Impact of STEMI Diagnosis and Catheterization Laboratory Activation Systems on Sex- and Age-Based Differences in
Christine Pacheco1,2, Laurie-Anne Boivin-Proulx2,3, Alexandra Bastiany4
1Hôpital Pierre-Boucher, Université de Montréal, Montréal, Québec, Canada.
Insights
Automated STEMI activation systems reduced treatment delays for women and the elderly. This approach may help address systemic biases in ST-elevation myocardial infarction care.
Area of Science:
- Cardiology
- Health Services Research
- Health Equity
Background:
- ST-elevation myocardial infarction (STEMI) patients, particularly women and the elderly, face significant treatment delays.
- Existing prehospital STEMI diagnosis and activation systems may not fully mitigate these disparities.
Purpose of the Study:
- To investigate sex- and age-based differences in STEMI treatment delay (TD) across various STEMI activation systems.
- To identify the role of different activation systems in mediating care gaps for vulnerable STEMI populations.
Main Methods:
- Retrospective comparative effectiveness study of 3 STEMI activation cohorts: traditional hospital-based, automated "physician-blind" prehospital, and prehospital with real-time physician oversight.
- Analysis of first medical contact-to-device (FMC-to-device) times, focusing on delays (>90 minutes) in women and patients aged 75 years or older.
- Assessment of independent predictors for suboptimal FMC-to-device times and in-hospital mortality.
Main Results:
- Traditional and physician-oversight systems showed significant delays in women and elderly STEMI patients.
- The automated "physician-blind" system demonstrated no significant age-based delay and a numerically lower, though still significant, delay for women.
- Female sex, off-hours presentation, and physician oversight independently predicted longer FMC-to-device times in prehospital cohorts.
- Advanced age, Killip class, and female sex were independently associated with in-hospital mortality.
Conclusions:
- Automated "physician-blind" STEMI activation systems appear to reduce treatment delays in women and the elderly, suggesting potential systemic bias in other systems.
- Implementing automated diagnosis and catheterization laboratory activation may offer a viable solution to improve STEMI care equity.
- Further large-scale studies are needed to confirm these findings and guide clinical practice.
Background:
Women and the elderly with ST-elevation myocardial infarction (STEMI) experience longer treatment delays despite prehospital STEMI diagnosis and catheterization laboratory activation systems. It is not known what role specific STEMI referral systems might play in mediating this gap in care. We therefore examined sex- and age-based differences in STEMI treatment delay (TD) in different STEMI activation systems.
Methods:
This observational comparative effectiveness study comprised 3 retrospective STEMI cohorts: a traditional hospital-based activation cohort (Cohort 1), an automated "physician-blind" prehospital activation cohort (Cohort 2), and a prehospital activation with real-time physician oversight cohort (Cohort 3). Outcomes of interest included sex and age group (< or ≥ 75 years) differences in suboptimal (> 90 minutes) first medical contact-to-device time (FMC-to-device) within each cohort, as well as independent predictors of suboptimal FMC-to-device and in-hospital mortality across cohorts.
Results:
Five hundred-sixty STEMI activations were analyzed. In Cohort 1 (n = 179), women and those ≥ 75 were more likely to experience suboptimal FMC-to-device times (78.7% vs 36.4%, P = 0.02 and 85.0% vs 58.3%, < 0.01, respectively). Similar findings were observed in Cohort 3 (n = 109) (53.5% vs 32.9%, 56.5% vs 33.3%, respectively; P = 0.05, for both). In Cohort 2 (n = 272), however, there was no significant age-based difference (30.4% vs 21.7%, P = 0.18), and the gap was numerically lower but still significant for women (32.1% vs 20.1%, P = 0.04). When examining prehospital activation cohorts only, female sex (P = 0.03), off-hours presentation (P < 0.01), and physician oversight (P < 0.01) were independent predictors of longer FMC-to-device times. Age ≥ 75 (P < 0.01), Killip class (P < 0.01), and female sex (P = 0.04) were independently associated with in-hospital mortality.
Conclusions:
Automated "physician-blind" STEMI activation was associated with a reduced TD gap in women and the elderly, suggesting possible systemic bias. Appropriately powered confirmatory studies are required, but incorporating automated diagnosis and catheterization laboratory activation may be a solution to treatment gaps in STEMI care.
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