此為英文文檔nber -Do PCI Facility Openings Differentially Affect AMI Patients by Individual Race and Community Segregation

NBERWORKINGPAPERSERIES

DOPCIFACILITYOPENINGSDIFFERENTIALLYAFFECTAMIPATIENTSBY

INDIVIDUALRACEANDCOMMUNITYSEGREGATION?

ReneeY.Hsia

Yu-ChuShen

WorkingPaper31626

/papers/w31626

NATIONALBUREAUOFECONOMICRESEARCH

1050MassachusettsAvenue

Cambridge,MA02138

August2023

WewouldliketothankNanditaSarkarforanalyticalsupportandMaddieFeldmeierforhereditorialassistance.ThisprojectwassupportedbythePilotProjectAwardfromtheNBERCenterforAgingandHealthResearch,fundedbytheNationalInstituteonAgingGrant(P30AG012810);theNationalInstituteonMinorityHealthandHealthDisparities(R01MD017482);andtheNationalHeart,Lung,andBloodInstitute(R01HL114822andR01HL134182).Thefundershadnoroleinthedesignandconductofthestudy;collection,management,analysis,andinterpretationofthedata;preparation,review,orapprovalofthemanuscript;ordecisiontosubmitthemanuscriptforpublication.TheviewsexpressedhereinarethoseoftheauthorsanddonotnecessarilyreflecttheviewsoftheNationalBureauofEconomic

Research.

NBERworkingpapersarecirculatedfordiscussionandcommentpurposes.Theyhavenotbeenpeer-reviewedorbeensubjecttothereviewbytheNBERBoardofDirectorsthataccompaniesofficialNBERpublications.

?2023byReneeY.HsiaandYu-ChuShen.Allrightsreserved.Shortsectionsoftext,nottoexceedtwoparagraphs,maybequotedwithoutexplicitpermissionprovidedthatfullcredit,including?notice,isgiventothesource.

DoPCIFacilityOpeningsDifferentiallyAffectAMIPatientsbyIndividualRaceandCommunitySegregation?

ReneeY.HsiaandYu-ChuShen

NBERWorkingPaperNo.31626

August2023

JELNo.I11,I14

ABSTRACT

PercutaneouscoronaryinterventionfacilityopeningsmayhavedifferentialeffectsontreatmentandhealthoutcomesforBlackversusWhitepatientsinresidentiallysegregatedversusintegratedcommunities.Thisstudylookedatchangesinpatienttreatmentandhealthoutcomes(same-dayPCI,PCIduringhospitalization,30-daymortality,and1-yearmortality)aftertheopeningofaPCIfacilitywithina15-minutedriveofacommunity.FindingsshowthatBlackpatientsinintegratedcommunitiesexperiencedthegreatestbenefitsafteraPCIopeningforeveryoutcomeexamined.HealthcarestakeholdersmaybeabletousethisdatatoprioritizePCIopeningsincommunitiesthatwillderivethegreatestbenefits

ReneeY.Hsia

UniversityofCaliforniaatSanFrancisco

SFGHMedicalCenter

1001PotreroAvenue

SanFrancisco,CA94110

Renee.Hsia@

Yu-ChuShen

DepartmentofDefenseManagement

NavalPostgraduateSchool

555DyerRoad

Monterey,CA93943

andNBER

yshen@

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Introduction

Disparitiesinthecardiovascularhealth,treatment,andlong-termmortalityratesofpatientswithacutemyocardialinfarction(AMI)havebeenwell-documented.Thedeathratefromacutecoronarysyndrome(ACS)is30%higherforBlackindividualscomparedtonon-HispanicWhiteindividuals,1andpost-myocardialinfarction(MI)survivalratesaresignificantlyhigherforWhiteindividualswhencomparedwithBlackindividuals.2,3Sadly,thesedisparitiesinoutcomesareexpectedtopersist,despitehundredsoflocalandfederalinitiativestoaddressracialinequitiesinhealthcare.4

Muchofthecurrentliteratureoninequitiesincardiaccarehasfocusedonpatientfactors(e.g.,race,education,willingnesstoseekcare)orproviderfactors(e.g.,unconsciousbias).3Asmallbutgrowingproportionofthedisparitiesliteratureisdevotedtosystemsor“builtenvironment”issuesofwherehealthcareservicesexist,andhasfoundthatmoreaffluentareastendtohavemorehospitalsandspecializedcenters,includingdedicatedtocardiaccenters.5,6Patientsfromracialandethnicminoritiesarelesslikelytobeadmittedtospecializedfacilities7andfaceanincreasinglikelihoodofundergoingcardiacprocedures,suchaspercutaneouscoronaryintervention(PCI),atlow-volumehospitalswhichhavebeenassociatedwithlessfavorableoutcomes.8

Oneofthegapsintheliteratureisthatmanyofthesestudiestendtobecross-sectional,examiningasinglepointintimetodeterminetheexistenceofdisparities;3however,itremainsunknownwhetherchangesinthebuiltenvironment,suchastheopeningofPCI-capablefacilities,havewidenedornarroweddisparitiesovertime.Thesecondconspicuousgapinknowledgeliesinamorepreciseidentificationofhowchangesintheprovisionofcarehavedifferentiallyaffectedpatientsattheindividuallevelbasedonthesocialconstructionofraceand

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atthepopulationlevel,whenacknowledgingthatresidentialsegregationmayaffectcardiacoutcomes.

OurstudyfocusesontheopeningofPCI-capablefacilitiesfrom2006-2017andthedifferentialeffectsoftheseopeningsonthetreatmentandhealthoutcomesofAMIpatientsbasedonindividualraceanddegreeofcommunitysegregation.Aclearerunderstandingofhowtheproliferationofthesespecializedhealthcareservicesaffecthistoricallydisadvantagedcommunitiesandpopulationsmayhelpelucidatefoundationalissuesaboutthewayourhealthcaresystemisstructuredandidentifypotentialtargetsofintervention.

Methods

Patientpopulationanddatasources

OuranalyticalsampleincludedallMedicareFee-for-ServicepatientswhowerediagnosedwithAMIbetweenJanuary2006andDecember2017.InordertogetacleanidentificationoftheeffectsofPCIopeningsonpatientoutcomes,ourmainanalysisexcludedpatientswhosecommunitiesexperiencedaPCIclosureduringthestudyperiod.OurcontrolgrouprepresentedAMIpatientsincommunitiesthatexperiencednoPCIcapacitychangeduringthestudyperiod.AsourmainanalysisfocusedondifferencesbetweenWhiteandBlackpatients,wealsoexcluded5%oftheanalyticalsamplethatwereneitherBlacknorWhite.

Theprimaryindividualpatientdatacomesfromthe100%MedicareProviderandAnalysisReview(MedPAR),whichcontainsMedicarebeneficiarysummaryfilesandislinkedtovitalstatus.Relevantdataelementsincludepatients’mailingZIPcodes,admissiondates,ICD-9and10diagnosticandprocedurecodes,demographics(e.g.,age,sex,race/ethnicgroup),and

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dateofdeath.WelinkedMedicaredatawith2010USCensusdataviaeachpatient’smailingZIPcodetoobtainthelongitudeandlatitudecoordinatesoftheircommunity.ThisenabledustoconstructsegregationmeasuresoutoftheBlackandWhitepopulationsinthosecommunities.Inaddition,weusedtheDartmouthHealthAtlastoidentifyhospitalserviceareasforeachZIPcode.9Toobtainthegeographiclocationsofallhospitals,weusedtheAmericanHospitalAssociation(AHA)annualsurveyswhichcontainhospitallongitudeandlatitudecoordinates,andfurthersupplementedthisdatawiththehospital’sheliportcoordinates(ifexistent).10Institutionalreviewboardapprovalwasnotrequiredforthisstudybecausenopatient-identifiabledatawasused.

IdentifyingPCIfacilityopeningsovertime

WecapturedPCIopeningswithina15-minutedriveofagivencommunityusingthefollowingsteps.First,foreveryyearweidentifiedwhethereachhospitalwasconsideredPCI-capableusingavolume-basedapproachfrompriorworkinordertominimizeself-reportingerrors.11,12AhospitalwasconsideredPCI-capableifithadperformedatleast4PCIprocedures(frombothinpatientoroutpatientsettings)inayear.Second,foreachhospital,wedefinedopeningyearasthefirstyearofatleasttwoconsecutiveyearsofoperationforaPCIhospital,asdoneinpreviousliterature.11,13

Third,inordertoidentifychangesinPCIcapacityforagivencommunity,wefirstcomputedactualdrivingtimebetweeneachcommunity-hospitalpairforeveryyearusingweb-basedmapsqueries,viaHEREdevelopermapsAPIkeyandautomationsoftwarefromStata,basedonthegeographicalcoordinatesofthepair.14,15Finally,havingidentifiedthesetofPCI-capablehospitalsoperatingwithina15-minutedriveforeachyear,weevaluatedyear-to-year

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changesandclassifiedcommunitiesaccordingtowhethertheyexperiencedaPCIhospitalopeningwithina15-minutedriveinagivenyear.Wechoseathresholdof15minutesbasedonthresholdsreportedinotherstudies,16–18andpriorliteratureshowingthatthemajorityofhospitalvisitsarewithin15minutesofapatient’sresidence.19

Patientcategoriesbasedonindividualraceandresidentialsegregation

WecategorizedourAMIpatientpopulationintofourcategoriesbasedonanindividual’sraceandtheircommunity’sdegreeofsegregation:(1)Whiteinraciallysegregatedcommunities(referencegroup);(2)Blackinsegregatedcommunities;(3)Whiteinintegratedcommunities;and(4)Blackinintegratedcommunities.Eachindividualpatient’sracewasidentifiedfromtheMedicarebeneficiarysummaryfile’sracerecord.Eachcommunity’sdegreeofresidentialsegregationwasmeasuredattheHospitalServiceArea(HSA)levelusingthedissimilarityindex,asresidentsfromZIPcodecommunitiesthatbelongedtothesameHSAincurredmostoftheirhospitalizationsfromhospitalsinthatarea.20

Thedissimilarityindexisthemostcommonmeasureofsegregationthatiseasytointerpretandhasbeenappliedinotherhealthanalyses.21,22Thereisalargebodyofliteraturedevotedtomeasuresofresidentialsegregation.23–25ThedissimilarityindexfortheithHSAwascomputedasDi=∑|?|,wherewiandBiwerethetotalWhiteandBlackpopulationcountsattheithHSA,respectively;andtherewereNZIPcodesinanHSA,wherewkandbkweretheWhiteandBlackpopulationcountofthekthZIPcode.WechoseZIPcodeasthebuildingblockofourHSAdissimilarityindexbasedonpriorliterature.26,27HSAswereclassifiedasraciallysegregatediftheirWhite–Blackdissimilarityindexwasinthetopone-thirdoftheoveralldissimilarityindexdistribution.Otherwise,theywerecategorizedasintegrated.In

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ordertotrackcommunitiesconsistentlyovertime,thesecommunitymeasuresweremadetime-invariantandbasedon2010Censusdata.

DesignatingCommunitieswithHighBaselinePCICapacity

Inoneofoursensitivityanalyses,westratifiedthesamplebasedonapatient’scommunitybaselinePCIcapacity.WehypothesizedthatPCIopeningmighthavesmallereffectinpatienthealthoutcomesincommunitieswithhighPCIcapacityatbaselineduetopossibleduplicationofservices,andlargereffectincommunitieswithlowPCIcapacity,asthelattercommunitieswouldhaveunmetneeds.

Forthepurposesofthisanalysis,wemeasuredPCIcapacityaspercentofpatientswhowereadmittedtoPCI-capablehospitals(regardlessofwhethertheyreceivedPCI)andclassifiedcommunitiesashaving“highcapacity”iftheyrankedinthetopquartileofPCIcapacitymeasuresbasedontheir2005-2006status.Tocreateareliableandstablecapacitymetric,weconsidered2factors:thegeographicalcoverageofeachmarketandthemarket’sPCIcapacity.Followingpriorwork,28–30weusedHospitalReferralRegions(HRR)asthebroadmarketdefinitiontoclassifycommunities.TheHRRmeasureaccountsforpatientflowandtransferpatternsandcontainsasufficientpatientpopulationforobtainingareliablemetric.Similartopriorwork,31weusedthefollowingregression-basedapproachtorankmarkets’baselinePCIlabcapacity.Usingthe2005and2006AMIpopulation,thisrisk-adjustedmetricwasobtainedbytakingtheHRRinterceptsfromaregression,wherethedependentvariablewaswhethertheAMIpatientwasadmittedtoahospitalwithaPCIlabthatincludedseparateHRRinterceptsontheright-handside,andcontrolsforpatientdemographicandcomorbidconditions.RankingsbasedontheHRRinterceptsfromthisregressionrepresentedtherelativePCIlabcapacityfor

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comparablepatientpopulationsacrossallHRRmarkets.Forexample,ifHRRAhadahighercoefficientthanHRRB,anidenticalAMIpatientwouldbemorelikelytohaveaccesstoaPCIlabinHRRAthaninHRRB.Weusedtwoyearsofbaselinedatatoincreasetheprecisionoftheranking.ZIPcodecommunitiesinHRRsrankedintheupperquartilewereclassifiedas“high-capacity”markets.Inasensitivityanalysis,weusedrawPCIcapacitytoranktheHRRsinsteadofusingtheregression-basedrank.Ourresultswererobusttothealternatedefinition.

Statisticalmethods

OuranalysisfocusedonchangesinthefollowingtreatmentsandhealthoutcomesforAMIpatientswhoexperiencedaPCIopeningwithina15-minutedriveoftheircommunity:(1)whetherthepatientreceivedPCItreatmentonthedayofadmission;(2)whetherthepatientreceivedPCItreatmentduringthecareepisode;(3)30-daymortality;and(4)1-yearmortality.TreatmentswereidentifiedusingICD-9andICD-10procedurecodesandproceduredates.Inouranalysis,weincludedreceiptofcoronaryangiographyinadditiontoreceiptofPCIsincethisprocedurerepresentsapreludetorevascularizationandaccountsfortheclinicalrealitiesoffailedPCIand/oranatomythatisnotsuitableforPCI.Mortalityoutcomeswerecomputedbylinkingavalidateddeathdatewithanadmissiondate.Wefocusedontime-specificmortalityratherthanin-hospitalmortalitytodetecteffectsonmortalitynotonlyintheacutephasebutinthelongertermaswell.

Ourstudydesignbeganwithadifference-in-differences(DD)framework,wherewecomparedoutcomesdefinedabovebetweenpatientswhoexperiencedaPCIopeningwithina15-minutedrivefromtheircommunity(treatmentgroups)andpatientsofthesamerace/segregationcategorywhodidnothaveanychangeinPCIcapacityduringthestudyperiod(controlgroups).

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TakethecategoryofBlackpatientswholivedinsegregatedcommunitiesasanexample,ourDDframeworkcompareschangesinoutcomesbetweenaBlackpatientwholivedinasegregatedcommunitythatexperiencedaPCIopeningandaBlackpatientwholivedinasegregatedcommunitythatdidnotexperienceaPCIopeningduringthestudyperiod.Wesubsequentlyimplementedadifference-in-differences-in-differences(DDD)thatallowedustocomparewhethertheeffectsofPCIopeningsonoutcomeswerestatisticallysignificantlydifferentacrossthe4patientcategories.

Becausewehadbinaryoutcomes,weestimatedalinearprobabilitymodelwithcommunity-fixedeffectstocontrolforanyunobservedtime-invariantheterogeneityacrosscommunitiesandheteroskedasticity-robuststandarderrorsclusteredatthecommunitylevel.32Weusedtwosetsofkeyvariables.ThefirstsetincludedindicatorsforwhetheracommunityexperiencedaPCIhospitalopeningwithina15-minutedrive.PCIopeningindicatorstookonavalueof1onandaftertheyearthatacommunityexperiencedaPCIopening.Thecoefficientestimatefromthisindicatorrepresentschangesinoutcomeswhenthereferencetreatmentgroup(Whitepatientsinsegregatedcommunities)experiencedaPCIopeningrelativetothecontrolgroup(patientswhosecommunitiesdidnothaveaPCIopeningduringthestudyperiod).ThesecondsetofkeyvariablesincludedtheinteractiontermbetweenthePCIopeningindicatorsandthepatientrace/segregationgroupindicators.Thecoefficientestimatesfromthissecondsetrepresentedadditionalchangesinoutcomesbetweeneachrace/segregationgrouprelativetothereferencegroupwhenbothgroupsofpatientsexperiencedanopening.

Othercontrolvariablesinthemodelincludedyearindicatorstocapturethemacro-leveltrends,patientdemographics(5-yearagegroups,raceandethnicity,sex),aswellasasetofdisease-relatedriskadjustmentsinaccordancewithpriorwork.33,34Itshouldbenotedthatwhile

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wecontrolledforindividualrace,therace/segregationgroupindicatorsandothercommunity-levelcharacteristicswerenotincludedinthemodel,sincetheyweresubsumedbythecommunity-fixedeffectsthatalreadycontrolledforobservedandunobserveddifferencesacrosscommunities.

Wealsostratifiedouranalysisbasedonacommunity’sbaselinePCIcapacity.ThisallowedustoexaminewhetherPCIopeningshadasmallereffectonpatienthealthoutcomesincommunitieswithhighPCIcapacityatbaseline,duetothepossibleduplicationofservices,and/orifopeningshadalargereffectincommunitieswithlowPCIcapacity,asthesecommunitieswouldhaveunmetneeds.Asdescribedabove,weclassifiedcommunitiesashaving“highcapacity”iftheyrankedinthetopquartileofregression-adjustedPCIcapacitymeasuresbasedontheir2005-2006status.ThestudywasdeemedexemptbytheUCSFHumanResearchProtectionProgrambecauseitdidnotincludehumansubjects.

Results

Atotalof2,388,180patientswereincludedinourstudy.Figure1showsthat28%wereWhitepatientslivinginsegregatedcommunities,4%wereBlackinsegregatedcommunities,63%wereWhiteinintegratedcommunities,and4%wereBlackinintegratedcommunities.Figure1alsoshowsthatBlackpatientsinsegregatedcommunitiesweremorelikelytoexperienceaPCIopening(26%)comparedtopatientsintheother3groups(15-18%).

Table1showsthat,demographically,BlackpatientsinbothintegratedandsegregatedcommunitieswereyoungerthanWhitepatients(29%and28%ofBlackpatientsinintegratedandsegregatedcommunitieswereundertheageof70versus19%and18%ofWhitepatients,respectively),withahigherproportionbeingfemale(over55%ofBlackpatientswerefemale

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versusunder48%amongWhitepatients).Intermsofdiseaseprofile,Blackpatientshadamuchhigherrateofdiabetes(40%and39%ofBlackpatientsinintegratedandsegregatedcommunitiesversus29%and28%ofWhitepatientsinintegratedandsegregated,respectively),renalfailure(34%versus21-22%,respectively)andhypertension(78%and77%versus67%).PatientswhowereWhite,regardlessofwhethertheywerelivinginintegratedorsegregatedcommunities,hadahigherlikelihoodofsufferingfromST-elevationMI(STEMI)thanBlackpatients(23%versus17%and16%).WecontrolledforthesediseaseprofiledifferencesinthestatisticalmodelssowecouldcomparetheexperiencesofcomparablepatientswhentheircommunitiesexperiencedaPCIopening.WhenexaminingthepercentageofpatientsincommunitieswithhighbaselinePCIcapacity,18%and26%ofpatientsinWhitesegregatedandintegratedcommunities,respectively,residedincommunitieswithhighbaselinecapacity;whereas21%and19%ofpatientsinBlacksegregatedandintegratedcommunities,respectively,hadhighbaselinecapacity.Finally,Table1showsthatpatientswhowereBlack,regardlessofresidentialsegregation,hadalowerrateofreceivingsame-dayPCI(37-38%)thanWhitepatients(46%).Unadjustedmortalitiesweresimilaracrossthefourraceandsegregationgroups.

TheFigure2highlightsresultsfromthecommunityfixed-effectsmodelsandillustratestherisk-adjustedpercentagepointchangesinoutcomesafteracommunityexperiencedaPCIopeningwithina15-minutedrive,relativetoacommunitywithnoPCIcapacitychange(fullregressionresultsinAppendixTable1).PanelAshowsthatwhenWhitepatientsinsegregatedcommunitiesexperiencedaPCIopening,theirprobabilityofsame-dayPCItreatmentincreasedby0.98(95%CI:0.19,1.77)percentagepointsrelativetoWhitepatientsinsegregatedcommunitieswhodidnothavePCIopeningsintheircommunity.Thischangerepresentsa2.1%relativeincreaseinsame-dayPCI(meanrateforthispatientcategoryis46%perTable1),the

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smallestbenefitofthefourgroups.Blackpatientsinintegratedcommunitiesexperiencedthelargestincreaseinlikelihoodofreceivingsame-dayPCI(3.92;95%CI:2.90,4.95)relativetoBlackpatientsinintegratedcommunitieswhodidnothaveaPCIopeningintheircommunity(panelA).Thisisequivalenttoan11%relativeincreasegiventhatthemeanrateofsame-dayPCIwas37%forpatientsinthiscategory.

ToexaminewhethertheeffectsofPCIopeningsobservedintheFigure2,panelAdifferedsignificantlyacrossthe4categoriesofpatients,wetestedthepointestimatedifferencesusingtheDDDframeworkdiscussedabove.TheasterisksinpanelAindicatesthatthe3.92percentagepointimprovementforBlackpatientsinintegratedcommunities,astheresultofaPCIopening,wasstatisticallysignificantlydifferentfromthe0.98percentagepointimprovementforWhitepatientsinsegregatedcommunitiesatthe0.01significancelevel.Inotherwords,thebenefitofaPCIopeningonlikelihoodofreceivingsame-dayPCIwasmorethanfivetimeshigherforBlackpatientsinintegratedcommunitiescomparedtoWhitepatientsinsegregatedcommunities(11%relativebenefitcomparedtoa2.1%relativebenefitwithnoPCIopeningswithinthesamerace/segregationcategory).

WeobservedthesamepatterninpanelBwhenexaminingchangesintheprobabilityofreceivingPCIduringahospitalization.Ingeneral,patientsinintegratedcommunitieshadlargerincreasesintheirprobabilityofreceivingPCIduringahospitalization(6.62and5.28percentagepointsforBlackandWhitepatients,respectively)thanthoseinsegregatedcommunities(3.60and2.20percentagepointsforBlackandWhitepatients,respectively).Overall,BlackpatientsbenefitedmorethanWhitepatients,conditionalonthesametypeofcommunity.Thesechangesareequivalenttoa12%increaseforBlackpatientsinintegratedcommunities,anda4%increase

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forWhitepatientsinsegregatedcommunitieswheneachexperiencedaPCIfacilityopeningneartheirrespectivecommunities.

Whenevaluatingmortality,differentialbenefitsacrossthefourgroupsofpatientswerepersistent.AsshowninpanelsCandD,Whitepatientsinsegregatedcommunitieshadnostatisticallysignificantbenefitin30-dayor1-yearmortalitywhentheyexperiencedaPCIopeningcomparedtopatientsinthesamerace/segregationcategorywithnoPCIopening.Onceagain,Blackpatientsinintegratedcommunitieshadthegreatestbenefit,witha1.30(CI:-1.98,-0.63)percentagepointdecreasein30-daymortalitywhenthecommunityexperiencedaPCIopening,representingan11%dropin30-daymortality(meanrateforthispatientcategorywas12%).Wehadsimilarfindingswhenlookingat1-yearmortality.Blackpatientsinintegratedcommunitiesexperienceda1.86(CI:-2.80,-0.93)percentagepointdecrease,ora6%drop,in1-yearmortalitywithaPCIfacilityopeningcomparedtopatientsinthesamerace/segregationcategorywithnoopening.

Finally,Table2showsthatwhenlimitingthesampletocommunitieswithouthighbaselinePCIcapacity,resultsweresimilartoourmainanalysis(Figure2andAppendixTable1).BlackpatientsinintegratedcommunitiesexperiencedthegreatestbenefitsacrossallfouroutcomeswhenaPCIfacilityopenedintheircommunity,comparedwiththeotherthreecommunitytypes.EvenincommunitieswithhighbaselinePCIcapacity,Blackpatientsinintegratedcommunitiescontinuedtoexhibitthegreatestreductionin1-yearmortality(-2.42;95%CI:-4.44,-0.41)andasignificantincreaseintheprobabilityofreceivingin-hospitalPCI(2.90;95%CI:0.25,5.54).Blackpatientsinsegregatedcommunitiesalsohada4.20(CI:2.02,6.38)and4.98(CI:2.49,7.46)percentagepointincreaseinprobabilityofsame-dayPCIand

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in-hospitalPCI,respectively.However,WhitepatientsinintegratedcommunitiesdidnotbenefitfromPCIopeningwhenbaselinePCIcapacitywashigh.

Discussion

OurstudyfounddifferentialbenefitsofPCIfacilityopeningswithina15-minutedrivebasedonpatientraceandcommunitydegreeofsegregation.ThegreatestbenefitsfromPCIopeningswereobservedforBlackpatientsinintegratedcommunitiesacrossalloutcomesexamined:same-dayPCI;PCIduringhospitalization;30-daymortality;and1-yearmortality.Conversely,thesebenefitswereleastnoticeableornon-existentforWhiteindividualsinsegregatedcommunitiesamongthefourrace/segregationcategories.Forexample,whenlookingatsame-dayPCI,BlackpatientsinintegratedcommunitiesexperiencedmorethanfivetimesthebenefitfromaPCIopeningcomparedwithWhitepatientsinsegregatedcommunities.

Itisimportanttokeepinmindthatonaverage,BlackpatientsineithertypeofcommunityhadalowerprobabilityofreceivingPCIandhigherlong-termmortalityratescomparedtotheirWhitecounterparts.ItisthereforecomfortingtoseethatPCIopeningsare,infact,allowingpreviouslydisadvantagedpopulationsachanceto“catchup”andreducedisparities,althoughtheaccelerationofimprovedoutcomeswasnotenoughtoachievecompleteparityduringth