Hospitals That Set STEMI Standards Can Better Serve Black Patients

Hospitals that apply a comprehensive protocol when providing STEMI care stand to improve key process metrics for patients irrespective of their race, data from the Cleveland Clinic suggest.

In the years after the Cleveland Clinic adopted its own protocol in July 2014, both Black and white patients saw gains in the use of guideline-directed medical therapy (GDMT), shorter door-to-balloon (D2B) times, lower fluoroscopy doses, and smaller contrast volumes.

“We wanted to standardize the steps that we do in the care of each STEMI patient and also distribute a little bit of shared responsibility across the board,” said lead author Raunak M. Nair, MD (Cleveland Clinic, OH). This latest report, published recently as a research letter in the Journal of the American Heart Association, follows others showing that the protocol offers improvements for both men and women, is sustainable, and isn’t dependent on socioeconomic status.

“Unfortunately, Black Americans continue to experience disproportionately higher rates of mortality and poor outcomes after STEMI, or after an acute myocardial infarction,” Nair told TCTMD. The differences in care are stark, he said. “There are several studies which have shown that they have much higher [emergency department] wait times, lower rates of intervention, and are often disproportionately deviated to hospitals with less resources, less availability of open heart surgery, all of which account for their poor outcomes.”

We need to be thinking about employing standardized measures that bring about equitable improvements to everyone. Raunak M. Nair

Yet thus far there have been no quality-improvement efforts targeted specifically at addressing these racial imbalances in the STEMI setting, said Nair. And a 2020 paper published in JAMA Network Open showed that broader initiatives to up quality and access, like regionalized STEMI networks coordinated among many hospitals, don’t necessarily overcome race/ethnicity-based disparities.

By contrast, in the Cleveland Clinic experience, “we had control of every single factor from the moment the patient entered to the moment the patient was discharged, so we were completely able to drive the care in the way that we wanted, and I think that probably accounts for the benefits we were able to see,” Nair explained.

The Cleveland Clinic’s comprehensive STEMI protocol consists of four elements:

• Emergency department activation of the cath lab without delay for a cardiology consult
• Use of a STEMI Safe Handoff Checklist to standardize triage and management, including GDMT
• Immediate transfer of patients to an available cath lab
• Emphasis on a “radial-first” approach to PCI

Nair and colleagues compared STEMI patients treated from January 2011 up to when the comprehensive protocol started and those treated after the protocol’s initiation up to mid-July 2019. Of the 687 patients in the first group, 30.2% were Black, and of the 1,064 in the second group, 25.4% were Black; other racial/ethnic groups were < 1% of the patient population and were excluded from this analysis. Baseline characteristics were mostly similar in Black and white patients, apart from Black patients being more likely to have had a prior MI and prior PCI.

With adoption of the STEMI protocol, there were numerous improvements, with no significant interaction by race.

Process Metrics Before vs After Adoption of Comprehensive STEMI Protocol

With the protocol in place, only one of the process metrics differed between Black and white patients: D2B. The reason likely relates to the fact that “our hospital is located closer to several Black American communities, and so they present directly to the emergency department,” whereas the white patients were more likely to be transferred, the researchers explain.

“Since Black Americans are often subjected to implicit bias in healthcare, adopting a comprehensive STEMI protocol would help in eliminating structural racism. Hospital systems that cater to a large proportion of Black Americans should be at the forefront of establishing such standards of care as this could be pivotal in improving the outcomes of this high-risk group,” they suggest.

Nair stressed the importance of agencies that issue clinical practice guidelines on a national level, noting they could direct hospitals to develop protocols. Individual clinicians, for their part, could bring up the possibility of a protocol at their own institution and encourage hospital administrators to bring about change. Importantly, the elements comprising the STEMI protocol don’t involve added cost, said Nair, so they are accessible for low-resource hospitals.

Given the expected rise in heart disease in the coming decades, “it’s encouraging for us to see that there are aspects of STEMI care that we could [address] that could improve the care for all patients,” said Nair, adding, “We need to be thinking about employing standardized measures that bring about equitable improvements to everyone.”