The Paradox of STEMI Regionalization: Widened Disparities Despite Some Benefits

Disparities in health care and health outcomes are largely the consequences of historical and contemporary structural inequities, which act in complex, mutually reinforcing ways upon communities and individuals. The implementation of clinical protocols holds potential to standardize medical care and treatment for all. However, the true impact of such policy changes can be known only through ongoing assessment. In this issue of JAMA Network Open, Hsia et al1 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.1 The investigators employed a quasi-experimental, population-based approach using observational study data to measure the differential outcomes associated with regionalization among different communities and included 139 494 patients with STEMI from 2006 to 2015. Importantly, data were included from local emergency medical service (EMS), zip code–level population statistics from the 2010 US Census, and hospital facility records.1 There might be a limit to the improvements in access to PCI as their analysis determined that regionalization was associated with slightly improved access to PCI-capable hospitals regardless of race. However, 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.1 Initiatives that might potentially advance health equity by narrowing health disparities often contend with labyrinthine structural barriers. A 4-tiered measurement framework has been proposed to help to set standards and benchmarks for realizing health equity.2 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).2 Applying this framework to health equity interventions is intended to identify priorities and achieve greater impact. We will apply it here to explore the disparate benefits of STEMI regionalization and the possible structural, institutional, and interpersonal causes for the observed disparities. In the framework, Level 1 measures access.2 The work of Hsia et al1 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 + Related article