The COVID-19 pandemic has significantly influenced the health care system by causing disruptions and delays to both urgent and emergent care, according to the authors of a study published by JAMA Network Open. Prior research has suggested that acute myocardial infarction (AMI) mortality had increased during the pandemic; however, it is not certain whether the pandemic has been associated with inequal growth in mortality for cardiovascular hospitalizations among racial minority groups.
The cross-sectional study examined patients who were hospitalized with AMI during the COVID-19 pandemic, particularly if there were associations with increased disparities in treatment and outcomes depending on the hospitals’ COVID-19 burden. Exposure of interest, or COVID-19burdenkt, is a weekly measure of the hospital’s proportion of Medicare patients who tested positive for COVID-19, classified as 0% to 2.0%, 2.1% to 10.0%, 10.1% to 20.0%, 20.1% to 30.0%, and greater than 30.0%. Further, the baseline model was expanded to include hospital characteristics, such as its rurality, resident-to-bed ratio, disproportionate share percentage, the proportion of Black and Hispanic patients, and the volume of patients with AMI.
A total of 1,319,273 patients on Medicare aged ≥65 years who were hospitalized with AMI were included in the study, of whom 579,817 (44.0%) were females, 122,972 (9.3%) were Black, 117,668 (8.9%) were Hispanic, and 1,078,633 (81.8%) were White. Each participant was admitted to the hospital with non-ST-elevation myocardial infarction (NSTEMI) or ST-elevation myocardial infarction (STEMI).
The patients were evaluated to determine whether they had different rates of revascularization (percutaneous coronary intervention or coronary artery bypass grafting during the index admission), 30-day mortality, 30-day all-cause readmission, or nonhome discharges (death or discharge either to a skilled nursing facility or nursing home, inpatient rehabilitation facility, long-term care hospital, or hospital transfer) in hospitals during times with high weekly COVID-19 burdens versus hospitals with low weekly COVID-19 burdens.
Compared to White patients, Black individuals who were hospitalized with NSTEMI were more likely to be readmitted (OR, 1.15; 95% CI, 1.11-1.19; P < .001) and discharged to a nonhome setting (OR, 1.13; 95% CI, 1.10-1.16; P < .001). Further, Hispanic individuals hospitalized with NSTEMI were more likely to die within 30 days of admission (OR, 1.07; 95% CI, 1.03-1.11; P < .001) or be readmitted (OR, 1.13; 95% CI, 1.07-1.19; P > .001); however, compared to White individuals, they were less likely to be discharged to nonhome settings (OR, 0.82; 95% CI, 0.76-0.87; P < .001).
Additionally, Black patients with NSTEMI had experienced a 7% greater increase in the odds of mortality (aOR, 1.07; 95% CI, 1.00-1.15; P = .04) compared to White individuals for each 10% increase in the hospital COVID-19 burden. Adjusted NSTEMI mortality rates for Black and White individuals hospitalized when the COVID-19 burden was 30% were 12.8% and 13.1%, respectively. During weeks with a COVID-19 burden of 40%, these rates had increased to 14.8% and 14.4%, respectively.
Black patients hospitalized with NSTEMI during weeks with a high COVID-19 burden did not experience greater increases in readmissions or nonhome discharges, compared to White patients. Hispanic individuals hospitalized with NSTEMI did not experience increases in mortality (aOR, 1.00; 95% CI, 0.94-1.06; P = .99), readmissions (aOR, 0.97; 95% CI, 0.88-1.06; P = .50), or nonhome discharges (aOR, 1.05; 95% CI, 0.99-1.11; P = .11) during weeks with high hospital COVID-19 burdens compared to White patients.
Rates of readmissions and nonhome discharges in patients with STEMI were not significantly higher in hospitals during weeks of higher COVID-19 burden. Further, odds of mortality did not increase in patients who were in a hospital during weeks with a high COVID-19 burden greater than 30% (aOR, 1.28; 95% CI, 1.00-1.64; P = .05).
Black and Hispanic individuals hospitalized with STEMI were more likely to die within 30 days of admission (OR, 1.24; 95% CI, 1.19-1.30; P < .001 and OR, 1.24; 95% CI, 1.19-1.30; P < .001, respectively), be readmitted (OR, 1.21; 95% CI, 1.15-1.27; P < .001 and OR, 1.21; 95% CI, 1.15-1.27; P < .001, respectively), and be discharged to nonhome settings (OR, 1.09; 95% CI, 1.04-1.15; P < .001 and OR, 1.09; 95% CI, 1.04-1.15; P < .001, respectively) compared with White individuals; however, Black and Hispanic individuals hospitalized with STEMI in hospitals during weeks with high hospital COVID-19 burdens did not experience greater increases in mortality, readmissions, or nonhome discharges compared with White patients.
Overall, patients with NSTEMI who were admitted to the hospital during weeks with a high hospital COVID-19 burden were less likely to undergo revascularization. They were more likely to die within 30 days of admission and be discharged to a nonhome setting, unlike those who were hospitalized during weeks of low COVID-19 burden. Although the discrepancy in revascularization rates did not deteriorate during the pandemic in hospitals with high COVID-19 burdens, the pre-existing gap in revascularization rates was noticeable. Compared to White patients, Black and Hispanic individuals hospitalized after AMI had lower odds (35% to 45%) of undergoing revascularization.
Limitations of this study include the limited population examined (Medicare patients aged ≥65 years), the measure of hospital COVID-19 burden being based on Medicare patients rather than all adult patients, and the lack of consideration for disparities in AMI prevalence or death prior to hospital admission. The results reported were based on baseline disparities, which may influence the magnitude of disparities between Black patients and White patients. Further, the study’s design is nonrandomized and unmeasured confounding is likely, therefore the findings may be hindered, according to the authors.
Reference
Glance L, Joynt Maddox K, Shang J, et al. The COVID-19 Pandemic and Associated Inequities in Acute Myocardial Infarction Treatment and Outcomes. JAMA Netw Open. 2023;6(8):e2330327. doi:10.1001/jamanetworkopen.2023.30327