Interventional cardiology

Better follow-up required post-PCI for Indigenous Australians

Indigenous Australians having PCI have poorer short and long term outcomes than non-Indigenous Australians, despite similar rates of procedural success and complications.

The findings, published in The Lancet Global Health, are sadly unsurprising given the consistent evidence of health disparities between Indigenous and non-Indigenous Australians, according to researchers, who say that “clinically effective and culturally safe care pathways are urgently needed to improve health outcomes among Indigenous Australians who are having PCI.”

The data from the Melbourne Interventional Group PCI registry comprised about 40,000 patient procedures performed between 2005 and 2018 in six public hospitals in metropolitan and regional Victoria.

Indigenous patients, representing about 0.4% of the cohort, were younger, more often women, and more likely to live in regional communities and areas of socioeconomic disadvantage.

“In the setting of increased remoteness, prevalence of thrombolysis and interhospital transfers were higher, resulting in longer door-to-balloon times for STEMI and overall length of stay,” the study authors said.

Indigenous patients were also more likely to be smokers and to have comorbidities including diabetes and severe renal impairment than other patients.

Multivariable regression models showed a significant association between Indigenous Australian status and worse long-term mortality after PCI, independent of confounders including socioeconomic status and remoteness, with a median follow-up of 5·2 years (aHR 2.49)

“Similarly, for secondary endpoints, multilevel multivariable logistic regression showed that Indigenous Australian status was independently associated with 30 day MACE [aOR 1.87] and 30 day mortality [aOR 2.78],” the study said.

The investigators said the study highlights that improvement in follow-up after PCI should be a focus “for all health-care services, communities, and policy makers with a shared commitment to improving health outcomes for Indigenous Australians”.

“Improving access to primary care, non-invasive cardiac investigations, and specialist follow-up, such as through telemedicine, in addition to streamlining care pathways for regional and remote ACS patients to reduce delays in treatment could have significant benefits,” they wrote.

Focus on follow up

A Comment article in the journal said it was concerning that there was virtually no change in the hazard ratios for mortality between the periods 2005-2009 and 2015-2018.

“This continued trend is despite in-hospital cardiac disparities for Aboriginal and Torres Strait Islander people being a national priority since 2014.”

“Targeted efforts over the past decade to increase culturally appropriate, clinically competent cardiac care in selected hospitals through addressing on-the-ground gaps seem not to have made any difference to disparities and outcomes more broadly.”

The authors suggested action at all levels including culturally responsive health promotion and disease prevention programs, addressing institutional racism, and coordinated post-acute care incorporating cardiac rehabilitation.

“It is not enough to continue to report the extent of the disparity,” they said.

“Providing support for health workers to unlearn behaviours and beliefs about indigenous people and their health, which drives the bias in decision making and care provision, is also essential for change.”

Lead author Dr Luke Dawson told the limbic that follow up was the main factor that could be improved.

“It suggests a greater focus on engagement with follow-up after stenting procedures would be worthwhile.”

“Once patients go back to communities there needs to be improved cardiac follow-up…whether that is in person or by telehealth.”

“It’s not a disease that gets stented and is then fixed. While that improves the flow, it still needs ongoing medication to prevent the plaque from progressing.”

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