Gender Disparities in STEMI Care and Outcomes
Would implementation of a systems-based comprehensive ST-segment elevation myocardial infarction (STEMI) protocol improve sex-based disparities in care and outcomes?
Starting in 7/15/2014, the Cleveland Clinic implemented a four-step STEMI protocol that included: 1) emergency department activation of the catheterization laboratory, 2) administration of guideline-directed medical therapy (GDMT) using a STEMI Safe Handoff checklist, 3) immediate transfer to an immediately available catheterization laboratory, and 4) radial first approach for percutaneous coronary intervention (PCI). Men and women with STEMI treated before the new protocol (1/1/2011–7/15/2014) were compared to those treated after (7/15/2014–12/31/2016), and outcomes included GDMT, door-to-balloon time, in-hospital adverse events, and 30-day mortality.
In the total cohort of 1,271 patients, 32% were women. In the 723 patients treated prior to the new protocol, women received less GDMT, had longer door-to-balloon time, and more in-hospital adverse events. After the protocol was implemented, there were no significant differences between men and women in terms of GDMT, door-to-balloon time, and in-hospital adverse events. Prior to the new protocol, women had 6.1% higher 30-day mortality than men (p = 0.002). After the new protocol, women had 3.2% higher 30-day mortality than men (p = 0.09).
The authors concluded that the systems-based approach to STEMI care could improve overall STEMI care and reduce disparities in women.
This study suggests that a systems-based approach to STEMI care can improve management and clinical outcomes for men and women; furthermore, these changes have the potential to reduce or eliminate gender disparities in care. It has previously been shown that women tend to have longer door-to-balloon time, receive less GDMT than men, and have higher complications and worse outcomes. The fundamental question is: Why do these sex-based disparities exist? While the complete answer is likely multi-faceted, the results of this study suggest that creating and following clearly defined systems-based care plans and checklists for all patients with a given diagnosis, can lead to improvements in care for women with STEMI. Whether systems-based protocols and checklists for other disease processes would lead to similar elimination of disparities is unknown, but seems promising.
Keywords: ACC18, ACC Annual Scientific Session, Acute Coronary Syndrome, Anterior Wall Myocardial Infarction, Catheterization, Checklist, Emergency Service, Hospital, Myocardial Infarction, Outcome Assessment (Health Care), Percutaneous Coronary Intervention, Sex Characteristics
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