The Journal of Emergency Medicine 533

DTCA over a 3-month period. Eight urologic DTCAs werefound in four magazines. All advertisements were product-claim advertisements that mentioned the name of the drug andmade claims about the indication or effectiveness (or both) ofthe drug. A median of three claims was made per DTCA. Fiftypercent claimed their product was ‘‘effective,’’ 38% claimedtheir product was ‘‘dependable,’’ and 100% claimed that theirproduct helped with ‘‘symptom control.’’ In addition, 88%claimed a change in ‘‘lifestyle.’’ No claims of ‘‘safety’’ wereidentified and no advertisement provided supporting evidencefor its claim. Seven of 8 advertisements (88%) included finan-cial inducements. Although a small sample of DTCA, the find-ings in this study echo previous studies of DTCA in otherspecialties of medicine. In particular, DTCA on urologic drugsfocuses on a limited number of newer products with less infor-mation available in regards to their benefits and risks.

[Stacy Trent, MD, MPH

Denver Health Medical Center, Denver, CO]

Comments: Although DTCA provides information for con-sumers to make informed health decisions, the focus on unsub-stantiated effectiveness and minimization of risk in DTCAlimits consumers’ ability to make truly informed decisionsabout their health care. Moreover, because DTCA is limited tonewer drugs that are patent protected, DTCA could, if success-ful in changing consumer behavior, increase the costs of care.

, A GEOSPATIAL ASSESSMENT OF TRANSPORTDISTANCE AND SURVIVAL TO DISCHARGE IN OUT-OF-HOSPITAL CARDIAC ARREST PATIENTS: IMPLI-CATIONS FOR RESUSCITATION CENTERS. Cudnik M,Schmicker R, Vaillancourt C, et al. Resuscitation 2010;81:518–23.

In this prospective, observational cohort study of patientswith out-of-hospital cardiac arrest (OOHCA), the authors stud-ied the effect of transport distance on survival to hospitaldischarge. This study relied on data from the Resuscitation Out-comes Consortium (ROC) Epistry, which is a registry of cardiacarrest patients within a diverse and heterogeneous collection ofover 200 EmergencyMedical Services (EMS) agencies and over200 hospitals. Between December 2005 and June 2007, 7540adult OOHCA patients were transported to ROC hospitals byEMS providers. Using geographic information system technol-ogy, the authors measured point distance (or straight line dis-tance) from the transport origin to the receiving hospital.Driving distance was then calculated using network distancealong the road network to the nearest hospital and to the desti-nation hospital. Point distance correlated well with driving dis-tance. Of the 7540 patients transported, 5412 (72%) went to theclosest hospital and the remainder were transported to receivinghospitals further from the origin of transport. When EMS elec-ted to transport patients to a hospital further from the scene,these hospitals were more likely to have a cardiac catheteriza-tion laboratory, an electrophysiology laboratory, higher patientvolumes, and a teaching institution framework. The overallmean difference between patients transported to the closest hos-pital vs. a further hospital was 1.70 miles (2.74 km). The authors

found that those taken to a further hospital had better survivalthan those transported to a closer hospital (16.5% vs. 12.1%,p < 0.001).

[Charles Reynolds, MD

Denver Health Medical Center, Denver, CO]

Comment: This study supports a growing body of evidencethat OOHCA patients may have better outcomes when trans-ported to higher volume hospitals with advanced capabilitiessuch as cardiac catheterization and therapeutic hypothermia.This study does not include favorable neurologic outcome asan endpoint, and this is a significant limitation. In addition,the authors did not track the specific interventions for patientstransported to hospitals with higher levels of care. Selectionbias is also a concern here; EMS providers may have selectivelytransported those patients without return of spontaneous returnof circulation to closer hospitals.

, IMPLICATIONS AND REASONS FOR THE LACKOF USE OF REPERFUSION THERAPY IN PATIENTSWITH ST-SEGMENT ELEVATION MYOCARDIAL IN-FARCTION: FINDINGS FROM THE CRUSADE INI-TIATIVE. Gharacholou M, Alexander KP, Chen AY, et al. AmHeart J 2010;159:757–63.

Although reperfusion therapy for patients with ST-segmentelevation myocardial infarction (STEMI) is a class I recommen-dation with reduction in mortality, many STEMI patients do notreceive reperfusion therapy. This study examined the outcomesof patients who received reperfusion therapy compared to pa-tients who did not receive reperfusion therapy, and identifiedthe factors associated with lack of reperfusion therapy amongeligible patients. The authors evaluated 8758 patients withSTEMIs participating in the CRUSADE quality improvementinitiative. Of the 8758 patients, 82.5% underwent percutaneouscoronary intervention (PCI) or received fibrinolysis, 10.3% hada documented contraindication to reperfusion, and 7.2% werereperfusion-eligible patients who did not receive reperfusiontherapy. When compared to STEMI patients who received re-perfusion therapy, in-hospital mortality rates were higher for pa-tients with contraindications to reperfusion (adjusted odds ratio1.77, 95% confidence interval [CI] 1.28–2.45) and in patientswho were eligible for reperfusion therapy but did not receive re-perfusion therapy (adjusted odds ratio 1.64, 95% CI 1.07–2.50).The main reasons listed as contraindications to reperfusion ther-apy included no ischemic indication (53.8%), risk for bleed(16.7%), and patient-related reasons such as DNR or associatedco-morbidities (25.3%). Among the reperfusion-eligible pa-tients who did not receive reperfusion, the associated factorsincluded increased age, signs of heart failure, prior stroke, fe-male gender, and treatment at a hospital without cardiac surgicalservices.

[Elisa M. Dannemiller, MD, MBA

Denver Health Medical Center, Denver, CO]

Comment: Given that the CRUSADE study included volun-tary participation by hospitals interested in quality improvement,