HomeJournal of the American Heart AssociationAhead of PrintImpact of a Comprehensive ST‐Segment–Elevation Myocardial Infarction Protocol on Key Process Metrics in Black Americans Open AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessLetterPDF/EPUBImpact of a Comprehensive ST‐Segment–Elevation Myocardial Infarction Protocol on Key Process Metrics in Black Americans Raunak M. Nair, Anirudh Kumar, Chetan P. Huded, Kathleen Kravitz, Grant W. Reed, Amar Krishnaswamy, Venu Menon, A. Michael Lincoff, Samir R. Kapadia and Umesh N. Khot Raunak M. NairRaunak M. Nair https://orcid.org/0000-0002-8939-141X , Cleveland Clinic Heart, , Vascular and Thoracic Institute, , Cleveland, , OH, , USA, , Cleveland Clinic Heart, , Vascular and Thoracic Institute Center for Healthcare Delivery Innovation, , Cleveland, , OH, , USA, Search for more papers by this author , Anirudh KumarAnirudh Kumar https://orcid.org/0000-0002-4413-5439 , Cleveland Clinic Heart, , Vascular and Thoracic Institute, , Cleveland, , OH, , USA, , Cleveland Clinic Heart, , Vascular and Thoracic Institute Center for Healthcare Delivery Innovation, , Cleveland, , OH, , USA, Search for more papers by this author , Chetan P. HudedChetan P. Huded , Saint Luke’s Mid America Heart Institute, , Kansas City, , MO, , USA, Search for more papers by this author , Kathleen KravitzKathleen Kravitz , Cleveland Clinic Heart, , Vascular and Thoracic Institute, , Cleveland, , OH, , USA, Search for more papers by this author , Grant W. ReedGrant W. Reed , Cleveland Clinic Heart, , Vascular and Thoracic Institute, , Cleveland, , OH, , USA, , Cleveland Clinic Heart, , Vascular and Thoracic Institute Center for Healthcare Delivery Innovation, , Cleveland, , OH, , USA, Search for more papers by this author , Amar KrishnaswamyAmar Krishnaswamy , Cleveland Clinic Heart, , Vascular and Thoracic Institute, , Cleveland, , OH, , USA, Search for more papers by this author , Venu MenonVenu Menon , Cleveland Clinic Heart, , Vascular and Thoracic Institute, , Cleveland, , OH, , USA, Search for more papers by this author , A. Michael LincoffA. Michael Lincoff , Cleveland Clinic Heart, , Vascular and Thoracic Institute, , Cleveland, , OH, , USA, Search for more papers by this author , Samir R. KapadiaSamir R. Kapadia , Cleveland Clinic Heart, , Vascular and Thoracic Institute, , Cleveland, , OH, , USA, Search for more papers by this author and Umesh N. KhotUmesh N. Khot *Correspondence to: Umesh N. Khot, MD, Heart, Vascular and Thoracic Institute Center for Healthcare Delivery Innovation, Cleveland Clinic, 9500 Euclid Ave/J2‐4, Cleveland, OH 44195. Email: E-mail Address: [email protected] https://orcid.org/0000-0001-6121-1280 , Cleveland Clinic Heart, , Vascular and Thoracic Institute, , Cleveland, , OH, , USA, , Cleveland Clinic Heart, , Vascular and Thoracic Institute Center for Healthcare Delivery Innovation, , Cleveland, , OH, , USA, Search for more papers by this author Originally published17 Apr 2023https://doi.org/10.1161/JAHA.122.028519Journal of the American Heart Association. 2023;0:e028519Black Americans continue to receive suboptimal care following an ST‐segment–elevation myocardial infarction (STEMI) compared with other racial groups.1 In addition to delays in transfer, lower rates of revascularization, and longer door‐to‐balloon times, such differences in care delivery contribute to the poor outcomes noted in this population.2, 3 However, despite well‐recognized disparities in the care received by Black Americans with STEMI, there have been no prior quality improvement efforts that have been successful at addressing this issue. Our study aimed to assess whether a comprehensive STEMI protocol (CSP) could improve key process metrics in Black Americans with STEMI and if these improvements were equitable to White Americans.Because of the patient‐specific nature of our data, we will not be able to share it with individuals outside of this research project. We performed a retrospective, registry‐based study of consecutive patients with STEMI treated with percutaneous coronary intervention (PCI) at the Cleveland Clinic main campus from January 1, 2011 to July 15, 2019. On July 15,2014, we implemented a CSP intending to minimize STEMI care variability by (1) emergency department catheterization laboratory activation; (2) use of an STEMI Safe Handoff Checklist, (3) immediate transfer to an immediately available catheterization laboratory; and (4) radial first approach to PCI.4 Patients treated from January 1, 2011 to July 14, 2014 were defined as the pre‐CSP group and those treated from July 15, 2014 to July 15, 2019 as the post‐CSP group. Race was collected from electronic medical records and reflects self‐identification. Differences in key process metrics (guideline‐directed medical therapy administration, radial access use, door‐to‐balloon time, contrast dose, and fluoroscopy dose) were assessed for all Black Americans admitted to our hospital with STEMI during the pre‐ and post‐CSP periods. Pre‐ and post‐CSP process metrics were also compared between Black Americans and White Americans to assess for differences in improvements. Other racial groups contributed to <1% of the total cohort and were excluded. Multivariable logistic and linear regression models were created to understand the impact of the interactive effect between race and CSP on each of the key process metrics. The study protocol was approved by the Cleveland Clinic Foundation Institutional Review Board; the need for informed consent was waived.There were 208 Black Americans in the pre‐CSP group and 271 in the post‐CSP group. Comorbidities were generally well balanced between the 2 groups except for a lower rate of prior myocardial infarction in the post‐CSP group (Table). After implementation of the CSP, guideline‐directed medical therapy increased (71.6% pre‐CSP to 81.9% post‐CSP, P=0.01), radial PCI use increased (14.4%–73.8%, P<0.001), median door‐to‐balloon time decreased (90 [Q1 64, Q3 120] minutes to 70 [45, 95] minutes, P<0.001), median fluoroscopy dose decreased (1610 [980, 2592] mGy to 1147 [742, 1844] mGy, P<0.001), and median contrast dose decreased (180 [140, 240] mL to 145 [110, 180] mL, P<0.001). Multivariable regression models created for each key process metric showed no significant interaction between race and CSP for any of the key process metric (P>0.05 for all) indicating that race did not significantly impact the benefits gained with CSP.Table . Comparison of Baseline Characteristics and Key Process Metrics Among Black American and White American Patients During the Pre‐ and Post‐CSP Time PeriodsComparison of baseline characteristics among BA and WA patients before and after CSP time periodsVariableBlack AmericansWhite AmericansPre‐CSP (n=208)Post‐CSP (n=271)P valuePre‐CSP (n=479)Post‐CSP (n=793)P valueAge, y, mean (SD)58.7 (12.27)60.4 (13.12)0.1662.77 (12.49)62.67 (12.18)0.89BMI, kg/m2 mean (SD)30.0 (7.39)30.5 (7.70)0.4928.83 (5.42)30.56 (9.93)<0.001Men, n (%)128 (61.5)168 (62)0.99338 (70.6)543 (68.5)0.47Hypertension, n (%)173 (83.2)222 (81.9)0.81334 (70.0)583 (73.5)0.20Dyslipidemia, n (%)151 (73.3)193 (74.2)0.90360 (75.5)561 (73.0)0.36Diabetes, n (%)79 (38)108 (39.9)0.75126 (26.3)229 (28.9)0.35COPD, n (%)22 (10.6)39 (14.4)0.2658 (12.1)102 (12.9)0.76Smoker, n (%)114 (54.8)165 (60.9)0.21207 (43.2)379 (47.9)0.12Chronic kidney disease, n (%)44 (23)48 (21.7)0.84108 (25.2)188 (25.9)0.85Prior myocardial infarction, n (%)93 (44.7)81 (29.9)0.001153 (31.9)153 (19.3)<0.001Prior PCI, n (%)50 (24)72 (26.6)0.6086 (18.0)182 (23.0)0.04Prior CABG, n (%)5 (2.4)11 (4.1)0.4631 (6.5)39 (4.9)0.29Presentation*0.050.66ED, n (%)94 (44.5)144 (53.1)74 (15.4)108 (13.6)Transfer, n (%)106 (51)109 (40.2)369 (77)625 (78.8)In‐hospital, n (%)9 (4.3)18 (6.6)36 (7.5)60 (7.6)Comparison of key process metrics among BA and WA patients before and after CSP time periodsVariableBlack AmericansWhite AmericansAdjusted P values for interaction†Pre‐CSP (n=208)Post‐CSP (n=271)P valuePre‐CSP (n=479)Post‐CSP (n=793)P valueGDMT, n (%)149 (71.6)221 (81.9)0.01368 (76.8)705 (88.9)<0.0010.34Radial use, n (%)30 (14.4)200 (73.8)<0.00197 (20.3)604 (76)<0.0010.25Door‐to‐balloon time, min, median (IQR)90 (64–120)70 (45–95)<0.001111.00 (86–146)91.00 (72–111)<0.0010.35Fluoroscopy dose, mGy, median (IQR)1610 (980.25–2592.25)1147 (742–1844)<0.0011517.00 (1001–2394)1212.00 (721–1933)<0.0010.35Contrast, mL, median (SD)180.00 (140, 240)145.00 (110, 180)<0.001170.00 (140, 225)140.00 (101, 180)<0.0010.66BA indicates Black American; BMI, body mass index; CABG, coronary artery bypass grafting; COPD, chronic obstructive pulmonary disease; CSP, comprehensive ST‐segment–elevation myocardial infarction protocol; ED, emergency department; GDMT, guideline‐directed medical therapy; IQR, interquartile range; and WA, White American.*Door‐to‐balloon time notably lower in Black American group at baseline as our hospital is located closer to several Black American communities, and so they present directly to the emergency department (49.5% Black Americans presented to emergency department vs 14.9% for White Americans, P<0.01).†Regression models assessing each of the key process metrics were adjusted for age, sex, body mass index, prior myocardial infarction, prior percutaneous coronary intervention, race, comprehensive ST‐segment–elevation myocardial infarction protocol, and the interaction between race and comprehensive ST‐segment–elevation myocardial infarction protocol.To our knowledge, our study is the first to show that a comprehensive STEMI protocol can successfully and equitably improve the care of Black American patients. We show that implementing a CSP can be pivotal in cultivating an “ideal PCI environment” in the Black American population, which ensures timely guideline‐directed medical therapy use, radial access PCI, and reduces the cumulative effect of fluoroscopy and contrast in Black American patients with STEMI. Furthermore, upon comparing the process metrics between Black Americans and White Americans during the post‐CSP time period, we saw that the there was no significant difference in the key process metrics between the 2 races suggesting that the benefits gained were equitable. Our findings imply that developing a CSP can be effective in reducing care variability in the management of Black American patients with STEMI. This is in contrast to the study by Hsia et al in which regionalization of STEMI care led to further worsening of care disparities between races.5 Since Black Americans are often subjected to implicit bias in health care, adopting a CSP 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.The results of our study should be interpreted with the following limitations. Our findings were obtained from observations at a single STEMI referral center and thus require further validation at other health care institutions. Secondly, because of the observational nature of our study, the effect of unmeasured covariates cannot be excluded.Implementing a CSP improved key process metrics in STEMI care for Black American patients and lead to equitable improvements. Rapid identification of STEMI, development of standardized care protocols, and procedural optimization are important components of the CSP that served to reduce care variability. Widespread adoption of the CSP by health care systems serving Black Americans can optimize the immediate care of this life‐threatening disease.Sources of FundingNone.DisclosuresNone.Footnotes*Correspondence to: Umesh N. Khot, MD, Heart, Vascular and Thoracic Institute Center for Healthcare Delivery Innovation, Cleveland Clinic, 9500 Euclid Ave/J2‐4, Cleveland, OH 44195. Email: [email protected]orgThis manuscript was sent to Sula Mazimba, MD, MPH, associate editor, for review by expert referees, editorial decision, and final disposition.For Sources of Funding and Disclosures, see page 3.References1 Raparelli V, Benea D, Nunez Smith M, Behlouli H, Murphy TE, D' Onofrio G, Pilote L, Dreyer RP. Impact of race on the in‐hospital quality of care among young adults with acute myocardial infarction. J Am Heart Assoc. 2021; 10:e021408. doi: 10.1161/JAHA.121.021408LinkGoogle Scholar2 Cooke CR, Nallamothu B, Kahn JM, Birkmeyer JD, Iwashyna TJ. Race and timeliness of transfer for revascularization in patients with acute myocardial infarction. Med Care. 2011; 49:662–667. doi: 10.1097/MLR.0b013e31821d98b2CrossrefMedlineGoogle Scholar3 Graham G. Racial and ethnic differences in acute coronary syndrome and myocardial infarction within the United States: from demographics to outcomes: racial/ethnic differences in ACS and MI. Clin Cardiol. 2016; 39:299–306. doi: 10.1002/clc.22524CrossrefMedlineGoogle Scholar4 Huded CP, Johnson M, Kravitz K, Menon V, Mouin A, Gullett T, Hantz S, Ellis SG, Podolsky SR, Meldon SW, et al. 4‐step protocol for disparities in STEMI care and outcomes in women. J Am Coll Cardiol. 2018; 71:2122–2132. doi: 10.1016/j.jacc.2018.02.039CrossrefMedlineGoogle Scholar5 Hsia RY, Krumholz H, Shen YC. Evaluation of STEMI regionalization on access, treatment, and outcomes among adults living in nonminority and minority communities. JAMA Netw Open. 2020; 3:e2025874. doi: 10.1001/jamanetworkopen.2020.25874CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails Article InformationMetrics Copyright © 2023 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.122.028519PMID: 37066811 Manuscript receivedOctober 17, 2022Manuscript acceptedMarch 21, 2023Originally publishedApril 17, 2023 Keywordscomprehensive protocolST‐segment–elevation myocardial infarctionPDF download SubjectsDisparitiesQuality and Outcomes