Dataset Information

Association of Hospital-Level Differences in Care With Outcomes Among Patients With Acute ST-Segment Elevation Myocardial Infarction in China.

ABSTRACT: Importance:The incidence of acute myocardial infarction has increased over the past decades in China, and management challenges include an unbalanced economy, disparate resources, and variable access to medical care across the nation. Objective:To examine the variations in care and outcomes of patients with ST-segment elevation myocardial infarction among 3 levels of hospitals in the typical Chinese public hospital model. Design, Setting, and Participants:This cross-sectional study used data from the China Acute Myocardial Infarction Registry to compare the differences in care and outcomes among patients at 108 hospitals from 31 provinces and municipalities throughout mainland China. Participants included patients with ST-segment elevation myocardial infarction directly admitted to hospitals between January 2013 and September 2014. Data analyses were performed from June 2015 to June 2019. Exposures:Care in province-level, prefecture-level, or county-level hospitals in China. Main Outcomes and Measures:The primary outcome was in-hospital mortality. Secondary outcomes included presentation, treatments, and major complications. Results:A total of 12?695 patients (9593 men [75.6%]; median [interquartile range] age, 63 [54-72] years) were included; 3985 were at province-level hospitals, 6731 were at prefecture-level hospitals, and 1979 were at county-level hospitals. Compared with patients admitted to province-level hospitals, those admitted to prefecture-level and county-level hospitals were older (median [interquartile range] age, 61 [52-70] years vs 63 [54-72] years and 65 [57-75] years) and more likely to be women (815 women [20.5%] vs 1620 women [24.1%] and 667 women [33.7%]). Patients in prefecture-level and county-level hospitals were less likely to use ambulances compared with patients at province-level hospitals (11.6% [95% CI, 10.8%-12.4%] and 12.0% [95% CI, 10.6%-13.5%] vs 19.4% [95% CI, 18.1%-20.7%]; P?

SUBMITTER: Xu H

PROVIDER: S-EPMC7584928 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Association of Hospital-Level Differences in Care With Outcomes Among Patients With Acute ST-Segment Elevation Myocardial Infarction in China.

Xu Haiyan H Yang Yuejin Y Wang Chuangshi C Yang Jingang J Li Wei W Zhang Xuan X Ye Yunqing Y Dong Qiuting Q Fu Rui R Sun Hui H Yan Xinxin X Gao Xiaojin X Wang Yang Y Jia Xuan X Sun Yi Y Wu Yuan Y Zhang Jun J Zhao Wei W Sabatine Marc S MS Wiviott Stephen D SD

JAMA network open 20201001 10

<h4>Importance</h4>The incidence of acute myocardial infarction has increased over the past decades in China, and management challenges include an unbalanced economy, disparate resources, and variable access to medical care across the nation.<h4>Objective</h4>To examine the variations in care and outcomes of patients with ST-segment elevation myocardial infarction among 3 levels of hospitals in the typical Chinese public hospital model.<h4>Design, setting, and participants</h4>This cross-section ...[more]

PMID: 33095249

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Project description:BackgroundWith the growing burden of non-ST-elevation myocardial infarction (NSTEMI), developing countries face great challenges in providing equitable treatment nationwide. However, little is known about hospital-level disparities in the quality of NSTEMI care in China. We aimed to investigate the variations in NSTEMI care and patient outcomes across the three hospital levels (province-, prefecture- and county-level, with decreasing scale) in China.MethodsData were derived from the China Acute Myocardial Infarction Registry on patients with NSTEMI consecutively registered between January 2013 and November 2016 from 31 provinces and municipalities throughout mainland China. Patients were categorized according to the hospital level they were admitted to. Multilevel generalized mixed models were fitted to examine the relationship between the hospital level and in-hospital mortality risk.ResultsIn total, 8,054 patients with NSTEMI were included (province-level: 1,698 patients; prefecture-level: 5,240 patients; county-level: 1,116 patients). Patients in the prefecture- and county-level hospitals were older, more likely to be female, and presented worse cardiac function than those in the province-level hospitals (P <0.05). Compared with the province-level hospitals, the rate of invasive strategies was significantly lower in the prefecture- and county-level hospitals (65.3, 43.3, and 15.4%, respectively, P <0.001). Invasive strategies were performed within the guideline-recommended timeframe in 25.4, 9.7, and 1.7% of very-high-risk patients, and 16.4, 7.4, and 2.4% of high-risk patients in province-, prefecture- and county-level hospitals, respectively (both P <0.001). The use of dual antiplatelet therapy in the county-level hospitals (87.2%) remained inadequate compared to the province- (94.5%, P <0.001) and prefecture-level hospitals (94.5%, P <0.001). There was an incremental trend of in-hospital mortality from province- to prefecture- to county-level hospitals (3.0, 4.4, and 6.9%, respectively, P-trend <0.001). After stepwise adjustment for patient characteristics, presentation, hospital facilities and in-hospital treatments, the hospital-level gap in mortality risk gradually narrowed and lost statistical significance in the fully adjusted model [Odds ratio: province-level vs. prefecture-level: 1.23 (0.73-2.05), P = 0.441; province-level vs. county-level: 1.61 (0.80-3.26), P = 0.182; P-trend = 0.246].ConclusionsThere were significant variations in NSTEMI presentation and treatment patterns across the three hospital levels in China, which may largely explain the hospital-level disparity in in-hospital mortality. Quality improvement initiatives are warranted, especially among lower-level hospitals.

Project description:BackgroundDespite the importance of ST-segment elevation myocardial infarction (STEMI) in China, no nationally representative studies have characterised the clinical profiles, management, and outcomes of this cardiac event during the past decade. We aimed to assess trends in characteristics, treatment, and outcomes for patients with STEMI in China between 2001 and 2011.MethodsIn a retrospective analysis of hospital records, we used a two-stage random sampling design to create a nationally representative sample of patients in China admitted to hospital for STEMI in 3 years (2001, 2006, and 2011). In the first stage, we used a simple random-sampling procedure stratified by economic-geographical region to generate a list of participating hospitals. In the second stage we obtained case data for rates of STEMI, treatments, and baseline characteristics from patients attending each sampled hospital with a systematic sampling approach. We weighted our findings to estimate nationally representative rates and assess changes from 2001 to 2011. This study is registered with ClinicalTrials.gov, number NCT01624883.FindingsWe sampled 175 hospitals (162 participated in the study) and 18,631 acute myocardial infarction admissions, of which 13,815 were STEMI admissions. 12,264 patients were included in analysis of treatments, procedures, and tests, and 11,986 were included in analysis of in-hospital outcomes. Between 2001 and 2011, estimated national rates of hospital admission for STEMI per 100,000 people increased (from 3·5 in 2001, to 7·9 in 2006, to 15·4 in 2011; ptrend<0·0001) and the prevalence of risk factors-including smoking, hypertension, diabetes, and dyslipidaemia-increased. We noted significant increases in use of aspirin within 24 h (79·7% [95% CI 77·9-81·5] in 2001 vs 91·2% [90·5-91·8] in 2011, ptrend<0·0001) and clopidogrel (1·5% [95% CI 1·0-2·1] in 2001 vs 82·1% [81·1-83·0] in 2011, ptrend<0·0001) in patients without documented contraindications. Despite an increase in the use of primary percutaneous coronary intervention (10·6% [95% CI 8·6-12·6] in 2001 vs 28·1% [26·6-29·7] in 2011, ptrend<0·0001), the proportion of patients who did not receive reperfusion did not significantly change (45·3% [95% CI 42·1-48·5] in 2001 vs 44·8% [43·1-46·5] in 2011, ptrend=0·69). The median length of hospital stay decreased from 12 days (IQR 7-18) in 2001 to 10 days (6-14) in 2011 (ptrend<0·0001). Adjusted in-hospital mortality did not significantly change between 2001 and 2011 (odds ratio 0·82, 95% CI 0·62-1·10, ptrend=0·07).InterpretationDuring the past decade in China, hospital admissions for STEMI have risen; in these patients, comorbidities and the intensity of testing and treatment have increased. Quality of care has improved for some treatments, but important gaps persist and in-hospital mortality has not decreased. National efforts are needed to improve the care and outcomes for patients with STEMI in China.FundingNational Health and Family Planning Commission of China.

Project description:BackgroundSex differences in clinical characteristics and in-hospital outcomes among patients with non-ST-segment-elevation myocardial infarction have been described in Western countries, but whether these differences exist in China is unknown.MethodsWe used a 2-stage random sampling design to create a nationally representative sample of patients admitted to 151 Chinese hospitals for non-ST-segment-elevation myocardial infarction in 2006, 2011, and 2015 and examined sex differences in clinical profiles, treatments, and in-hospital outcomes over this time. Multivariable logistic regression models adjusting for age or other potentially confounding clinical covariates were used to estimate these sex-specific differences.ResultsAmong 4611 patients, the proportion of women (39.8%) was unchanged between 2006 and 2015. Women were older with higher rates of hypertension, diabetes, and dyslipidemia. Among patients without contraindications, women were less likely to receive treatments than men, with significant differences for aspirin in 2015 (90.3% versus 93.9%) and for invasive strategy in 2011 (28.7% versus 45.7%) and 2015 (34.0% versus 48.4%). After adjusting for age, such differences in aspirin and invasive strategy in 2015 were not significant, but the difference in invasive strategy in 2011 persisted. The sex gaps in the use of invasive strategy did not narrow. From 2006 to 2015, a significant decrease in in-hospital mortality was observed in men (from 16.9% to 8.7%), but not in women (from 11.8% to 12.0%), with significant interaction between sex and study year (P=0.023). After adjustment, in-hospital mortality in women was significantly lower than men in 2006, but not in 2011 or 2015.ConclusionsSex differences in cardiovascular risk factors and invasive strategy after non-ST-segment-elevation myocardial infarction were observed between 2011 and 2015 in China. Although sex gaps in in-hospital mortality were largely explained by age differences, efforts to narrow sex-related disparities in quality of care should remain a focus.RegistrationURL: http://www.Clinicaltrialsgov; Unique identifier: NCT01624883.

Dataset Information

Association of Hospital-Level Differences in Care With Outcomes Among Patients With Acute ST-Segment Elevation Myocardial Infarction in China.

Publications

Association of Hospital-Level Differences in Care With Outcomes Among Patients With Acute ST-Segment Elevation Myocardial Infarction in China.

Similar Datasets

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