Evaluation of STEMI Regionalization on Access, Treatment, and Outcomes Among Adults Living in Nonminority and Minority Communities

Abstract

IMPORTANCE Cardiac care regionalization, specifically for patients with ST-segment elevation myocardial infarction (STEMI), has been touted as a potential mechanism to reduce systematic disparities by protocolizing the treatment of these conditions. However, it is unknown whether such regionalization arrangements have widened or narrowed disparities in access, treatment, and outcomes for minority communities.OBJECTIVE To determine the extent to which disparities in access, treatment, and outcomes have changed for patients with STEMI living in zip codes that are in the top tertile of the Black or Hispanic population compared with patients in nonminority zip codes in regionalized vs nonregionalized counties. DESIGN, SETTING, AND PARTICIPANTSThis cohort study used a quasi-experimental approach exploiting the different timing of regionalization across California. Nonpublic inpatient data for all patients with STEMI from January 1, 2006, to October 31, 2015, were analyzed using a difference-indifference-in-differences estimation approach. EXPOSURE Exposure to the intervention was defined as on and after the year a patient's county was exposed to regionalization. MAIN OUTCOMES AND MEASURES Access to percutaneous coronary intervention (PCI)-capablehospital, receipt of PCI on the same day and at any time during the hospitalization, and time-specific all-cause mortality. RESULTSThis study included 139 494 patients with STEMI; 61.9% of patients were non-Hispanic White, 5.6% Black, 17.8% Hispanic, and 9.0% Asian; 32.8% were women. Access to PCI-capable hospitals improved by 6.3 percentage points (95% CI, 5.5 to 7.1 percentage points; P < .001) when patients in nonminority communities were exposed to regionalization. Patients in minority communities experienced a 1.8-percentage point smaller improvement in access (95% CI, −2.8 to −0.8 percentage points; P < .001), or 28.9% smaller, compared with those in nonminority communities when both were exposed to regionalization. Regionalization was associated with an improvement to same-day PCI and in-hospital PCI by 5.1 percentage points (95% CI, 4.2 to 6.1 percentage points; P < .001) and 5.0 percentage points (95% CI, 4.2 to 5.9 percentage points; P < .001), respectively, for patients in nonminority communities. Patients in minority communities experienced only 33.3% and 15.1% of that benefit. Only White patients in nonminority communities experienced mortality improvement from regionalization.

Differential benefits of cardiac care regionalization based on driving time to percutaneous coronary intervention

“…The exact tradeoffs between the therapies are not always clear, especially when patients present at different times in the course of their disease. In other work evaluating the effects of STEMI regionalization in California, White patients living in nonminority communities have been the only racial/ethnic group to experience 30‐day, 60‐day, and 1‐year mortality benefits, which could be due to differential quality of hospitals available to different segments of the population 15 . Thus, it is difficult to draw conclusions about the longer‐term effects of regionalization on mortality—regardless of baseline access to PCI.…”

“…Outcomes included: 1) access to PCI‐capable hospitals, 2) treatment defined as receipt of PCI either on the day of admission or during the care episode; and 3) health outcomes (30‐, 90‐, and 365‐day mortality). Access to PCI‐capable hospitals was defined by admission to a PCI‐capable hospital using an all‐payer volume threshold of 50 PCIs per year from prior literature 15 …”

“…Access to PCI-capable hospitals was defined by admission to a PCI-capable hospital using an all-payer volume threshold of 50 PCIs per year from prior literature. 15 Because the patient cohort was patients diagnosed with STEMI, coronary angiography was included in our definition of PCI to capture attempts at intervention. While PCI is generally the definitive treatment for STEMI, inclusion of coronary angiography accounts for clinical realities of failed PCI attempts, false-positive diagnoses of STEMI, and referral to coronary artery bypass grafting in cases where such intervention would be clinically preferred over PCI.…”

“…In other work evaluating the effects of STEMI regionalization in California, White patients living in nonminority communities have been the only racial/ethnic group to experience 30-day, 60-day, and 1-year mortality benefits, which could be due to differential quality of hospitals available to different segments of the population. 15 Thus, it is difficult to draw conclusions F I G U R E 1 Outcomes trends for patients with STEMI in communities with closest PCI facility <30 minutes and patients with STEMI in communities with closest PCI facility ≥30 minutes over study period (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015). PCI, percutaneous coronary intervention; STEMI, STelevation myocardial infarction Regionalization of STEMI care was first recommended in Europe, with initial studies done in smaller geographic regions with centralized and more universalized health care systems.…”

Structural discrimination in emergency care: How a sick system affects us all

“…In a regionalized network, health systems, hospitals, physician groups, and EMS agencies work together to match medical resources to patient needs in an effort to improve outcomes and reduce costs for an entire geographic area. 28 For example, in the context of cardiac care regionalization, an emergency medical system instructs prehospital transport to directly transport heart attack patients to facilities that offer emergency PCI, bypassing hospitals that do not offer the treatment. This patient-centered approach allows for patients to receive the care they need faster, which is critical for time-sensitive cardiac conditions.…”