The Paradox of STEMI Regionalization: Widened Disparities Despite Some Benefits

“In this issue of JAMA Network Open, Hsia et al sought to determine whether efforts to improve access, treatment, and outcomes for patients with ST-elevation myocardial infarction (STEMI) by means of cardiac care regionalization were associated with widened or narrowed disparities between minority and nonminority communities at the zip code level across the state of California. Access was defined as admission to a hospital with percutaneous coronary intervention (PCI) capability; treatment was defined as receiving coronary angiography or PCI (as clinically indicated) the day of admission or at any time during hospitalization; and outcomes were defined as all-cause mortality at 30, 90, or 365 days. Minority communities were defined as those zip codes wherein the share of Black or Hispanic residents were in the top tertile of the overall California distribution.

[..] in minority communities the improvement in access was 28.9% less when compared to nonminority communities. Regionalization was also associated with improvements in same-day PCI and in-hospital PCI, but patients in minority communities experienced only 33.3% and 15.1% of those benefits, respectively. Only White patients in nonminority communities experienced mortality improvement after regionalization.

[..] A 4-tiered measurement framework has been proposed to help to set standards and benchmarks for realizing health equity. The framework comprises measurements in the realms of access (Level 1), transitions of care (Level 2), quality of care (Level 3), and socioeconomic/environmental impact (Level 4). Applying this framework to health equity interventions is intended to identify priorities and achieve greater impact.

[..] work of Hsia et al revealed that STEMI regionalization in California did not yield more equitable access. One potential explanation for this offered by the investigators is the difference in EMS use in minority communities vs nonminority communities. By using EMS, patients can be more quickly routed to PCI-capable hospitals for STEMI. However, the knowledge that EMS may be expensive and require out-of-pocket payment can deter patients and their families from calling EMS. Minority communities in the study had higher percentages of individuals receiving Medicaid, lower median per capita income, and higher proportions of inhabitants living in low-income zip codes1; these factors can translate into disparate PCI access.

[..] Patients with STEMI from minority communities were less likely to receive same-day PCI or PCI during their hospital stay even after gaining access to a hospital with PCI capability. Potential explanations for this disparity could be both institutional and interpersonal. STEMI regionalization facilitates access to hospitals that perform PCI but does not ensure that these hospitals are of comparable quality or ability. Prior investigations have shown that low-quality hospitals care for disproportionate shares of minority patients.

[..] The literature has described differential treatment recommendation based on patient race alone, even with identical presenting symptoms—the selection for cardiac catheterization is one example. These findings suggest that patient race can be a factor associated with the likelihood of receiving standard of care treatment. Practitioner bias in treatment decision-making is an important factor in health disparities. Additionally, the exploitation of Black Americans was normative in medical institutions for most of US history; Black individuals were routinely subjected to nonconsensual, nontherapeutic research. As a result, minority patients may be more likely to decline procedures offered to them.

[..] Only White patients living in nonminority communities experienced a survival benefit after cardiac care regionalization. This result highlights the likely impact of the social determinants of health, including structural and interpersonal racism. Minority communities had less favorable socioeconomic and demographic profiles than the nonminority communities. Structural racism—the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice—underlie these disparities. At the interpersonal level, racial and ethnic differences in mortality in nonminority communities likely reflect, in part, the well-documented negative effects of the everyday discrimination perceived by minorities on their health outcomes. The persistence of intracommunity mortality disparities by race—even when comorbidities and major social determinants of health such as housing quality, income level, employment status, educational attainment, food security, personal safety, environmental quality, and recreational opportunities are interracially comparable—lends credence to the postulation that racism itself is a social determinant of health and a fundamental cause of health disparities.

Measures of socioeconomic and environmental impact (Level 4) evaluate the effect of interventions on communities, beyond the level of individual patients. For example, STEMI regionalization may contribute to the closure of smaller hospital centers without PCI capability, which can cause untoward effects on noncardiac community health, employment opportunities, and per capita income.”

Full editorial, Roswell RO, Brown RM and Richardson S. JAMA Network Open 2020.11.16