Abstract / Summary
Importance The proliferation of percutaneous coronary intervention (PCI) facilities across the US has raised questions about whether expanding capacity improves outcomes in areas already served vs those without prior access. Objective To evaluate the association between the opening of PCI-capable facilities and outcomes following acute myocardial infarction (AMI) in communities with and without baseline PCI access. Design, Setting, and Participants This cohort study used California data from inpatient, emergency department, and ambulatory surgery encounters from January 1, 2011, to December 31, 2022, including all adults hospitalized with a primary diagnosis of AMI. Zip code communities were categorized by baseline (2011) access to PCI-capable facilities within a 30-minute drive. Exposure Opening of a PCI-capable facility within 30 minutes of a community’s zip code during the study period. Main Outcomes and Measures Primary outcomes were (1) admission to a PCI-capable facility, (2) receipt of PCI during the index hospitalization, (3) unscheduled acute care visit within 30 days, and (4) all-cause mortality at 30 days and 1 year. Linear probability models with community and time-fixed effects estimated changes in outcomes following PCI facility openings separately for communities with and without baseline access. Results Among 590 282 patients with AMI (157 435 younger than age 60 years [27%]; 222 773 female [38%]; 63 460 Asian [11%], 129 137 Hispanic [22%], 315 326 White [53%]), 500 778 (85%) lived in communities with baseline PCI access, and 89 504 (15%) lived in communities without; 18 805 patients (21%) without baseline access experienced a PCI opening. Openings in communities without baseline access were associated with a 30.0 percentage point (pp) increase (95% CI, 28.2 to 31.8 pp) in admission to PCI-capable hospitals and a 5.1 pp increase (95% CI, 3.3 to 7.0 pp) in PCI receipt, along with reductions in 30-day (–1.8 pp; 95% CI, –3.2 to –0.5 pp) and 1-year (–2.8 pp; 95% CI, –4.7 to –1.0 pp) mortality. In contrast, openings in communities with baseline access were associated with smaller gains in admission (1.5 pp; 95% CI, 1.1 to 1.9 pp), modest increases in PCI use (1.0 pp; 95% CI, 0.5 to 1.6 pp), decreases in unscheduled visits within 30 days (–0.7 pp; 95% CI, –1.2 to –0.2 pp), and no mortality change. Sensitivity analyses restricted to higher-volume PCI centers (50 annual cases or more) yielded consistent findings. Conclusions and Relevance In this cohort study of 590 282 patients with AMI in California, opening new PCI facilities was associated with substantial improvements in communities without prior PCI availability, including a 53% relative increase in access to admission, 16% increase in PCI use, and 20% and 15% reductions in 30-day and 1-year mortality, respectively. In contrast, already served areas showed smaller benefits and no mortality improvement. PCI expansion should prioritize underserved regions to maximize population-level benefits and avoid inefficient duplication of services.