1998 Initiative to Reduce Health Disparities Improved PCI Usage

The reduction in disparities in percutaneous coronary intervention (PCI) usage among patients with ST-segment-elevation myocardial infarction (STEMI) observed over time may be due, in part, to a program launched in 1998, according to results of a study published in the Journal of the American Heart Association.

In 1998, a $400 million initiative to reduce health disparities through education and research was launched by President Clinton. One of these goals was to improve cardiovascular disease (CVD) outcomes in minority communities.

This study was designed to evaluate whether the program may have affected trends in PCI usage among Black and Hispanic populations. To that end, data from the Myocardial Infarction Data Acquisition System (MIDAS), which is a state-wide database from New Jersey, were assessed. Patients (N=124,334) with STEMI between 1994 and 2015 were evaluated for PCI receipt and mortality outcomes.

The patients were Black (n=7942; mean age, 62.1 years; 55.56% men), Hispanic (n=27,665; mean age, 64.7 years; 65.54% men), and White (n=88,727; mean age, 66.8 years; 63.36% men). Among Black patients, 9.75% had no insurance, 75.65% had hypertension, 39.23% had diabetes, and 30.22% had heart failure. Among Hispanic patients, 8.64% had no insurance, 60.89% had hypertension, 29.95% had diabetes, and 28.36% had heart failure. Among White patients, 4.45% had no insurance, 59.58% had hypertension, 25.4% had diabetes, and 29.23% had heart failure.

Overall, fewer Black (43.84%; P <.01) and Hispanic (44.36%; P <.01) patients received PCI compared with White patients (45.62%; P <.01).

Over time, the rates of PCI usage have been increasing, in which the disparities in usage have been gradually eliminated for Hispanic patients between 2000 and 2004 (P =.17) and have improved but remained lower among Black patients (P =.08) compared with White patients. By 2005 to 2009, the rates of PCI were higher among Hispanic patients compared with White patients (P =.02) and were similar between Black and White patients (P =.29). In 2010 to 2015, no differences were observed between the White and Hispanic (P =.05) or Black (P =.12) patients, but Hispanic patients were more likely to receive PCI than Black patients (P =.02).

There were overall downward trends for in-hospital mortality, all-cause 1-year mortality, and CVD-specific 1-year mortality rates.

In no time period did in-hospital mortality rates differ significantly between any groups. However, 1-year all-cause mortality was higher among Hispanic (odds ratio [OR], 0.88; P <.01) and Black (OR, 1.26; P <.01) patients in 1994 to 1999 compared with White patients and by 2010 to 2015, neither Hispanic (P =.26) nor Black (P =.16) patients were at higher mortality risk than White patients. Similar trends in 1-year CVD-specific mortality were observed.

This study may have been limited by not having access to data about medications, angiography, or risk factors.

“The federal initiative to eliminate racial and ethnic disparities launched in 1998 was associated with a reduction in disparity in access to PCI revascularization in patients with STEMI,” the study authors wrote. “This study provides an understanding of the effectiveness of our current efforts to combat health disparities and may give future directions to federal legislation.”