Percutaneous Coronary Intervention–Capable Facility Openings and Acute Myocardial Infarction Outcomes by Patient Race and Community Segregation

This cohort study investigates differential changes in patient outcomes after percutaneous coronary intervention–capable facility openings by patient race and community segregation.


Introduction
Patients of racial and ethnic minority groups are less likely to be admitted for specialized cardiac care and receive specialized cardiac services compared with White patients. 1,2It is possible that these disparities are due to the built environment of where such services exist.We investigated differential changes in patient outcomes after percutaneous coronary intervention-capable facility (PCI-CF) openings by patient race and community segregation.

Methods
We studied Medicare Fee-for-Service patients with acute myocardial infarction (AMI) from January 1, 2006, to December 31, 2017, and geocoded PCI-CF openings within a 15-minute drive of a community.We divided our patient population into 4 groups based on individual race (Black vs White, administratively identified through the Medicare Master Beneficiary Summary File) and residential segregation (segregated vs integrated, using a dissimilarity index 3 ).This retrospective cohort study followed the STROBE reporting guideline and was approved by the National Bureau of Economic Research with no patient consent required because the study used deidentified data.
Statistical analysis was performed from September 1, 2022, to August 20, 2023.We used linear probability models with community fixed effects to determine changes in outcomes (whether the patient received PCI treatment [defined in the eTable in Supplement 1], time-specific mortality) when a community experienced a PCI-CF opening.Analysis was conducted using Stata, version 17. 4

Results
Of 2 388 180 patients with AMI studied from 2006 to 2017, 27.7% and 63.4% were White patients in segregated and integrated communities, respectively; 4.4% each were Black patients in segregated and integrated communities (Table ).For White patients in segregated communities (reference group), the risk-adjusted probability of receiving PCI on day of admission improved by 0.98 (95% CI, 0.19-1.77)percentage points, a 2.1% relative increase, after a PCI-CF opening within a 15-minute drive, relative to that same community type with no PCI capacity change (Figure , A). Black patients in integrated communities showed a 3.92 (95% CI, 2.90-4.95)percentage point increase after a PCI-CF opening, the largest increase of all groups, equivalent to an 10.6% relative increase, which was statistically significantly different from the improvement experienced by the reference group.increase for Black patients in integrated communities and a 3.5% relative increase for White patients in segregated communities.
Black patients in integrated communities had a 1.30 (95% CI, -1.98 to -0.63) percentage point decrease, or 10.7% relative decrease in 30-day mortality (Figure , C), and a 1.86 (95% CI, -2.80 to -0.93) percentage point decrease, or 6.2% relative decrease, in 1-year mortality (Figure , D) after a PCI-CF opening, while White patients in segregated communities experienced no statistically significant benefits.

Discussion
Our study found differential benefits associated with a PCI-CF opening based on patient race and community segregation.Black patients in integrated communities demonstrated the greatest benefits across all outcomes, including a 5 times greater likelihood of receiving same-day PCI after a PCI-CF opening compared with White patients in segregated communities.Study limitations included the use of administrative data and PCI limited to the inpatient setting.
Similar patterns were observed in the probability of PCI during hospitalization (Figure, B).Patients in integrated communities had larger increases in their probability of PCI during a hospitalization (6.62 [95% CI, 5.40-7.84]percentage points and 5.28 [95% CI, 4.45-6.11]percentage points for Black and White patients, respectively) than those in segregated communities (3.60 [95% CI, 2.43-4.78]percentage points and 2.20 [95% CI, 1.29-3.11]percentage points for Black and White patients, respectively) after a PCI-CF opening.These changes are equivalent to a 12.3% relative+ Supplemental contentAuthor affiliations and article information are listed at the end of this article.Open Access.This is an open access article distributed under the terms of the CC-BY License.

Table . Descriptive
Statistics of Patient Characteristics Figure.Risk-Adjusted Percentage Point Changes in Outcomes After a Percutaneous Coronary Intervention (PCI)-Capable Facility Opening Within a 15-Minute Drive Range plots indicate 95% CIs of point estimates.NA indicates not applicable.
Aa Testing changes in outcomes that are statistically significantly different from White patients in segregated communities.