Variation in revascularisation use and outcomes of patients in hospital with acute myocardial infarction across six high income countries: cross sectional cohort study

Abstract

Objectives To compare treatment and outcomes for patients admitted to hospital with a primary diagnosis of ST elevation or non-ST elevation myocardial infarction (STEMI or NSTEMI) in six high income countries with very different healthcare delivery systems. Design Retrospective cross sectional cohort study. Setting Patient level administrative data from the United States, Canada (Ontario and Manitoba), England, the Netherlands, Israel, and Taiwan. Participants Adults aged 66 years and older admitted to hospital with STEMI or NSTEMI between 1 January 2011 and 31 December 2017. Outcomes measures The three categories of outcomes were coronary revascularisation (percutaneous coronary intervention or coronary artery bypass graft surgery), mortality, and efficiency (hospital length of stay and 30 day readmission). Rates were standardised to the age and sex distribution of the US acute myocardial infarction population in 2017. Outcomes were assessed separately for STEMI and NSTEMI. Performance was evaluated longitudinally (over time) and cross sectionally (between countries). Results The total number of hospital admissions ranged from 19 043 in Israel to 1 064 099 in the US. Large differences were found between countries for all outcomes. For example, the proportion of patients admitted to hospital with STEMI who received percutaneous coronary intervention in hospital during 2017 ranged from 36.9% (England) to 78.6% (Canada; 71.8% in the US); use of percutaneous coronary intervention for STEMI increased in all countries between 2011 and 2017, with particularly large rises in Israel (48.4-65.9%) and Taiwan (49.4-70.2%). The proportion of patients with NSTEMI who underwent coronary artery bypass graft surgery within 90 days of admission during 2017 was lowest in the Netherlands (3.5%) and highest in the US (11.7%). Death within one year of admission for STEMI in 2017 ranged from 18.9% (Netherlands) to 27.8% (US) and 32.3% (Taiwan). Mean hospital length of stay in 2017 for STEMI was lowest in the Netherlands and the US (5.0 and 5.1 days) and highest in Taiwan (8.5 days); 30 day readmission for STEMI was lowest in Taiwan (11.7%) and the US (12.2%) and highest in England (23.1%). Conclusions In an analysis of myocardial infarction in six high income countries, all countries had areas of high performance, but no country excelled in all three domains. Our findings suggest that countries could learn from each other by using international comparisons of patient level nationally representative data.

Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries

“…We applied the same inclusion and exclusion criteria in the same order in each country, although some variations to reflect local differences in data architecture were allowed. More detail is available elsewhere on the data sources used for each country …”

“…From prior work, recording of comorbidities differs markedly across countries due to different incentives for coding . As a result, adjusting for recorded comorbidities in between-country comparisons is likely biased.…”

Readmission Reduction as a Hospital Quality Measure

“…For example, Samsky et al reported that reductions in 30-day readmission rates for heart failure in Canada between 2005 and 2015 were similar to those observed in the US. Cram et al found that reductions in readmissions for myocardial infarction observed in the US between 2011 and 2017 were matched in Canada, the Netherlands, Israel, and Taiwan.…”

Choices that fail health and wellbeing

“…If you made these choices, how could professionals and the public be confident that you will take full advantage of the opportunity of a data-centric health service, including a full and frank conversation about companies’ use of health data (doi:10.1136/bmj.o1018)?13 Could you be trusted with striking new evidence that joint injections for osteoarthritis are potentially beneficial and help us rethink osteoarthritis as a disease of tear, flare, and repair instead of wear and tear (doi:10.1136/bmj-2021-068446, doi:10.1136/bmj.o1028)?1415 Or be relied on to learn the lessons from a multinational study of outcomes after revascularisation for acute myocardial infarction (doi:10.1136/bmj-2021-069164)?16 And you would probably struggle to maximise the clear potential of telemedicine for surgery, a potential that is being realised in the international support for the surgeons and people of Ukraine (doi:10.1136/bmj.o1078). 17…”