While acute myocardial infarction — commonly referred to as a heart attack — remains a leading cause of death in the United States, deaths have decreased significantly over the past two decades in part due to improved treatment methods, according to Charleen Hsuan, associate professor of health policy and administration at Penn State. However, not all patients may receive the recommended treatment.
According to a new study, led by Hsuan, Hispanic and non-Hispanic Black patients in Florida who experienced a ST-elevation myocardial infarction (STEMI) — a severe type of heart attack where a major coronary artery is completely blocked — were less likely to receive the recommended treatment of percutaneous coronary intervention (PCI) compared to non-Hispanic white patients.
The study was recently published in JAMA Network Open.
“I’ve always been interested in emergency care quality and how that quality can differ between patients based on their insurance status and demographics,” Hsuan said. “There is a lot of research about these differences, making it difficult for policymakers to pinpoint where they should pay attention. By focusing on one specific condition, we can begin to understand where their focus should be to combat the disparities in treatment received by patients.”
Approximately one-fourth of acute myocardial infarctions are STEMIs. Improved methods to treat STEMI patients include thrombolytic therapy — using medication to dissolve blood clots — and PCI — a minimally invasive medical procedure that improves blood flow to the heart by widening narrow or blocked arteries.
According to previous research, PCI reduces the mortality in STEMI patients by approximately 30%. Clinical guidelines recommend PCI for STEMI patients within 90 minutes if they arrive at a hospital with the ability to administer PCI and within 120 minutes if a hospital transfer is needed.
In the current study, to better understand how well hospitals follow the guidelines and the potential care pathways available to patients, the research team analyzed a sample of 139,629 patients in the state of Florida who were diagnosed with STEMI between 2011 and 2021. First, they mapped out whether a patient initially came to a hospital that had PCI capability and if the patient received PCI. If not, the researchers examined whether the patient was transferred to a different hospital and whether they received PCI at the new hospital.
They found significant racial disparities across all steps of the emergency care process, according to Hsuan.
Among patients in the sample, 82.6% of non-Hispanic white patients initially came to a PCI-capable hospital to receive care. In contrast, non-Hispanic Black patients were less likely than white patients to come to a PCI-capable hospital.
Of the Black patients who did initially come to a PCI-capable hospital, they were 10.7% less likely to receive a PCI compared to white patients. Of the patients who initially came to a non-PCI capable hospital, Black patients were 5.3% less likely than white patients to be transferred to another hospital. Of those who were transferred, Black patients were 20.3% less likely to receive a PCI at the transfer hospital.
Hispanic patients experienced disparities at some steps in the care process, but not all. Hispanic patients were 3.8% less likely than white patients to initially come to a PCI-capable hospital to receive care. Hispanic patients who initially came to a non-PCI capable hospital were 5.6% less likely to be transferred to another hospital.
“These are extremely large differences,” Hsuan said. “They all added up to explain why previous studies found a higher mortality rate in STEMI patients who are Hispanic and non-Hispanic Black compared to patients who are white.”
According to Hsuan, the study highlights areas where policymakers — both state and federal lawmakers, along with hospital administrators — could potentially focus their attention, such as whether a STEMI patient received a PCI when they initially arrived at a PCI-capable hospital and, if transferred, whether the patients received a PCI at the transfer hospital.
Because all data were collected in Florida, the findings of this study cannot necessarily be generalized more broadly across the United States. However, Florida is the third most populous state in the nation, making this an issue that likely affects millions of Americans, according to Hsuan. More research is needed to determine the drivers of these disparities, which Hsuan theorized could be any number of factors including insurance differences, hospital availability or geographic location.
This study is part of a larger line of research for Hsuan, examining the process and quality of transfer care nationwide.
“While this study focused on racial and ethnic disparities, it has large implications for everyone’s quality of care,” Hsuan said. “Differences by demographics highlight that emergency care can be improved for everyone. The key takeaway is that people are not receiving the care recommended by physicians and medical associations, and this study was a big step in identifying the why so we can begin closing the gap and ensure all patients receive appropriate treatment.”
Other Penn State authors on the paper include David J. Vanness, professor of health policy and administration; Haoyu Bi, doctoral candidate in the Department of Health Policy and Administration at Penn State; and Jeannette Rogowski, professor of health policy and administration.
Other authors include Michelle P. Lin, associate professor of emergency medicine at Stanford University; Alexis Zebrowski, executive director of data strategy at Mount Sinai Health System; Renee Y. Hsia, professor and associate chair of health services research at the University of California San Francisco; Brendan G. Carr, Chief Executive Officer of Mount Sinai Health System; Eric Wei, CEO of NYC Health + Hospitals/Bellevue and professor of emergency medicine at the Mount Sinai Icahn School of Medicine; and David G. Buckler, director of Emergency Medicine Data and Analytics at the Mount Sinai Icahn School of Medicine.
The National Institute on Minority Health and Health Disparities, National Center for Advancing Translational Sciences, National Institutes of Health, the Social Science Research Institute and the College of Health and Human Development at Penn State supported this work.