P2654Impact of cultural and linguistic diversity on ischaemic time and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI)
Authors: Biswas S , Dinh D , Lucas M , Duffy S J , Brennan A , Liew D , Cox N , Neil C , Reid C M , Lefkovits J , Stub D 
Published: October 2019

Abstract

Background
Healthcare providers worldwide increasingly must face the challenge of providing care to culturally and linguistically diverse patients who may have limited proficiency in the primary working language of the country they are in. This language discordance may lead to delayed treatment and worse outcomes. The impact of limited English proficiency (LEP), in a predominantly English-speaking country like Australia, on time to reperfusion and outcomes following PCI for STEMI has not been previously studied.

Objective
Among patients undergoing PCI for STEMI, to compare baseline and procedural characteristics, time to reperfusion, and 30-day clinical outcomes in patients with LEP, compared to their English-proficient counterparts.

Method
We prospectively collected data on 7,721 patients undergoing PCI for STEMI between January 2013 and December 2017 who were enrolled in the state-wide multi-centre Victorian Cardiac Outcomes Registry. Data linkage to Department of Health administrative datasets was used to identify patients' primary spoken language. Patients who identified a language other than English as their primary spoken language were classified as having LEP. Patients' postcodes were used to identify socioeconomic status through Australian Government census data. The primary endpoint was 30-day major adverse cardiovascular events (MACE)

Results
Of the 7,721 patients included, 568 (7.4%) had LEP. Patients with LEP were more likely to be older, female, diabetic, have lower socioeconomic status and have severe renal impairment (all p<0.02). They were also more likely to present to a non-PCI capable hospital (p<0.001). Among primary PCI patients (n=5,385), symptom-to-balloon time was longer in the LEP group (237 [IQR 158–429] vs. 195 [IQR 141–326] minutes, p<0.001), driven mostly by longer symptom-to-door times (STDT) (150 [IQR 90–276] vs. 114 [IQR 75–215] minutes, p<0.001). LEP patients were also less likely to have a STDT≥120 minutes (48.8% vs. 41.7%, p-0.004). Patients with LEP had higher 30-day mortality (8.8% vs. 6.5%, p=0.04) and MACE (11.8 vs. 9.1%, p=0.04). They were also more likely to have severe left ventricular (LV) dysfunction post-STEMI (11.2% vs. 8.4%, p=0.003) and heart failure readmissions within 30 days of PCI (5.2% vs. 2.0%, p<0.001). On multivariate analysis, LEP was not an independent predictor of 30-day MACE (OR 1.27, 95% CI 0.82–1.95), but was an independent predictor of STDT≥120 minutes (OR 1.24, 95% CI 1.02–1.52).
Comparison of reperfusion times

Conclusion
Limited English-proficient patients with STEMI undergoing PCI tend to present later than their English-proficient counterparts and are more likely to have severe LV dysfunction and heart failure readmissions. LEP is an independent predictor of prolonged STDT but not 30-day MACE. This suggests that more effort needs to be placed in providing education in different languages to culturally and linguistically diverse patients, to encourage early presentation in the setting of STEMI.