Racial Disparities in STEMI Care Process—Not All Roads Lead to Reperfusion

For patients presenting with acute coronary syndrome (ACS), evidence-based guidelines with the highest levels of recommendations outline care from initial assessment of suspected ACS to revascularization strategies to long-term follow-up and secondary prevention. 1 Prior work 2 has shown racial disparities in access to care, with fewer percutaneous coronary interventions (PCI) and higher mortality rates for Black and Hispanic patients compared with White patients presenting with ST-segment elevation myocardial infarction (STEMI).Disparities have the potential to be introduced at each step of the care process, from initial ACS assessment to long-term management after discharge.Addressing these racial disparities requires a nuanced understanding of when and how they emerge to support efforts to improve patient care for all.With this background, Hsuan et al 3 performed a cross-sectional study of adult patients presenting with a primary or discharge diagnosis of STEMI using merged statewide all-payer hospital discharge data from the Healthcare Cost and Utilization Project State Inpatient Database and State Emergency Department Database in Florida from 2011 to 2021.The study aimed to examine and quantify racial disparities from initial emergency department presentation to transfers for PCI.As such, the authors evaluated the association between race, defined as Hispanic, non-Hispanic Black, non-Hispanic White, and non-Hispanic other or missing, and 4 primary process outcomes: initial arrival at a PCI-capable hospital, receipt of PCI if initially at a PCI-capable hospital, interhospital transfer if initially at a non-PCI-capable hospital, and receipt of PCI following transfer.The study included 139 629 patients diagnosed with STEMI, of whom 9.09% were Black, 15.17% were Hispanic, 70.56% were White, and 5.17% were other race or were missing race.Most patients presented to a PCI-capable hospital, including 82.6% of White patients with STEMI.Black patients were 1.8 (95% CI, -2.6 to -1.1) percentage points [pp] less likely and Hispanic patients were 3.1 (-3.7 to -2.4) pp less likely to present at a PCI-capable hospital compared with White patients.Racial disparities in PCI receipt among those presenting to a PCI-capable hospital were observed with 80.5% of White patients with STEMI undergoing PCI, while Black patients were 8.6 (-9.5 to -7.7) pp less likely to undergo catheterization, with no difference for Hispanic patients.For patients presenting to a hospital not capable of PCI, 74.8% of White patients were transferred, with Black patients 4.0 (95% CI, -6.4 to -1.5) pp less likely and Hispanic patients 4.2 (95% CI, -6.3 to -2.0) pp less likely to be transferred.Among those transferred from a non-PCI-capable hospital, 65.4% of White patients received PCI, while Black patients were 13.3 (-16.6 to -9.9) pp less likely to receive an intervention.These findings highlight racial disparities across the entire STEMI care process, from initial presentation to transfer to capable hospitals to receiving PCI at those hospitals.By examining each step in the STEMI care pathway, the authors 3 expanded on previous work 2 showing limited PCI access for racial minority populations.By including all payers and focusing on STEMI care for which clear evidence-based guidelines exist, the authors identified time points for which there are opportunities to improve care processes.With all patients with STEMI included, the authors could quantify disparities and highlight when interventions could have the greatest population impact.The most significant racial disparity was in receiving PCI after transfer to a capable hospital.However, addressing this disparity would not yield the largest outcome improvements because few patients present to non-PCI-capable hospitals.Since more than 8 of 10 patients with STEMI initially present at PCI-capable hospitals, reducing disparities in PCI access at these hospitals would produce the greatest impact overall.