To Close Equity Gaps With New PCI-Capable Hospitals, Location Matters

Opening new PCI-capable hospitals may help close racial gaps when it comes to access and outcomes following acute MI, with Black patients particularly likely to see benefits if the facilities are situated in communities that are largely Black or integrated, new research suggests.

By analyzing Medicare data, investigators saw improvements in terms of access to same-day PCI and reductions in mortality for Black patients with acute MI after the opening of a PCI-capable facility in a Black or integrated neighborhood. Access to same-day revascularization improved for white patients after a PCI-eligible facility opened in white or integrated neighborhoods, but the improvement was less pronounced.

The results, say researchers, suggest that “improving resource allocation and supporting the opening of PCI-capable hospitals in Black and integrated communities” can help eliminate some of the structural barriers when it comes to the delivery of cardiovascular care.

“Basically, not all PCI openings are the same,” lead investigator Renee Y. Hsia, MD (University of California, San Francisco), told TCTMD. “Depending on where they open, you can get more bang for your buck.” She added that research around structural barriers to care has often focused on whether the patient was able to access the necessary services, but researchers are learning it’s really about where these services are placed.

“I'd say that while the introduction of new PCI-capable facilities is often associated with improved access to care and better patient outcomes, these benefits are differentially distributed by patient race and community segregation,” said Hsia.

Published last week as a research letter in JAMA Network Open, the study is part of an attempt to understand if the built environment narrows or widens health disparities between different racial and ethnic groups. Multiple studies have shown that Black patients with ACS are less likely than non-Hispanic white patients to receive appropriate medical therapy, such as aspirin, other antiplatelet drugs, beta-blockers, or statins, and are less likely to undergo PCI. Mortality rates are also higher for Black patients who have ACS compared with white patients. 

Better PCI Access and Survival

For the analysis, Hsia and coinvestigator Yu-Chu Shen, PhD (Naval Postgraduate School, Monterey, CA), analyzed Medicare fee-for-service patients with acute MI between 2006 and 2017 and geocoded the opening of a PCI-capable facility within a 15-minute drive of a community. The neighborhoods were classified as racially integrated or segregated using the dissimilarity index, which is a measure of how the two groups are distributed within a community (scored from 0 to 1, where the maximum value of 1 reflects complete segregation).

Of the 2,388,180 patients with acute MI, 27.7% and 63.4% occurred in white patients living in segregated and integrated communities, respectively. In contrast, 4.4% of the acute MIs occurred in Black patients living in segregated neighborhoods, with the same proportion in integrated neighborhoods.

After a PCI-capable hospital opened nearby, white patients living in a segregated community had a slight improvement in the risk-adjusted probability of receiving PCI on the day of admission (0.98% absolute increase) when compared with similar patients in a similar neighborhood that saw no change in PCI facilities.

In contrast, Black patients living in a racially integrated community had a 3.92% absolute increase in the risk-adjusted probability of same-day revascularization after a PCI-capable facility opened nearby. Black patients living in a segregated community also saw an increase in the probability of undergoing same-day PCI after the opening of the PCI facility, but the absolute increase was smaller (2.02% increase versus Black patients in a segregated neighborhood with no change in PCI capacity).

All groups were more likely to receive PCI during hospitalization for acute MI, but the largest increase in the risk-adjusted probability was seen in white and Black patients living in integrated communities where a PCI-capable facility opened (5.28% and 6.62% absolute increase compared with similar patients/neighborhoods without a change in PCI capacity). For white and Black patients in segregated communities, the probability of receiving PCI during hospitalization increased 2.20% and 3.60%, respectively.

Depending on where they open, you can get more bang for your buck. Renee Y. Hsia

Importantly, 30-day and 1-year mortality declined for Black patients living in segregated and integrated communities after the opening of PCI-capable facility (0.69% and 1.30% decrease at 30 days, respectively, and 1.37% and 1.86% decrease at 1 year, respectively). When compared with white patients with acute MI living in a segregated community, a group that served as the reference group, these mortality reductions were statistically significant.

“We found that Black patients in integrated communities demonstrated the greatest benefits across all four outcomes examined,” said Hsia. “In contrast, white patients in segregated communities experienced smaller benefits in timely access to PCI and no significant benefits in mortality after a PCI facility opening.”

To TCTMD, Hsia said she was surprised by the magnitude of the differences seen with the openings. The hope, she added, is that these new data will be used by “policymakers and healthcare stakeholders to recognize the importance and magnitude of distributing specialized cardiac services to communities that will ultimately procure the greatest benefits.”