International research for acute myocardial infarction lacks comparisons of whole health systems. We assessed time trends for care and outcomes in Sweden and the UK.
We used data from national registries on consecutive patients registered between 2004 and 2010 in all hospitals providing care for acute coronary syndrome in Sweden and the UK. The primary outcome was all-cause mortality 30 days after admission. We compared effectiveness of treatment by indirect casemix standardisation. This study is registered with ClinicalTrials.gov, number NCT01359033.
We assessed data for 119,786 patients in Sweden and 391,077 in the UK. 30-day mortality was 7·6% (95% CI 7·4-7·7) in Sweden and 10·5% (10·4-10·6) in the UK. Mortality was higher in the UK in clinically relevant subgroups defined by troponin concentration, ST-segment elevation, age, sex, heart rate, systolic blood pressure, diabetes mellitus status, and smoking status. In Sweden, compared with the UK, there was earlier and more extensive uptake of primary percutaneous coronary intervention (59% vs 22%) and more frequent use of ß blockers at discharge (89% vs 78%). After casemix standardisation the 30-day mortality ratio for UK versus Sweden was 1·37 (95% CI 1·30-1·45), which corresponds to 11,263 (95% CI 9620-12,827) excess deaths, but did decline over time (from 1·47, 95% CI 1·38-1·58 in 2004 to 1·20, 1·12-1·29 in 2010; p=0·01).
We found clinically important differences between countries in acute myocardial infarction care and outcomes. International comparisons research might help to improve health systems and prevent deaths.
Seventh Framework Programme for Research, National Institute for Health Research, Wellcome Trust (UK), Swedish Association of Local Authorities and Regions, Swedish Heart-Lung Foundation.
The aim of this study was to assess the impact of a mobile emergency care unit (MECU) staffed with an anaesthetist, in terms of increased survival among patients with acute myocardial infarction (MI). The setting was an urban area with 330 000 inhabitants. This was a quasi-experimental before-and-after-study including consecutive emergency calls during September to November 1996 (Period 1, without the MECU) and September to November 1997 (Period 2, including the MECU). Fifty-four ambulance patients had their MI diagnosis confirmed at hospital during Period 1, and another 54 in Period 2. The 28-day mortality was collected from relevant registers. Twenty-four (44%) of Period 2 patients were transported by the MECU. MECU patients had lower systolic blood pressure (SBP) than other patients, both before and after hospital admission. Nitroglycerine treatment was relatively frequent in MECU patients, and cardioversion, anaesthesia and intubation was applied exclusively in these patients. After arrival at hospital, MECU patients had thrombolysis relatively often (46% versus 23% in other Period 2 patients) but percutaneous transluminal coronary angioplasty (PTCA) relatively infrequently (21% vs 30%). The total mortality was significantly lower in Period 2 than in Period 1 patients (11% vs 21%,
Hospital report cards are increasingly being implemented for quality improvement despite lack of strong evidence to support their use.
To determine whether hospital report cards constructed using linked hospital and prescription administrative databases are effective for improving quality of care for acute myocardial infarction (AMI).
The Administrative Data Feedback for Effective Cardiac Treatment (AFFECT) study, a cluster randomized trial.
Patients with AMI who were admitted to 76 acute care hospitals in Quebec that treated at least 30 AMI patients per year between April 1, 1999, and March 31, 2003.
Hospitals were randomly assigned to receive rapid (immediate; n = 38 hospitals and 2533 patients) or delayed (14 months; n = 38 hospitals and 3142 patients) confidential feedback on quality indicators constructed using administrative data.
Quality indicators pertaining to processes of care and outcomes of patients admitted between 4 and 10 months after randomization. The primary indicator was the proportion of elderly survivors of AMI at each study hospital who filled a prescription for a beta-blocker within 30 days after discharge.
At follow-up, adjusted prescription rates within 30 days after discharge were similar in the early vs late groups (for beta-blockers, odds ratio [OR], 1.06; 95% confidence interval [CI], 0.82-1.37; for angiotensin-converting enzyme inhibitors, OR, 1.17; 95% CI, 0.90-1.52; for lipid-lowering drugs, OR, 1.14; 95% CI, 0.86-1.50; and for aspirin, OR, 1.05; 95% CI, 0.84-1.33). In addition, adjusted mortality was similar in both groups, as were length of in-hospital stay, physician visits after discharge, waiting times for invasive cardiac procedures, and readmissions for cardiac complications.
Feedback based on one-time, confidential report cards constructed using administrative data is not an effective strategy for quality improvement regarding care of patients with AMI. A need exists for further studies to rigorously evaluate the effectiveness of more intensive report card interventions.
Age-related differences in patients with an acute coronary syndrome (ACS) have not been well characterized in prior observational studies that often included only certain age groups or subjects with myocardial infarction (MI).
We stratified 4627 patients admitted with an ACS across 9 provinces between 1999 and 2001 enrolled in the Canadian ACS Registry into 3 age groups ( or = 75 years) to evaluate differences in clinical characteristics, management, and 1-year outcome.
Older patients more frequently had previous angina, MI, or heart failure and were less likely to have positive cardiac markers, ST elevation, and Q-wave MI or to receive thrombolytics, beta-blockers, and cholesterol-lowering and antiplatelet agents in hospital, at discharge, and at 1 year. In multivariable analyses controlling for patient factors, every decade increase in age was independently associated with reduced use of coronary angiography (odds ratio [OR] 0.79, 95% CI 0.74-0.84, P
Department of Medicine, Section of Cardiology, Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden. tomas.jernberg@karolinska.se
Only limited information is available on the speed of implementation of new evidence-based and guideline-recommended treatments and its association with survival in real life health care of patients with ST-elevation myocardial infarction (STEMI).
To describe the adoption of new treatments and the related chances of short- and long-term survival in consecutive patients with STEMI in a single country over a 12-year period.
The Register of Information and Knowledge about Swedish Heart Intensive Care Admission (RIKS-HIA) records baseline characteristics, treatments, and outcome of consecutive patients with acute coronary syndrome admitted to almost all hospitals in Sweden. This study includes 61,238 patients with a first-time diagnosis of STEMI between 1996 and 2007.
Estimated and crude proportions of patients treated with different medications and invasive procedures and mortality over time.
Of evidence-based treatments, reperfusion increased from 66% (95%, confidence interval [CI], 52%-79%) to 79% (95% CI, 69%-89%; P
Cardiology Evaluation Unit, Agence d'évaluation des technologies et des modes d'interventions en santé, Montreal, Québec, Canada. laurie.lambert@aetmis.gouv.qc.ca
Guidelines emphasize the importance of rapid reperfusion of patients with ST-elevation myocardial infarction (STEMI) and specify a maximum delay of 30 minutes for fibrinolysis and 90 minutes for primary percutaneous coronary intervention (PPCI). However, randomized trials and selective registries are limited in their ability to assess the effect of timeliness of reperfusion on outcomes in real-world STEMI patients.
To obtain a complete interregional portrait of contemporary STEMI care and to investigate timeliness of reperfusion and outcomes.
Systematic evaluation of STEMI care for 6 months during 2006-2007 in 80 hospitals that treated more than 95% of patients with acute myocardial infarction in the province of Quebec, Canada (population, 7.8 million).
Death at 30 days and at 1 year and the combined end point of death or hospital readmission for acute myocardial infarction or congestive heart failure at 1 year by linkage to Quebec's medicoadministrative databases.
Of 1832 patients treated with reperfusion, 392 (21.4%) received fibrinolysis and 1440 (78.6%) received PPCI. Fibrinolysis was untimely (>30 minutes) in 54% and PPCI was untimely (>90 minutes) in 68%. Death or readmission for acute myocardial infarction or heart failure at 1 year occurred in 13.5% of fibrinolysis patients and 13.6% of PPCI patients. When the 2 treatment groups were combined, patients treated outside of recommended delays had an adjusted higher risk of death at 30 days (6.6% vs 3.3%; odds ratio [OR], 2.14; 95% confidence interval [CI], 1.21-3.93) and a statistically nonsignificant increase in risk of death at 1 year (9.3% vs 5.2%; OR, 1.61; 95% CI, 1.00-2.66) compared with patients who received timely treatment. Patients treated outside of recommended delays also had an adjusted higher risk for the combined outcome of death or hospital readmission for congestive heart failure or acute myocardial infarction at 1 year (15.0% vs 9.2%; OR, 1.57; 95% CI, 1.08-2.30). At the regional level, after adjustment, each 10% increase in patients treated within the recommended time was associated with a decrease in the region-level odds of overall 30-day mortality (OR, 0.80; 95% CI, 0.65-0.98).
Among patients in Quebec with STEMI, reperfusion delivered outside guideline-recommend delays was associated with significantly increased 30-day mortality, a statistically nonsignificant increase in 1-year mortality, and significantly increased risk of the composite of mortality or readmission for acute myocardial infarction or heart failure at 1 year.
Notes
Comment In: JAMA. 2010 Jun 2;303(21):2188-920516422
The extent to which better spending produces higher-quality care and better patient outcomes in a universal health care system with selective access to medical technology is unknown.
To assess whether acute care patients admitted to higher-spending hospitals have lower mortality and readmissions.
The study population comprised adults (>18 years) in Ontario, Canada, with a first admission for acute myocardial infarction (AMI) (n = 179,139), congestive heart failure (CHF) (n = 92,377), hip fracture (n = 90,046), or colon cancer (n = 26,195) during 1998-2008, with follow-up to 1 year. The exposure measure was the index hospital's end-of-life expenditure index for hospital, physician, and emergency department services.
The primary outcomes were 30-day and 1-year mortality and readmissions and major cardiac events (readmissions for AMI, angina, CHF, or death) for AMI and CHF.
Patients' baseline health status was similar across hospital expenditure groups. Patients admitted to hospitals in the highest- vs lowest-spending intensity terciles had lower rates of all adverse outcomes. In the highest- vs lowest-spending hospitals, respectively, the age- and sex-adjusted 30-day mortality rate was 12.7% vs 12.8% for AMI, 10.2% vs 12.4% for CHF, 7.7% vs 9.7% for hip fracture, and 3.3% vs 3.9% for CHF; fully adjusted relative 30-day mortality rates were 0.93 (95% CI, 0.89-0.98) for AMI, 0.81 (95% CI, 0.76-0.86) for CHF, 0.74 (95% CI, 0.68-0.80) for hip fracture, and 0.78 (95% CI, 0.66-0.91) for colon cancer. Results for 1-year mortality, readmissions, and major cardiac events were similar. Higher-spending hospitals had higher nursing staff ratios, and their patients received more inpatient medical specialist visits, interventional (AMI cohort) and medical (AMI and CHF cohorts) cardiac therapies, preoperative specialty care (colon cancer cohort), and postdischarge collaborative care with a cardiologist and primary care physician (AMI and CHF cohorts).
Among Ontario hospitals, higher spending intensity was associated with lower mortality, readmissions, and cardiac event rates.
Notes
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Data from randomized trials has demonstrated the superiority of bivalirudin to glycoprotein IIb/IIIa inhibitors plus heparin in patients undergoing primary percutaneous coronary intervention. Real-world performance of bivalirudin in primary percutaneous coronary intervention and the benefit of bivalirudin over heparin remain unknown in an era of routine dual antiplatelet therapy.
From July 2004 to December 2010, 2317 consecutive patients were indexed in the University of Ottawa Heart Institute ST-segment-elevation myocardial infarction registry. During this period 748 patients received bivalirudin, 699 patients received glycoprotein IIb/IIIa inhibitors, and 676 patients received unfractionated heparin alone. The primary outcome was the rate of noncoronary artery bypass graft related thrombolysis in myocardial infarction major bleeding. Bivalirudin significantly reduced the primary outcome compared with heparin plus glycoprotein IIb/IIIa inhibitors (2.7% versus 7.3%, adjusted OR 2.96, 95% CI: 1.61-5.45, P
Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study.
Uncertainty remains over optimal antithrombotic treatment of patients with atrial fibrillation presenting with myocardial infarction and/or undergoing percutaneous coronary intervention. We investigated the risk and time frame for bleeding following myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation according to antithrombotic treatment.
Patients with atrial fibrillation and admitted with myocardial infarction or for percutaneous coronary intervention between 2000 and 2009 (11 480 subjects, mean age 75.6 years [SD ±10.3], males 60.9%) were identified by individual level linkage of nationwide registries in Denmark. Fatal or nonfatal (requiring hospitalization) bleeding was determined according to antithrombotic treatment regimen: triple therapy (TT) with vitamin K antagonist (VKA)+aspirin+clopidogrel, VKA+antiplatelet, and dual antiplatelet therapy with aspirin+clopidogrel. We calculated crude incidence rates and adjusted hazard ratios by Cox regression models. Within 1 year, 728 bleeding events were recorded (6.3%); 79 were fatal (0.7%). Within 30 days, rates were 22.6, 20.3, and 14.3 bleeding events per 100 person-years for TT, VKA+antiplatelet, and dual antiplatelet therapy, respectively. Both early (within 90 days) and delayed (90-360 days) bleeding risk with TT exposure in relation to VKA+antiplatelet was increased; hazard ratio 1.47 (1.04;2.08) and 1.36 (0.95;1.95), respectively. No significant difference in thromboembolic risk was observed for TT versus VKA+antiplatelet; hazard ratio, 1.15 (0.95;1.40).
High risk of bleeding is immediately evident with TT after myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation. A continually elevated risk associated with TT indicates no safe therapeutic window, and TT should only be prescribed after thorough bleeding risk assessment of patients.
