Download An International Perspective on the Time to Treatment for Acute

Clinical Scholarship
An International Perspective on the Time
to Treatment for Acute Myocardial Infarction
Kathleen Dracup, Debra K. Moser, Sharon McKinley, Carol Ball, Keiko Yamasaki,
Cho-Ja Kim, Lynn V. Doering, Mary A. Caldwell
Purpose: To compare delay and circumstances of decisions to seek care in patients with acute
myocardial infarction (AMI) in the United States (US), England, Australia, South Korea,
and Japan.
Design: Comparative prospective design.
Methods: Patients diagnosed with AMI (N=913) were interviewed within 72 hours of hospital
admission for confirmed AMI using the Response to Symptoms Questionnaire. Delay times
were calculated from review of emergency room records and patients’ interviews. Analysis
of variance was used to test differences in delay time among countries.
Findings: Median delay ranged from 2.5 hours in England to 6.4 hours in Australia, with the
three Pacific Rim countries reporting median delay times > 4 hours. The majority of patients
experienced initial symptoms at home (range: 56% in Japan to 73% in the US) with the most
common witness being a family member (32% in South Korea to 48% in England). Ambulance
use was widely divergent with the highest use in England (85%) and the lowest use in the
US (42%).
Conclusions: In all countries, median delay was too long to obtain maximum benefit from
AMI therapies, particularly thrombolysis. Education and counseling of patients and families
to reduce prehospital delay in AMI episodes might be more effective if the various factors
influencing patients’ first responses to symptoms are considered, as well as differences in
health care systems.
JOURNAL
OF
NURSING SCHOLARSHIP, 2003; 35:4, 317-323. ©2003 SIGMA THETA TAU INTERNATIONAL.
[Key words: myocardial infarction, delay time, US, England, Pacific Rim]
*
P
rompt reperfusion therapy for an acute myocardial
infarction (AMI) can limit myocardial damage with
subsequent positive effect on morbidity and mortality
(Berger, Schulman, et al., 1999). However, the efficacy of
therapy is directly related to the interval between symptom
onset and treatment (Berger, Ellis, et al., 1999; Goldberg et
al., 1998). Patients who receive treatment within the 1st hour
of the onset of symptoms receive the most benefit, and many
patients are excluded from reperfusion therapy because of
excessive delay. Mean delay times of 4.6 to 24 hours and
median delay times of 2 to 6.4 hours have been reported in
studies conducted in North America and Europe in the past 2
decades (Dracup, McKinley, & Moser, 1997; GISSI, 1995;
Luepker et al., 2000; Newby et al., 1996). This study was
conducted to document and compare delay times and
associated factors in five countries.
*
*
Kathleen Dracup, RN, DNSc, Gamma Tau, Dean and Professor, School of
Nursing, University of California, San Francisco; Debra K. Moser , RN,
DNSc, Delta Psi , Professor, School of Nursing, University of Kentucky,
Lexington; Sharon McKinley, RN, PhD, Professor of Critical Care Nursing,
University of Technology, Sydney, Australia; Carol Ball , RN, PhD, St.
Bartholomew School of Nursing and Midwifery, City University, London,
England; Keiko Yamasaki , RN, MSN, Tokyo Women’s Medical College
Hospital, Tokyo, Japan; Cho-Ja Kim, RN, PhD, Dean, College of Nursing,
Yonsei University, Seoul, Korea; Lynn V. Doering , RN, DNSc, Associate
Professor, School of Nursing, University of California, Los Angeles; Mary A.
Caldwell, RN, MBA, PhD, Alpha Eta, Assistant Adjunct Professor, School of
Nursing, University of California, San Francisco. Supported in part from
grants to Dr. Dracup from University of California Pacific Rim Research
Program and Fulbright Foundation. Correspondence to Dr. Dracup, School
of Nursing, University of California, 2 Koret Ave., Rm N319, Box 0604, San
Francisco, CA 94143-0604. E-mail: [email protected]
Accepted for publication January 9, 2003.
Journal of Nursing Scholarship
Fourth Quarter 2003
317
Time to Treatment for AMI
Background
Recently, the National Institutes of Health launched a
campaign to reduce prehospital delay in the US, targeting
both health care professionals and the lay public (Dracup et
al., 1997; Lenfant, LaRosa, Horan, & Passamani, 1990).
Several randomized trials have been conducted to test public
education strategies (Luepker et al., 2000; Meischke,
Eisenberg, Schaeffer, Larsen, & Henwood, 1994; Moses et
al., 1991). All have been conducted in Western industrialized
societies and all have been focused on providing information
about AMI symptoms and the appropriate steps to take to
reduce treatment delay.
Few studies to date have included the social factors that
contribute to delay and none have indicated the difference in
treatment-seeking behavior in AMI between and among
various countries. Health care systems and cultural attitudes
toward health and illness vary from country to country, and
these differences might affect the ability of patients with AMI
to label and respond to cardiac symptoms in a timely manner,
thereby increasing or decreasing prehospital delay times. For
example, a health care system in which patients are
encouraged to seek emergency care in facilities without
cardiodiagnostic capabilities as is the case in many
community clinics in Japan (Matsuda, 2000) can lead to
significant delay in patients’ diagnosis and treatment.
Moreover, fundamental differences exist in how patients from
different cultures respond to illness and interact with health
care providers. For example, people from Asian cultures who
experience cardiac symptoms might turn first to traditional
herbal medicines before calling a physician or seeking care
at an emergency facility (Chan et al., 2003).
Leventhal’s model of self-regulatory conception of illness
(Leventhal & Cameron, 1987; Leventhal, Nerenz, & Steele,
1984) behavior is often used to characterize delay in care-seeking
behaviors and it has served as a foundation for interventions in
Western cultures (Dracup, 1997; Dracup & Moser, 1997;
Leventhal, Safer, & Panagis, 1983). According to this model,
beliefs about health are hierarchical—based on previous
experiences with illness and other information provided in the
social environment. Internal and environmental factors such as
sociodemographic and clinical characteristics and cultural roles
and expectations affect how one responds to a health threat.
Environmental stimuli such as family and coworkers can also
affect care-seeking behaviors, along with friends, health care
providers, and the media.
As illustrated in the Figure, a person experiencing a health
problem goes through three stages: (a) a mental representation
of the health threat (cognitive and emotional), (b) development
of an action plan for coping with the perceived threat, and (c)
an appraisal that includes an assessment of how well the plan
addresses the threat. A feedback mechanism underlies the
mental representation and the coping strategies during
subsequent illness events. The inclusion of internal and
environmental stimuli makes the model particularly
appropriate for evaluating the influence of culture on careseeking behavior. With this model, one assumes that at least
318
Fourth Quarter 2003
Journal of Nursing Scholarship
some of the variation in human responses is attributable to
cultural influences (Dreher & MacNaughton, 2002).
World Health Organization (WHO) officials have projected
that noncommunicable diseases, particularly heart disease,
will increase dramatically in all developing countries over
the next few decades (WHO, 1996). By 2020, ischemic heart
disease is expected to become the leading cause of disease
burden worldwide, overtaking communicable diseases, poor
reproductive health, and malnutrition as the leading cause of
death (Reddy & Yusuf, 1998). Ischemic heart disease in Asia
as a significant cause of mortality is well documented
(Thailand Annual Health Statistics, 1994; Toshima, 1994).
Therefore, a determination of prehospital delay patterns for
treatment of AMI in both Western and Pacific Rim countries
is important in preparing future global public health initiatives
and in planning health initiatives in countries with ethnically
and culturally diverse populations.
We conducted this study to document current rates of
prehospital delay and to compare delay times in two Western
countries (the US and England) and three Pacific Rim countries
(Australia, Japan, and South Korea). We also described patients’
and others’ initial responses to symptoms and examined the
relationship between patients’ sociodemographic and clinical
characteristics in predicting time to treatment of AMI.
Internal &
environmental stimuli
Cognitive
representation
Coping
procedures
AMI
symptoms
Outcome
appraisals
Emotional
representation
Seek
care
Figure.Theoretical framework adapted from Leventhal’s self-regulatory
model of illness behaior (Leventhal & Cameron, 1987).
Methods
Sample and Setting
Participants (N=913) were recruited from 10 community
hospitals and university medical centers in five countries:
Australia, Japan, Korea, England, and the US. Patients were
eligible for inclusion if they were diagnosed as having an
AMI via cardiac enzyme or standard electrocardiographic
criteria, had been hospitalized for 72 hours or less, were pain
free and hemodynamically stable, alert, and oriented; living
independently (not in a chronic care facility); and free from
complicating malignancy or other debilitating illness.
Procedures
Institutional review boards or their equivalent at the participating
sites approved the study protocol. Following approval of the attending
Time to Treatment for AMI
physician, a study investigator or research assistant approached
patients meeting the study criteria. The study was explained
and written consent to participate was obtained. Participants
were interviewed as soon as possible following hospitalization
to optimize their ability to recount events immediately before
hospitalization. Mean time between hospital admission and time
_38 hours (median 44 hours). All interviews
of interview was 53+
were conducted in patients’ primary language by a nativespeaking researcher. Clinical data were obtained via patients’
interviews and from medical records.
The time from symptom onset to hospital admission was
established in two ways. Medical records were reviewed to
obtain the emergency department physicians’ identification of
time of symptom onset and the time of patient admission. Each
participant was also interviewed and asked to identify the time
that he or she experienced the symptoms that brought them to
the hospital. In the case of symptoms that came and went (i.e.,
intermittent symptoms), participants were thoroughly
interviewed by one of the researchers to determine the nature of
the symptoms and the exact time that symptoms of a cardiac
nature began. Careful interviewing techniques designed to assist
patients to remember accurately the time of symptom onset
were used (Dempsey, Dracup, & Moser, 1995; Dracup,
McKinley et al., 1997; Dracup & Moser, 1997; Reilly, Dracup,
& Dattolo, 1994). When a discrepancy occurred between the
time to hospitalization recorded in the medical record and the
patient’s account, the patient’s cardiologist was consulted along
with the electrocardiographic and serum cardiac enzyme data
obtained upon admission to determine which of the two values
to use (Rawles, Metcalfe, Shirreffs, Jennings, & Kenmure, 1990).
Instruments
Patients were interviewed using the Response to Symptoms
Questionnaire (Burnett, Blumenthal, Mark, Leimberger, & Califf,
1995). This questionnaire was designed to obtain information about
the events that occurred before hospital admission, including the
patient’s cognitive and psychological responses to symptoms and
the responses of people who were with the patient. Both the clinical
data form used for medical chart review and the Response to
Symptoms Questionnaire were translated from English into Japanese
and Korean and then back translated by a second person to ensure
equivalency. Previous investigations have shown adequate reliability
and validity of this instrument (Dracup & Moser, 1997).
Statistical Analyses
Proportions and measures of central tendency were used to indicate
sample characteristics, delay time, initial symptom experiences,
and first response to symptoms. Because delay time was skewed by
a number of extreme observations, a logarithmic transformation of
delay time was used in all analyses. Analysis of variance (ANOVA)
was performed to test the overall differences in delay time between
countries. Two-factor ANOVAs were used to test for differences in
delay time within various subgroups among the countries. The
subgroups included sociodemographic variables (sex, age, years of
formal education, residence—rural, urban, or suburban—yearly
household income converted to US dollars, and marital status)
and clinical characteristics (maximum pain level experienced
during AMI, admission systolic blood pressure, admission pulse,
smoking status, and history of hypertension, diabetes mellitus, or
previous AMI).
Findings
Characteristics of the Sample
A total of 913 patients with AMI were enrolled in this study: 192
from the US, 127 from South Korea, 136 from Japan, 141
from England, and 317 from Australia. Sample characteristics
by country are shown in Table 1. Mean ages for the five
_11 to 63+_12 and years of education
countries ranged from 57+
ranged from 10+_4 to 13+_3. Mean systolic blood pressure
ranged from a low of 128+_30 in South Korea to a high of
Table 1. Sample Characteristics (N=913)
Age (M±SD)
Education (M±SD)
Male (%)
Current smoker (%)
Residence (%)
Rural
Urban
Suburban
Married (%)
History of: (%)
Hypertension
Diabetes
AMI
Coronary bypass
Angioplasty
United States
(n=192)
61±13
12.8±3.0
50.0
30.9
South Korea
(n=127)
57±11
11.3±4.5
77.2
67.7
Japan
(n=136)
61±11
12.8±3.1
80.1
68.4
England
(n=141)
61±13
10.1±4.3
77.3
44.0
2.9
92.8
4.3
75.7
Australia
(n=317)
63±12
9.9±4.4
65.9
na
na
na
na
na
69.4
p
.000
.000
.000
.000
.000
na
na
na
.000
46.3
26.9
26.9
67.0
13.4
81.5
5.0
92.1
5.9
80.9
12.5
86.0
57.1
27.0
30.7
10.1
21.7
48.8
24.6
7.9
0.8
3.9
54.8
34.8
15.4
2.9
8.1
41.8
26.2
20.6
6.4
5.0
53.4
18.7
28.3
12.1
na
.061
.007
.000
.000
.000
Note. na = not available.
Journal of Nursing Scholarship
Fourth Quarter 2003
319
Time to Treatment for AMI
143+_29 in the US and England. The majority of patients lived
in urban or suburban areas with easy access to hospitals and
were living with a spouse. On average, 23% of all patients
had experienced a previous AMI (range 7.8% to 30.6% in
the five countries).
Delay Times
The mean delay time for the entire group was 17.3±45
hours, and the median was 4 hours. The mean delay times
were markedly skewed by the few participants who delayed
many hours and even days from the time of symptom onset.
Thus, median values reflect delay times more accurately than
do mean values. Median delay time in each country is shown
in Table 2. Using ANOVA and log-transformed delay times,
the overall difference for the countries was significant at
p=.001. Posthoc comparisons with Bonferroni adjustment indicated
a significant difference between England and Japan (p=.04), and
between Australia and England (p=.001). All other comparisons
were statistically nonsignificant. In all countries studied, the median
delay times were too long for patients to receive maximal advantage
of optimal AMI therapies according to current clinical guidelines.
Table 2. Comparison Among Countries of Time from
Symptom Onset to Hospital Admission (in Hours)
Mean±SD)
Median
25th percentile
75th percentile
United
States
(n=192)
22.5±69.3
3.3
1.1
15.2
South
Korea
(n=127)
14.7±29.8
4.4
1.8
13.3
Japan
(n=136)
21.7±63.6
4.5
2.0
16.3
England
(n=141)
8.0±14.0
2.5
1.5
8.7
Australia
(n=317)
17.4±26.4
6.4
1.7
6.4
Note. Overall difference: p=.001. Posthoc Bonferroni: p=.04 for England and
Japan; p=.001 for Australia and England, p>.05 for all others.
Table 3. Initial Symptom Experience and Response
United
South
States
Korea
Japan
(n=192)
(n=127)
(n=136)
Patient location when symptoms began (%)
Home
72.9
59.2
55.7
Work
7.4
10.7
12.9
In vehicle
5.3
3.9
5.7
Others’ home
2.1
1.9
1.4
Public place
9.6
11.7
10.7
None of these
2.7
12.6
13.6
Witness (%)
Alone
29.8
17.5
Spouse or partner 43.1
32.0
Other family
14.4
24.3
Friend
3.2
7.8
Coworker
7.4
11.7
Other
2.1
6.8
Mode of transportation to hospital (%)
Private car
56.4
32.4
Ambulance
41.5
51.0
Public transportation —
15.7
Other
2.1
1.0
320
Fourth Quarter 2003
England
(n=141)
Australia
(n=317)
70.9
14.2
2.8
1.4
9.9
0.7
68.5
12.3
2.8
3.2
5.4
7.9
32.9
33..6
15.0
8.6
7.1
2.9
29.8
48.2
11.3
2.8
7.8
—
38.8
38.5
9.1
5.4
6.0
2.2
13.6
67.1
10.0
9.3
7.8
85.1
2.8
4.3
35.4
61.4
0.9
2.2
Journal of Nursing Scholarship
Initial Symptom Experience and Responses to Symptoms
The most common location where patients experienced initial
AMI symptoms was the home (56% in Japan to 73% in the
US). The most frequent witness at the time of symptom onset
was the spouse (32% in South Korea to 48% in England). The
majority of patients in each country except the US were
transported to the hospital by ambulance. In the US, most
participants (58%) used private transportation to get to the
hospital. See Table 3 for comparisons.
Table 4. Initial Symptom Experience and Response
United
South
States
Korea
(n=192) (n=127)
First response of patient (%)
Wished or prayed
symptoms would
go away
14.9
25.5
Tried to relax
21.3
7.8
Pretended nothing
was wrong
7.4
—
Tried not to think
about it
4.3
—
Took medication
17.6
15.7
Called physician
1.6
1.0
Tried self-help remedy 12.2
20.6
Told someone nearby
12.8
7.9
3.7
5.9
Called EMSa
Transported to the
hospital without EMS 3.2
15.7
Drove to physician’s
office or clinic
1.1
—
Other action
—
—
First response of person consulted (%)
Did nothing
4.4
2.9
Encouraged not to
worry
4.9
—
Comforted patient
7.7
5.8
Suggested rest or
medications
9.3
17.5
Suggested medical help 27.9
12.6
Called EMS
19.7
16.5
Took patient to hospital 17.5
24.3
Became upset
1.5
1.0
No one else knew
7.1
12.6
Other type of response —
6.8
Identification of origin of symptoms (%)
Heart
35.1
42.9
Stomach
32.4
38.8
Muscle pain
12.2
5.1
Fatigue
3.2
4.1
Flu
8.0
—
Respiratory
2.7
6.1
Other
5.9
3.1
aEmergency
Japan
(n=136)
England
(n=141)
Australia
(n=317)
15.8
16.5
10.7
15.0
9.2
20.6
0.7
3.6
12.4
0.7
17.3
2.2
23.7
10.1
4.3
2.9
30.7
5.0
3.6
13.5
7.9
4.4
16.8
1.6
2.2
22.5
1.6
3.6
6.4
—
2.9
2.2
0.7
—
0.3
8.3
13.6
0.7
14.0
3.6
5.0
5.0
2.1
3.7
5.9
6.4
25.0
12.9
7.1
0.7
23.6
2.1
9.9
18.4
29.8
7.8
—
26.2
—
4.4
25.0
14.0
4.4
0.7
25.7
2.2
50.0
16.7
9.4
12.3
1.4
8.0
2.2
37.9
45.7
7.9
0.7
2.1
5.7
—
40.3
24.3
12.8
7.7
1.0
—
14.1
Medical Services
In all countries, most participants initially responded
inappropriately to their symptoms. Table 4 shows the first
responses in the five countries. For example, in Japan the
most common first response was to try a self-help remedy,
with only 4.3% calling an emergency medical system (EMS).
The highest percentage of patients calling an EMS as a first
Time to Treatment for AMI
response was in England (8%) and in South Korea (6%). The
lowest was in Australia at 1.6%.
When participants told someone else about their symptoms,
only a minority of witnesses called an EMS (13% in Japan to
30% in England). Table 4 shows the first responses of
witnesses. Participants were asked to describe their initial
perceptions of the source of their symptoms. Most patients
thought their symptoms originated with either the heart or
stomach and generally less than 10% in each country indicated
other causes.
Bivariate Analyses of Delay Times Within Subgroups by
Country
Delay times were compared within the countries based on
sociodemographic, clinical, and risk-factor variables. No
variables were consistently associated with delay time among
countries. Examination of sociodemographic and clinical
factors predictive of delay with multivariate analyses failed
to reveal a clinically relevant profile of patients likely to
delay or not delay in any of the countries.
Discussion
The current study is the first to compare delay time in
seeking care for symptoms of AMI and to describe the initial
symptom experience and first responses to symptoms in an
international cohort. Although the five countries were located
on four different continents, and therefore have a broad range
of traditions and cultures, all five are industrialized and have
medical communities that share common treatment
philosophies. The standard of care in all five is early
revascularization in evolving AMI with thrombolysis or
angioplasty with or without stent. Thus, the importance of
symptom identification by the patient and prompt presentation
to the hospital (ideally 1 hour or less) is shared by all.
In all five countries time to treatment was substantially
longer than recommended. This finding was surprising given
the recent intensive campaigns conducted by clinicians,
pharmaceutical companies, and public health experts to reduce
delay time both nationally and internationally. It was not
substantially different than the times reported over a decade
ago (Kereiakes et al., 1990; Wielgosz, & Nolan, 1991). The
lack of relationship between knowledge gained in public
educational campaigns and behavioral change might be
counterintuitive for clinicians, but it is interpretable from
public health studies (Luepker et al., 2000; Meischke et al.,
1994; Moses et al., 1991). Knowledge does not necessarily
lead to behavior change. For example, in the one country
where the majority of participants reported knowing about
early treatment options (i.e., the US), the median delay time
was still over 3 hours (Dracup, McKinley et al., 1997). Our
data, combined with those of other investigators (Luepker et
al., 2000; Meischke et al., 1994; Moses et al., 1991), indicate
that community education programs alone are not sufficient
to reduce delay. Additional country or culture-specific issues
might require study. For example, Japanese patients might
preferentially call or visit their physicians when experiencing
symptoms of AMI rather than calling emergency services or
going to the hospital. This choice contributes substantially to
delay time and would need to be addressed in interventions
related to delay time.
In the majority of cases, the first response to symptoms was
inappropriate because participants did not activate an EMS.
Delay time has been shown to be significantly lower when
patients activate an EMS and come to the hospital via
ambulance compared to patients who do not call an EMS
(Kereiakes, Gibler, Martin, Pieper, & Anderson, 1992;
Meischke, 1995). Barriers to calling an EMS have been shown
to be substantial in the US (Dracup & Moser, 1997) and
Australia (Dracup, McKinley, Moser, 1997). Responses might
be related to cultural influences. For example, in this study,
Korean participants chose first to pray that the symptoms
would go away. Koreans often view illness as a result of bad
luck or misfortune and they remain stoic and feel unable to
change the course of the disease (Lipson, Dibble, & Minarik,
1996). This response could result in delays in seeking care.
Japanese participants were most likely to administer a selfhelp remedy or take medications, rather than calling an EMS.
Researchers have noted that older Japanese (a majority of
the population with AMI) may not respond to illness until it
is advanced and they often turn to home remedies when ill
(Matsumoto et al., 1995).
The structure of the health care system might also influence a
person’s decision to call an EMS. For example, all Australian
patients have nationalized health care without any monetary
fee for care, but the EMS system is private and financial cost
might be a barrier to its use. In contrast, in England the EMS
is part of nationalized health care. The findings from the
current study indicate that first responses might vary by
culture or country, but the study should be replicated with
attention to how the cultural milieu and health care system
affects response time.
In all five countries, the majority of participants experienced
symptoms at home and were with their spouses. This finding,
which has not been documented before in Pacific Rim countries
but has been reported in Western countries (Alonzo, 1986;
Dracup, McKinley, et al., 1997), shows the important
potential role of spouses in helping patients interpret
symptoms. In this sample, participants’ first responses to
symptoms were inappropriate strategies that increased delay
time. Less than 8% of patients in all countries reported calling
the EMS as a first response, the action deemed most
appropriate by the National Heart Attack Alert Program
(Dracup, Alonzo, et al., 1997; Lenfant et al., 1990). Spouses
and other lay people correctly recommended calling the EMS
or going to the hospital as the most common initial response,
further indicating the important role of others in helping
patients choose the best course of action when faced with
AMI symptoms among all countries and cultures. However,
examining interrelationships between spouses is important.
Spouses in Western cultures such as the US, England, and
Australia have nearly equal standing in their relationships,
but they often do not in other cultures. Korean and Japanese
Journal of Nursing Scholarship
Fourth Quarter 2003
321
Time to Treatment for AMI
cultures tend to be strongly patriarchal (Lipson et al., 1996;
Matsumoto, 2000) which could affect decision making about
appropriate responses to AMI symptoms. Age also conveys
strong authority in the Japanese and Korean cultures, and
younger family members might be reluctant to urge older
family members to call an EMS (Matsumoto, 2000).
Previous researchers have found that delay is reduced when
patients immediately recognize their symptoms as cardiac in
origin (Ruston, Clayton, & Calnan, 1998). Unfortunately, less
than 50% of patients in any country first identified their
symptoms as cardiac in origin. Surprisingly, patients in Japan
and South Korea most often labeled symptoms as cardiac, despite
the fact that coronary artery disease is a relatively new
phenomenon in Asian countries and participants in these two
countries had the lowest incidence of previous AMI compared
to those in the other three countries. The most common
misinterpretation in all countries was that the symptoms were
gastrointestinal in origin. This finding indicated that education
based simply on providing patients with knowledge of typical
AMI symptoms can be ineffective if health care providers do
not also help patients appropriately interpret symptoms.
Much of the previous research on factors that are associated
with patients’ treatment-seeking delay has been focused on
identification of sociodemographic and clinical variables that
could increase delay (Ghali, Cooper, Kowatly, & Liao, 1993;
Meischke, Eisenberg, & Larsen, 1993; Newby et al., 1996).
Such research has shown that previous experience with AMI
symptoms does not result in decreased delay times (Ghali et
al., 1993; GISSI, 1995), but findings have been inconsistent.
For example, some investigators have reported an inverse
relationship between pain intensity and delay time (GISSI,
1995) but others have found no such association (Bleeker et
al., 1995; Hofgren et al., 1988).
In some studies, women have been found to delay longer
than do men (Meischke et al., 1993; Newby et al., 1996), but
others showed no sex difference in delay times (Dracup &
Moser, 1997). The current study did not indicate consistent
factors associated with delay among the countries studied.
No differences in patients’ delay times in any country were
based on sex, marital status, residence, admission blood
pressure, pain intensity, or history of previous AMI. The lack
of association indicates the importance of looking beyond
sociodemographic and clinical variables to include cognitive,
emotional, and cultural factors to explain delay. Leventhal’s
model can be useful by indicating sociodemographic, family,
social, cognitive, and emotional factors that contribute to
mental representations of illness and subsequent responses to
that illness.
This study showed some differences in delay and patients’
responses to symptoms of AMI, but it had significant
limitations. The sample was nonrandom and it included
primarily people living in urban areas. Other countries, and
different cultures within countries, could show different results.
Additionally, the nature of the health care system in each
country and its influence on delay time was not investigated.
This study was descriptive, and causal relationships between
population characteristics, health care system characteristics,
322
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Journal of Nursing Scholarship
and delay cannot be drawn. The findings cannot be
generalized, including to other patients in these five countries.
Conclusions
This study adds to the growing literature on the subject of
patients’ response to AMI symptoms and is among the first to
report data about patients’ responses to symptoms of AMI in
Pacific Rim countries. Delayed treatment was a substantial
problem in all of the countries studied. The majority of patients
in all countries did not accurately identify the symptoms as
being cardiac and did not call the EMS. In all countries
studied, the majority of first responses were inappropriate;
however, family members more often than patients selected
an appropriate course of action, indicating the importance of
involving family members in all patient education efforts.
Future education and counseling programs might be more
effective if social and cultural factors influencing patients’
first responses to symptoms are considered.
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