Relationship of Neighborhood Deprivation and Outcomes of a Comprehensive ST-Segment-Elevation Myocardial Infarction Protocol

Background We evaluated whether a comprehensive ST-segment-elevation myocardial infarction protocol (CSP) focusing on guideline-directed medical therapy, transradial percutaneous coronary intervention, and rapid door-to-balloon time improves process and outcome metrics in patients with moderate or high socioeconomic deprivation. Methods and Results A total of 1761 patients with ST-segment-elevation myocardial infarction treated with percutaneous coronary intervention at a single hospital before (January 1, 2011-July 14, 2014) and after (July 15, 2014- July 15, 2019) CSP implementation were included in an observational cohort study. Neighborhood deprivation was assessed by the Area Deprivation Index and was categorized as low (≤50th percentile; 29.0%), moderate (51st -90th percentile; 40.8%), and high (>90th percentile; 30.2%). The primary process outcome was door-to-balloon time. Achievement of guideline-recommend door-to-balloon time goals improved in all deprivation groups after CSP implementation (low, 67.8% before CSP versus 88.5% after CSP; moderate, 50.7% before CSP versus 77.6% after CSP; high, 65.5% before CSP versus 85.6% after CSP; all P<0.001). Median door-to-balloon time among emergency department/in-hospital patients was significantly noninferior in higher versus lower deprivation groups after CSP (noninferiority limit=5 minutes; P_{noninferiority} high versus moderate = 0.002, high versus low <0.001, moderate versus low = 0.02). In-hospital mortality, the primary clinical outcome, was significantly lower after CSP in patients with moderate/high deprivation in unadjusted (before CSP 7.0% versus after CSP 3.1%; odds ratio [OR], 0.42 [95% CI, 0.25-0.72]; P=0.002) and risk-adjusted (OR, 0.42 [95% CI, 0.23-0.77]; P=0.005) models. Conclusions A CSP was associated with improved ST-segment-elevation myocardial infarction care across all deprivation groups and reduced mortality in those from moderate or high deprivation neighborhoods. Standardized initiatives to reduce care variability may mitigate social determinants of health in time-sensitive conditions such as ST-segment-elevation myocardial infarction.