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4-Step Protocol for Disparities in STEMI Care and Outcomes in Women
Chetan P Huded1, Michael Johnson1, Kathleen Kravitz2
1Heart and Vascular Institute Center for Healthcare Delivery Innovation, Cleveland, Ohio; Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Insights
A new STEMI protocol improved care for women with ST-segment elevation myocardial infarction (STEMI), reducing disparities in treatment and outcomes compared to men. This systems-based approach enhanced STEMI care for women.
Area of Science:
- Cardiology
- Health Services Research
- Sex Differences in Medicine
Background:
- Women with ST-segment elevation myocardial infarction (STEMI) historically receive suboptimal care and experience worse outcomes than men.
- The impact of strategies aimed at reducing STEMI care variability on sex-based disparities remains largely unknown.
Purpose of the Study:
- To assess and compare the care and outcomes of men versus women experiencing STEMI.
- To evaluate the effectiveness of a comprehensive STEMI protocol in mitigating sex-based disparities in STEMI care and outcomes.
Main Methods:
- Implementation of a 4-step STEMI protocol including emergency department catheterization lab activation, STEMI Safe Handoff Checklist, immediate transfer to an available catheterization lab, and radial-first percutaneous coronary intervention (PCI).
- Prospective study of consecutive STEMI patients, comparing guideline-directed medical therapy (GDMT) adherence, door-to-balloon time (D2BT), in-hospital adverse events, and 30-day mortality stratified by sex before and after protocol implementation.
Main Results:
- Before the protocol, women had less GDMT and longer D2BT than men, with higher rates of in-hospital adverse events and 30-day mortality.
- Following the comprehensive STEMI protocol, sex disparities in GDMT, D2BT, and in-hospital adverse events were resolved.
- The absolute sex difference in 30-day mortality decreased significantly after protocol implementation, though it remained higher in women.
Conclusions:
- A systems-based approach to STEMI care effectively reduces sex disparities.
- The comprehensive 4-step STEMI protocol significantly improves the care and outcomes for women with STEMI.
Background:
Women with ST-segment elevation myocardial infarction (STEMI) receive suboptimal care and have worse outcomes than men. Whether strategies to reduce STEMI care variability impact disparities in the care and outcomes of women with STEMI is unknown.
Objectives:
The study assessed the care and outcomes of men versus women with STEMI before and after implementation of a comprehensive STEMI protocol.
Methods:
On July 15, 2014, the authors implemented: 1) emergency department catheterization lab activation; 2) STEMI Safe Handoff Checklist; 3) immediate transfer to an immediately available catheterization lab; and 4) radial first approach to percutaneous coronary intervention (PCI). The authors prospectively studied consecutive patients with STEMI and assessed guideline-directed medical therapy (GDMT) before PCI, median door-to-balloon time (D2BT), in-hospital adverse events, and 30-day mortality stratified by sex before (January 1, 2011 to July 14, 2014; control group) and after (July 15, 2014 to December 31, 2016) implementation of the STEMI protocol.
Results:
Of 1,272 participants (68% men, 32% women), women were older with more comorbidities than men. In the control group, women had less GDMT (77% vs. 69%; p = 0.019) and longer D2BT (median 104 min; [interquartile range (IQR): 79 to 133] min vs. 112 [IQR: 85 to 147] min; p = 0.023). Women had more in-hospital stroke, vascular complications, bleeding, transfusion, and death. In the comprehensive 4-step STEMI protocol, sex disparities in GDMT (84% vs. 80%; p = 0.32), D2BT (89 [IQR: 68 to 106] min vs. 91 [IQR: 68 to 114] min; p = 0.15), and in-hospital adverse events resolved. The absolute sex difference in 30-day mortality decreased from the control group (6.1% higher in women; p = 0.002) to the comprehensive 4-step STEMI protocol (3.2% higher in women; p = 0.090).
Conclusions:
A systems-based approach to STEMI care reduces sex disparities and improves STEMI care and outcomes in women.
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