACS from 2014 to 2018 were included. They had been treated in a prehospital setting by emergency physicians from the district of Börde (rual area; BK) or the city of Magdeburg (urban area; MD). Data were collected from emergency physician protocols (fields to be ticked and the free texts) and subjected to multivariable logistic regression. The results showed that acetylsalicylic acid is given significantly more frequently in BK than in MD, as is heparin. Oxygen is also administered more frequently in BK than in MD, although the difference is barely significant. There is no significant difference between BK and MD in terms of the prehospital performance of a 12-lead ECG. The biggest differences between the groups are in prehospital stay duration (higher in BK due to longer travel times) and heparin administration. In the case of prehospital emergency medical care for ACS, these results refute the frequent claims in the literature of significantly poorer medical care in rural areas: in the rural district of Börde, ACS was generally treated by emergency physicians closer to the guidelines than in the state capital of Magdeburg.
C. Breitling and F. Meyer. are equal senior authors.
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Introduction
In Germany, considerable differences in medical care between urban and rural regions have been pointed out for years. These differences concern both the availability of medical facilities and the quality and accessibility of care. For example, in urban areas, the density of general practitioners and specialists is significantly higher than in rural areas. In addition, specialised medical services are often only available to a limited extent in rural areas, and patients1 often have to travel further to receive these specialised treatments [1, 2].
These aforementioned differences have so far almost exclusively been investigated for out- and inpatient medical care; there have been no major studies investigating possible differences in prehospital emergency medical care to date.
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This article thus aims to highlight possible differences and variabilities in clinical care using a prehospital standardised clinical picture, namely acute coronary syndrome (ACS).
Patients and methods
Study-associated definitions, specifications and guideline references
The guideline for treatment of acute coronary syndrome (ACS) valid at the time of recording included STEMI (ST-elevation myocardial infarction), NSTEMI (non-ST-elevation myocardial infarction) and unstable angina pectoris.
STEMI is defined as follows:
duration of symptoms 10–20 min;
sustained ST segment elevations > 0.1 mV in two neighbouring leads;
STEMI equivalent: any left bundle branch block that is thought to be new (in cases of clinical suspicion of myocardial ischaemia).
NSTEMI is defined as follows:
typical angina pectoris symptoms without sustained ST segments;
possibly sustained or dynamic ST segment depression, abnormal T waves or unspecific/unremarkable electrocardiogram (ECG) findings.
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Unstable angina pectoris symptoms are defined as follows:
chest pain at rest;
increase in attack frequency, duration and pain intensity with insufficient drug effect (e.g. not sensitive to nitroglycerin).
The preclinical treatment of patients with the abovementioned symptoms included the following after diagnosis:
1.
establishment of intravenous access;
2.
preparation of a 12-lead ECG;
3.
administration of 250–300 mg acetylsalicylic acid (ASA) intravenously (i.v.);
4.
administration of 70 international units (IU) heparin i.v. per kilogram of bodyweight;
5.
oxygen administration via nasal probe (2–4 L/min) if SPO2 < 90%;
6.
for anxious patients, administration of benzodiazepines;
7.
for pain visual analogue scale (VAS) ≥ 4, morphine i.v.;
8.
1–2 strokes sublingual (s. l.) nitroglycerin spray;
9.
transport in upper body elevation to the nearest suitable hospital (for ST elevation/new left bundle branch block hospital with cardiac catheterisation laboratory) [3‐7].
The MONAH1 trial was a clinical, systematic retrospective bicentre observational comparative study to reflect on everyday clinical practice using real-world data as a contribution to quality assurance in emergency medicine within the framework of clinical care research.
All consecutive patients with a diagnosis of ACS were included over a defined observation period. They were treated in a prehospital setting by emergency physicians from the district of Börde or from the city of Magdeburg (capital of the German state Saxony-Anhalt).
Inclusion criteria
The following diagnoses in the emergency physician protocols were included in the study:
acute coronary syndrome (ACS).
ST-elevation myocardial infarction (STEMI).
non-ST-elevation myocardial infarction (NSTEMI).
unstable angina pectoris symptoms.
myocardial infarction.
acute myocardial infarction.
Exclusion criteria
Operations of the rescue helicopter Christoph 36 (DRF station at Magdeburg) in the Börde district and Magdeburg were not recorded. Christoph 36 is only deployed in the Börde district and in the state capital Magdeburg if ground-based emergency doctors are not available in a timely manner or if particularly rapid transport of the patient is necessary. Taking the Christoph 36 mission logs into account would distort the picture of the regular ambulance service, as the helicopter is only used sporadically as a supra-regional rescue resource, and the emergency physicians always come from the two maximum-care providers in the city of Magdeburg; these missions thus do not reflect the regular care provided to the population. In addition, an organisational problem arose: the emergency physician logs are archived by the operator of Christoph 36, the German air rescue service, and were not released for evaluation for data protection reasons.
With a total area of 2367.15 km2, the Börde district is the second largest district in Saxony-Anhalt. In 2023, 168,593 inhabitants lived in the Börde district. This corresponds to 71 inhabitants/km2.
Emergency doctor locations in the Börde district comprise
1.
Wolmirstedt: honorary emergency physicians provided by the Association of Doctors on the Register of the National Health Insurance Scheme (Kassenärztliche Vereinigung).
2.
Haldensleben: honorary emergency physicians provided by the Association of Doctors on the Register of the National Health Insurance Scheme.
3.
Oschersleben: honorary emergency physicians provided by Association of Doctors on the Register of the National Health Insurance Scheme.
Magdeburg is the largest city in Saxony-Anhalt. It has an area of 201.03 km2. In 2023, Magdeburg had 242,491 inhabitants. This corresponds to 1206 inhabitants/km2.
Emergency doctor locations in Magdeburg comprise
1.
the University Hospital of Magdeburg: hospital of subspecialised and maximum care; emergency physicians provided by the Dept. of Anaesthesiology and Intensive Care.
2.
the Magdeburg Municipal Hospital: maximum-care hospital; emergency physicians provided by the Dept. of Anaesthesiology and Intensive Care, the Dept. of Internal Medicine (Cardiology and Diabetology), the Dept. of General and Abdominal Surgery, and the Dept. of Trauma Surgery.
3.
the emergency doctors’ office in the city centre (Max-Otten Street); staffed by emergency physicians from the specialist departments of the Municipal Hospital.
Raw data collection
The emergency physician protocols were completed by hand at all emergency physician locations in the Börde district. The emergency doctor protocols were also completed by hand at two of the three emergency doctor locations in the state capital Magdeburg. At the emergency physician location of the University Hospital Magdeburg, emergency physician protocols have been filled out electronically since 2015. A pad from the company NIDA GmbH (Niederdorfelden, Germany) was used. However, the pad failed for several months due to technical problems, so that the emergency doctor site at the university hospital also reverted to handwritten DIVI emergency physician protocols in their current form.
For all emergency physician protocols, both the fields to be ticked and the free texts were used for evaluation. A general definition of how to deal with missing data was made beforehand. Missing tactical and demographic data were simply ignored, but the protocols were used for evaluation of the other parameters. This means that only protocols that were completed for a characteristic were used for evaluation. Missing medical information on preclinical treatment in the protocols was assessed as not performed and is indicated in the results section as not documented. For example, for the evaluation of the quality criterion “12-lead ECG in ACS”, if neither 12-lead ECG was ticked in the protocol nor were ECG changes in the chest wall leads reported in the free text, then 12-lead ECG was assessed as not performed. This approach was necessary to be able to evaluate and compare the protocols with regard to the preclinical measures carried out. Furthermore, this approach is in line with German case law regarding missing medical documentation [8].
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The aim of this study was to analyse and compare the prehospital quality of emergency medical care. For this purpose, all emergency physician protocols of the defined study period of 5 years of the district of Börde (“BK”) and the state capital of Magdeburg (“MD”) as well as the protocols with the abovementioned diagnoses were investigated.
Statistics
All data were recorded using Microsoft Excel (version 2010; Redmond, WA, USA) and then analysed descriptively and statistically using SPSS (version 29; IBM SPSS Statistics, Armonk, NY, USA) and subjected to statistical tests. Cross-tabulation and chi-square tests were used. The significance level was set at p < 0.05.
Ethical considerations
Patient data were recorded anonymously. The names of the emergency physicians were also anonymised. Only their qualifications (specialist or resident) were saved for further analyses. The speciality of each specialist and the currently employing hospital of each resident were stored for further analyses.
Approval was obtained from the ethics committee of Otto-von-Guericke University with University Hospital (reference number: 73/25). The study was officially documented and listed as a retrospective study in the Germany-wide German Medical Study and Data Registry under the identifier DRKS00036944.
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Results
In total, emergency physician protocols of 2787 consecutive patients with a corresponding suspected diagnosis were found in the defined observation period from 2014 to 2018, which were included in the analysis. Of these, 1349 (6.7% of all emergency ambulance [Notarzteinsatzfahrzeuge, NEF] deployments in the Börde district [BK]) deployment protocols were attributable to the Börde district (rural region) and 1438 (3.3% of all NEF deployments in the state capital of Magdeburg) to the state capital of Magdeburg (MD; urban region). Demographic data are presented in Table 1 (protocols in which a certain piece of information was not available were not included in the analysis of the respective parameters).
Table 1
Demographic and professional characteristics of patients and emergency physicians (n = 2779–2786)
Variable
Category
BK (rural)
MD (urban)
Total
Gender (n = 2779)
Male
879 (65.2%)
858 (60.0%)
1737 (62.5%)
Female
470 (34.8%)
572 (40.0%)
1042 (37.5%)
Age (years; n = 2786)
Mean ± SD
67.8 ± 13.1
70.5 ± 12.4
69.2 ± 12.8
Median
69
72
71
Range (min–max)
20–94
22–96
20–96
Minimum
20
22
20
Maximum
94
96
96
Physician qualification (n = 2443)
Resident
190
716
906
Specialist
829
708
1537
BK Börde district (rural), MD state capital Magdeburg (urban), SD standard deviation
The prehospital treatment measures and outcomes in patients with acute coronary syndrome are presented in Table 2 (protocols in which a certain piece of information was missing were not included in the analysis of the respective parameters, or the absence of the data were assessed as “not carried out”).
Table 2
Prehospital treatment measures and outcomes in patients with acute coronary syndrome (n = 2463–2787)
Measure
Category
BK (rural)
MD (urban)
Total
Prehospital length of stay (min; n = 2463)
Mean ± SD
45 ± 13.5
32 ± 8.7
–
Median (range)
43 (12–124)
31 (7–67)
–
Nitroglycerin spray use (n = 2531)
Yes
593 (48.2%)
696 (53.5%)
1289 (50.9%)
Not documented
638 (51.8%)
604 (46.5%)
1242 (49.1%)
Morphine i.v. (VAS ≥ 4/10; n = 2787)
Yes
673 (49.9%)
641 (44.6%)
1314 (47.1%)
Not documented
676 (50.1%)
797 (55.4%)
1473 (52.9%)
ASA i.v. (n = 2787)
Yes
1170 (86.7%)
1155 (80.3%)
2325 (83.4%)
Not documented
179 (13.3%)
283 (19.7%)
462 (16.6%)
Heparin i.v. (n = 2787)
Yes
1178 (87.3%)
1140 (79.3%)
2318 (83.2%)
Not documented
171 (12.7%)
298 (20.7%)
469 (16.8%)
12-lead ECG performed (n = 2787)
Yes
828 (61.4%)
846 (58.8%)
1674 (60.1%)
Not documented
521 (38.6%)
592 (41.2%)
1113 (39.9%)
Oxygen (SpO2 < 90%; n = 231)
Yes
84
99
183
No
16
32
48
BK Börde district (rural), MD state capital Magdeburg (urban), ASA acetylsalicylic acid, VAS visual analogue scale, SD standard deviation
In order to assess the influence of the place of residence variable (BK vs. MD) independently of the age and gender of the patients, multivariable logistic regression was performed, and the results are presented in Table 3. The adjusted odds ratios and the 95% confidence intervals are provided for interpretation of the results.
Table 3
Multivariable analysis (BK vs. MD): adjusted odds ratios for prehospital interventions
The results of Table 4 can be summarised as follows:
prehospital stay: effect size d = 0.56 → medium effect; the length of stay prior to hospital admission differs significantly between the groups.
nitroglycerin spray: effect size V = 0.047 → small effect; although there are differences in the administration of nitroglycerin spray, these are only minor and practically insignificant.
morphine i.v.: effect size V = 0.052 → small effect; there are differences in morphine administration between the groups, but they are very minor.
ASA i.v.: effect size V = 0.090 → small effect; ASA is administered more frequently in one group, but the difference is small and of limited practical relevance.
heparin i.v.: effect size V = 0.106 → moderate effect; there is a clearer difference between the groups here—heparin is used significantly more frequently in one group.
12-lead ECG: effect size V = 0.022 → small effect (practically no difference); there is practically no relevant difference between the groups in terms of ECG performance.
oxygen administration (at SpO2 <90%): effect size V = 0.092 → small effect (wide confidence interval); there is a tendency for oxygen to be administered more frequently in one group, but the difference is small overall and statistically uncertain.
The corresponding results of statistical tests can be summarised as follows:
prehospital length of stay: Student’s t‑test, t = −27.92, p = 5.83 × 10⁻148 (significant).
nitroglycerin spray: χ2-test, p < 0.05 (significant; lower use in BK).
morphine i.v. (VAS≥4/10): χ2-test, p < 0.05 (significant; higher use in BK).
ASA intravenous: χ2-test, p < 0.05 (significant; higher use in BK).
heparin i.v.: χ2-test, p < 0.05 (significant; higher use in BK).
12-lead ECG: χ2-test not significant.
oxygen at SpO2 <90%: χ2 = 1.96, p = 0.161, not significant.
It can be said that ASA is given more frequently in BK than in MD, and the difference is statistically significant (approximately 53% higher probability). Heparin is given more frequently in BK than in MD, and the difference is significant (approximately 69% higher probability). Oxygen is administered more frequently in BK than in MD, although the difference is barely significant (approximately 2.3 times higher probability). There is no significant difference between BK and MD in terms of the performance of a 12-lead ECG.
Therefore, emergency physicians in BK perform medication measures (ASA, heparin) and oxygen administration significantly more frequently than in MD, while there is no relevant difference in ECG. The biggest differences between the groups are in prehospital stay duration (moderate effect) and heparin administration (moderate effect), while the differences in all other measures are small to negligible.
Discussion
In the case of prehospital emergency medical care for ACS, the data presented herein refute the frequent claims in the literature of significantly poorer medical care in rural areas, at least in the regional authorities analysed [1, 2]. It was shown that in the district of Börde—representative of the rural region—ACS is generally treated by emergency physicians closer to the guidelines than in the state capital of Magdeburg, with the exception of the prehospital preparation of a 12-lead ECG and the prehospital administration of oxygen (no significant difference between the two regional authorities analysed). One possible reason for this could be the significantly higher density of specialists. Whether longer professional experience and more intensive training always lead to more guideline-compliant treatment is the subject of controversial debate in the literature. For example, the studies by Bjornson et al. and Wei et al. found no advantage in terms of mortality and outcome if the treating physicians had to resuscitate in the prehospital setting and had previously completed an advanced cardiovascular life support (ACLS) course [9, 10]. However, Knapp et al. found that the severity of injury was assessed significantly better by more experienced physicians than by less experienced physicians [11]. On the other hand, the significantly longer prehospital stay could be a reason for the more guideline-compliant treatment of patients with a suspected diagnosis of ACS. This is because with significantly longer transport times to the nearest suitable hospital, the patient with the corresponding suspected diagnosis must receive more extensive care in order to be transported with stable circulation and without pain. However, Mills et al. found no correlation between prehospital length of stay and mortality [12]. However, this study did not examine the guideline-compliant treatment of specific clinical pictures.
Strengths
This study addresses an overdue topic that has received little attention to date, namely the investigation of possible differences in prehospital emergency medical care in urban and rural regions, using a representative patient clientele, as previous studies have tended to focus on possible differences in out- and inpatient medical care in various urban structures. Over the past 10 years, there has been no comparable large-scale study that has examined the guideline-compliant prehospital care of a clinical picture in a coherent manner while comparing differences in the care of patients in rural areas and large cities and additionally examining the qualifications of the emergency doctors providing treatment.
Methodological criticism
The evaluation of the manually completed emergency physician protocols was associated with considerable organisational hurdles. For data protection reasons, the logs in the Börde district could only be analysed in the Office for Fire and Civil Protection, which only offered limited access to data due to limited opening hours. The following aspects made things even more difficult: the logs were filed consecutively by operation number; this initially made it necessary to differentiate between rescue service and emergency physician logs. Some of the years had been moved to external archives due to a lack of space and had to be retrieved again. Another factor that should not be neglected is the travelling distance of 40 km. The evaluation of the emergency physician protocols of the state capital Magdeburg was also made more difficult by external archiving that had already taken place. Due to the organisational difficulties mentioned, the evaluation of the data was delayed until 2023.
However, the methodology of the clinical systematic retrospective exploratory bicentre observational comparison study described herein was very suitable for using real-world data from everyday clinical practice to vividly reflect this and, thus, make a sufficient contribution to emergency medical quality assurance and indicated clinical care research.
Outlook
Further evaluations are currently being carried out, e.g. on the influence of documentation and the influence of the emergency physician’s qualifications (specialist vs. resident and the specialist’s field of expertise), in the MONAH 1 study.
Conclusion
The analysis shows relevant differences in prehospital care between rural (BK) and urban regions (MD). While the prehospital length of stay is longer in rural areas, as expected, treatment is more often closer to the guideline. This discrepancy highlights the need for targeted education and training measures in urban centres and structural adjustments in rural regions in order to optimally coordinate both areas of care and, finally, to responsibly promote an adequate increase in the quality of clinical care.
Fig. 1
Rural region—Börde district—supraregional to the city of Magdeburg with the emergency doctor locations of Wolmirstedt: honorary emergency physicians provided by the Association of Doctors on the Register of the National Health Insurance Scheme; Haldensleben: honorary emergency doctors provided by the Association of Doctors on the Register of the National Health Insurance Scheme; and Oschersleben: honorary emergency doctors provided by the Association of Doctors on the Register of the National Health Insurance Scheme. (Source: Association of Doctors on the Register of the National Health Insurance Scheme)
Urban region—state capital Magdeburg—in the greater Magdeburg area with the emergency doctor locations of the University Hospital of Magdeburg: hospital (KH) of subspecialised and maximum care, emergency physicians provided by the Dept. of Anaesthesiology and Intensive Care; Magdeburg Municipal Hospital: maximum-care hospital, emergency physicians provided by the Dept. of Anaesthesiology and Intensive Care, Dept. of Internal Medicine (Cardiology and Diabetology) and Dept. of General and Abdominal Surgery; and the emergency doctors’ office in the city centre (Max-Otten Street); staffed by emergency doctors from the specialist departments of the Municipal Hospital. (Source: Municipal Hospital of Magdeburg, University Hospital of Magdeburg)
T. Hofmann and C. Schmidt wrote the manuscript and T. Hofmann took the lead in writing the manuscript. F. Meyer and C. Breitling supervised the project.
Funding
The study was self-financed.
Conflict of interest
T. Hofmann declares that he has no competing interests.
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For all “patients” listed and mentioned (in terms of terminology), all forms are meant, such as patients and others—for the sake of simplification, including better readability, only one gender was used in the wording of the entire text.
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