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Acknowledging the role of patient heterogeneity in hospital outcome reporting: Mortality after acute myocardial infarction in five European countries.

ABSTRACT: BACKGROUND:Hospital performance, presented as the comparison of average measurements, dismisses that hospital outcomes may vary across types of patients. We aim at drawing out the relevance of accounting for patient heterogeneity when reporting on hospital performance. METHODS:An observational study on administrative data from virtually all 2009 hospital admissions for Acute Myocardial Infarction (AMI) discharged in Denmark, Portugal, Slovenia, Spain, and Sweden. Hospital performance was proxied using in-hospital risk-adjusted mortality. Multilevel Regression Modelling (MLRM) was used to assess differences in hospital performance, comparing the estimates of random intercept modelling (capturing hospital general contextual effects (GCE)), and random slope modelling (capturing hospital contextual effects for patients with and without congestive heart failure -CHF). The weighted Kappa Index (KI) was used to assess the agreement between performance estimates. RESULTS:We analysed 46,875 admissions of AMI, 6,314 with coexistent CHF, discharged from 107 hospitals. The overall in-hospital mortality rate was 5.2%, ranging from 4% in Sweden to 6.9% in Portugal. The MLRM with random slope outperformed the model with only random intercept, highlighting a much higher GCE in CHF patients [VPC = 8.34 (CI95% 4.94 to 13.03) and MOR = 1.69 (CI95% 1.62 to 2.21) vs. VPC = 3.9 (CI95% 2.4 to 5.9), MOR of 1.42 (CI95% 1.31 to 1.54) without CHF]. No agreement was observed between estimates [KI = -0,02 (CI95% -0,08 to 0.04]. CONCLUSIONS:The different GCE in AMI patients with and without CHF, along with the lack of agreement in estimates, suggests that accounting for patient heterogeneity is required to adequately characterize and report on hospital performance.

SUBMITTER: Comendeiro-Maaloe M

PROVIDER: S-EPMC7004308 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Acknowledging the role of patient heterogeneity in hospital outcome reporting: Mortality after acute myocardial infarction in five European countries.

Comendeiro-Maaløe Micaela M Estupiñán-Romero Francisco F Thygesen Lau Caspar LC Mateus Céu C Merlo Juan J Bernal-Delgado Enrique E

PloS one 20200206 2

<h4>Background</h4>Hospital performance, presented as the comparison of average measurements, dismisses that hospital outcomes may vary across types of patients. We aim at drawing out the relevance of accounting for patient heterogeneity when reporting on hospital performance.<h4>Methods</h4>An observational study on administrative data from virtually all 2009 hospital admissions for Acute Myocardial Infarction (AMI) discharged in Denmark, Portugal, Slovenia, Spain, and Sweden. Hospital performa ...[more]

PMID: 32027676

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Project description:BackgroundInternational guidelines recommend that the decision threshold for troponin should be the 99th percentile of a normal population, or, if the laboratory assay is not sufficiently precise at this low level, the level at which the assay achieves a 10% or better coefficient of variation (CV). Our objectives were to examine US hospital laboratory troponin reports to determine whether either the 99th percentile or the 10% CV level were clearly indicated, and whether nonconcordance with these guidelines was a potential barrier to detecting clinically important microscopic or 'microsize' myocardial infarctions (MIs). To confirm past reports of the clinical importance of microsize MIs, we also contrasted in-hospital, 28-day and 1-year mortality among those with microsize and nonmicrosize MI.MethodsIn the REasons for Geographic And Racial Differences in Stroke national prospective cohort study (n=30,239), 1029 participants were hospitalized for acute coronary syndrome (ACS) between 2003-2009. For each case, we recorded all thresholds of abnormal troponin on the laboratory report and whether the 99th percentile or 10% CV value were clearly identified. All cases were expert adjudicated for presence of MI. Peak troponin values were used to classify MIs as microsize MI (< five times the lowest listed upper limit of normal) and nonmicrosize MI.ResultsParticipants were hospitalized at 649 acute care US hospitals, only 2% of whose lab reports clearly identified the 99th percentile or the 10% CV level; 52% of reports indicated an indeterminate range, a practice that is no longer recommended. There were 183 microsize MIs and 353 nonmicrosize MIs. In-hospital mortality tended to be lower in the microsize than in the nonmicrosize MI group (1.1 vs. 3.6%, p?=?0.09), but 28-day and 1-year mortality were similar (2.5% vs. 2.7% [p?=?0.93] and 5.2% vs. 4.3% [p?=?0.64], respectively).ConclusionsCurrent practices in many US hospitals created barriers to the clinical recognition of microsize MI, which was common and clinically important in our study. Improved hospital troponin reporting is warranted.

Project description:Aim:The acute phase of myocardial infarction (MI) is accompanied by edema contributing to tissue damage and disease outcome. Here, we aimed to identify the mechanism whereby vascular endothelial growth factor (VEGF)-A induces myocardial edema in the acute phase of MI to eventually promote development of therapeutics to specifically suppress VEGFA-regulated vascular permeability while preserving collateral vessel formation. Methods and Results:VEGFA regulates vascular permeability and edema by activation of VEGF receptor-2 (VEGFR2), leading to induction of several signaling pathways including the cytoplasmic tyrosine kinase c-Src. The activated c-Src in turn phosphorylates vascular endothelial (VE)-cadherin, leading to dissociation of endothelial adherens junctions. A particular tyrosine at position 949 in mouse VEGFR2 has been shown to be required for activation of c-Src. Wild-type mice and mice with phenylalanine replacing tyrosine (Y) 949 in VEGFR2 (Vegfr2 Y949F/Y949F ) were challenged with MI through permanent ligation of the left anterior descending coronary artery. The infarct size was similar in wild-type and mutant mice, but left ventricular wall edema and fibrinogen deposition, indicative of vascular leakage, were reduced in the Vegfr2 Y949F/Y949F strain. When challenged with large infarcts, the Vegfr2 Y949F/Y949F mice survived significantly better than the wild-type strain. Moreover, neutrophil infiltration and levels of myeloperoxidase were low in the infarcted Vegfr2 Y949F/Y949F hearts, correlating with improved survival. In vivo tyrosine phosphorylation of VE-cadherin at Y685, implicated in regulation of vascular permeability, was induced by circulating VEGFA in the wild-type but remained at baseline levels in the Vegfr2 Y949F/Y949F hearts. Conclusion:Suppression of VEGFA/VEGFR2-regulated vascular permeability leads to diminished edema without affecting vascular density correlating with improved myocardial parameters and survival after MI.

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Acknowledging the role of patient heterogeneity in hospital outcome reporting: Mortality after acute myocardial infarction in five European countries.

Publications

Acknowledging the role of patient heterogeneity in hospital outcome reporting: Mortality after acute myocardial infarction in five European countries.

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