Department of Emergency Medicine, University of California, San Francisco.
Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco.
JAMA Netw Open. 2020 Nov 2;3(11):e2025874. doi: 10.1001/jamanetworkopen.2020.25874.
Cardiac care regionalization, specifically for patients with ST-segment elevation myocardial infarction (STEMI), has been touted as a potential mechanism to reduce systematic disparities by protocolizing the treatment of these conditions. However, it is unknown whether such regionalization arrangements have widened or narrowed disparities in access, treatment, and outcomes for minority communities.
To determine the extent to which disparities in access, treatment, and outcomes have changed for patients with STEMI living in zip codes that are in the top tertile of the Black or Hispanic population compared with patients in nonminority zip codes in regionalized vs nonregionalized counties.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a quasi-experimental approach exploiting the different timing of regionalization across California. Nonpublic inpatient data for all patients with STEMI from January 1, 2006, to October 31, 2015, were analyzed using a difference-in-difference-in-differences estimation approach.
Exposure to the intervention was defined as on and after the year a patient's county was exposed to regionalization.
Access to percutaneous coronary intervention (PCI)-capable hospital, receipt of PCI on the same day and at any time during the hospitalization, and time-specific all-cause mortality.
This study included 139 494 patients with STEMI; 61.9% of patients were non-Hispanic White, 5.6% Black, 17.8% Hispanic, and 9.0% Asian; 32.8% were women. Access to PCI-capable hospitals improved by 6.3 percentage points (95% CI, 5.5 to 7.1 percentage points; P < .001) when patients in nonminority communities were exposed to regionalization. Patients in minority communities experienced a 1.8-percentage point smaller improvement in access (95% CI, -2.8 to -0.8 percentage points; P < .001), or 28.9% smaller, compared with those in nonminority communities when both were exposed to regionalization. Regionalization was associated with an improvement to same-day PCI and in-hospital PCI by 5.1 percentage points (95% CI, 4.2 to 6.1 percentage points; P < .001) and 5.0 percentage points (95% CI, 4.2 to 5.9 percentage points; P < .001), respectively, for patients in nonminority communities. Patients in minority communities experienced only 33.3% and 15.1% of that benefit. Only White patients in nonminority communities experienced mortality improvement from regionalization.
Although regionalization was associated with improved access to PCI hospitals and receipt of PCI treatment, patients in minority communities derived significantly smaller improvement relative to those in nonminority communities.
心脏护理区域化，特别是针对 ST 段抬高型心肌梗死（STEMI）患者，被吹捧为通过制定这些疾病的治疗方案来减少系统性差异的潜在机制。然而，尚不清楚这种区域化安排是否扩大或缩小了少数族裔社区在获得、治疗和结果方面的差异。
确定在接受 STEMI 治疗的患者中，与非少数族裔邮政编码相比，居住在邮政编码中黑人和西班牙裔人口排名前三分之一的邮政编码的患者在获得、治疗和结果方面的差异在区域化与非区域化县之间发生了多大程度的变化。
设计、地点和参与者：本队列研究采用准实验方法，利用加利福尼亚州不同时间的区域化来利用不同的时间。使用差分差分差异估计方法，分析了 2006 年 1 月 1 日至 2015 年 10 月 31 日期间所有 STEMI 患者的非公开住院数据。
暴露于干预措施的定义为患者所在县接受区域化治疗的那一年及以后。
能够进行经皮冠状动脉介入治疗（PCI）的医院的获得、当天和住院期间任何时间接受 PCI 的情况以及特定时间的全因死亡率。
这项研究包括了 139494 例 STEMI 患者；61.9%的患者是非西班牙裔白人，5.6%是黑人，17.8%是西班牙裔，9.0%是亚洲人；32.8%是女性。当非少数族裔社区的患者接受区域化治疗时，能够获得 PCI 能力的医院的机会增加了 6.3 个百分点（95%CI，5.5 至 7.1 个百分点；P<.001）。少数族裔社区的患者获得机会的改善幅度小了 1.8 个百分点（95%CI，-2.8 至-0.8 个百分点；P<.001），与接受区域化治疗的非少数族裔社区相比，改善幅度较小，仅为 28.9%。区域化治疗与当天进行 PCI 和住院期间进行 PCI 分别改善了 5.1 个百分点（95%CI，4.2 至 6.1 个百分点；P<.001）和 5.0 个百分点（95%CI，4.2 至 5.9 个百分点；P<.001），非少数族裔社区的患者。少数族裔社区的患者仅受益了 33.3%和 15.1%。只有非少数族裔社区的白人患者受益于死亡率的下降。
尽管区域化与获得 PCI 医院的机会增加和接受 PCI 治疗有关，但少数族裔社区的患者的改善幅度明显低于非少数族裔社区的患者。
