Mortalidad intrahospitalaria por infarto agudo de miocardio. Relevancia del tipo de hospital y la atención dispensada. Estudio RECALCAR

Impact on Mortality of Different Network Systems in the Treatment of ST-segment Elevation Acute Myocardial Infarction. The Spanish Experience

INTRODUCTION AND OBJECTIVES

To analyze the association between the development of network systems of care for ST-segment elevation myocardial infarction (STEMI) in the autonomous communities (AC) of Spain and the regional rate of percutaneous coronary intervention (PCI) and in-hospital mortality.

METHODS

From 2003 to 2012, data from the minimum basic data set of the Spanish taxpayer-funded health system were analyzed, including admissions from general hospitals. Diagnoses of STEMI and related procedures were codified by the International Diseases Classification. Discharge episodes (n = 302 471) were distributed in 3 groups: PCI (n = 116 621), thrombolysis (n = 46 720), or no reperfusion (n = 139 130).

RESULTS

Crude mortality throughout the evaluation period was higher for the no-PCI or thrombolysis group (17.3%) than for PCI (4.8%) and thrombolysis (8.6%) (P < .001). For the aggregate of all communities, the PCI rate increased (21.6% in 2003 vs 54.5% in 2012; P < .001) with a decrease in risk-standardized mortality rates (10.2% in 2003; 6.8% in 2012; P < .001). Significant differences were observed in the PCI rate across the AC. The development of network systems was associated with a 50% increase in the PCI rate (P < .001) and a 14% decrease in risk-standardized mortality rates (P < .001).

CONCLUSIONS

From 2003 to 2012, the PCI rate in STEMI substantially increased in Spain. The development of network systems was associated with an increase in the PCI rate and a decrease in in-hospital mortality.

Changes in Acute Coronary Syndrome Treatment and Prognosis After Implementation of the Infarction Code in a Hospital With a Cardiac Catheterization Unit

INTRODUCTION AND OBJECTIVES

Emergency care systems have been created to improve treatment and revascularization in myocardial infarction but they may also improve the management of all patients with acute coronary syndrome.

METHODS

A comparative study of all patients admitted with acute coronary syndrome before and after implementation of an infarction protocol.

RESULTS

The study included 1210 patients. While the mean age was the same in both periods, the patient group admitted after implementation of the protocol had a lower prevalence of diabetes mellitus and hypertension but more active smokers and higher GRACE scores. The percentage of ST-segment elevation acute coronary syndrome (29.8%-39.5%) and coronary revascularizations (82.1%-90.1%) significantly increased among patients admitted with acute coronary syndrome, and primary angioplasty became routine (51.9%-94.9%); there was also a reduction in time to catheterization and an increase in early revascularization. The mean hospital stay was significantly shorter after implementation of the infarction protocol. In-hospital mortality was unchanged, except in high-risk patients (38.8%-22.4%). After discharge, no differences were observed between the 2 periods in cardiovascular mortality, all-cause mortality, reinfarction, or major cardiovascular complications.

CONCLUSIONS

After implementation of the infarction protocol, the percentage of patients admitted with ST-segment elevation acute coronary syndrome and the mean GRACE score increased among patients admitted with acute coronary syndrome. Hospital stay was reduced, and primary angioplasty use increased. In-hospital mortality was reduced in high-risk patients, and prognosis after discharge was the same in both periods.

Benchmarking in Thoracic Surgery. Third Edition

INTRODUCTION

Benchmarking entails continuous comparison of efficacy and quality among products and activities, with the primary objective of achieving excellence.

OBJECTIVE

To analyze the results of benchmarking performed in 2013 on clinical practices undertaken in 2012 in 17 Spanish thoracic surgery units.

METHODS

Study data were obtained from the basic minimum data set for hospitalization, registered in 2012. Data from hospital discharge reports were submitted by the participating groups, but staff from the corresponding departments did not intervene in data collection. Study cases all involved hospital discharges recorded in the participating sites. Episodes included were respiratory surgery (Major Diagnostic Category 04, Surgery), and those of the thoracic surgery unit. Cases were labelled using codes from the International Classification of Diseases, 9th revision, Clinical Modification. The refined diagnosis-related groups classification was used to evaluate differences in severity and complexity of cases.

RESULTS

General parameters (number of cases, mean stay, complications, readmissions, mortality, and activity) varied widely among the participating groups. Specific interventions (lobectomy, pneumonectomy, atypical resections, and treatment of pneumothorax) also varied widely.

CONCLUSIONS

As in previous editions, practices among participating groups varied considerably. Some areas for improvement emerge: admission processes need to be standardized to avoid urgent admissions and to improve pre-operative care; hospital discharges should be streamlined and discharge reports improved by including all procedures and complications. Some units have parameters which deviate excessively from the norm, and these sites need to review their processes in depth. Coding of diagnoses and comorbidities is another area where improvement is needed.

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.

Prognostic Benefit of Beta-blockers After Acute Coronary Syndrome With Preserved Systolic Function. Still Relevant Today?

INTRODUCTION AND OBJECTIVES

The scientific evidence for using beta-blockers after acute coronary syndrome stems from studies conducted in the days before coronary revascularization and in patients with ventricular dysfunction. The aim of this study was to analyze the current long-term prognostic benefit of beta-blockers in patients with acute coronary syndrome and preserved left ventricular ejection fraction.

METHODS

We conducted a retrospective cohort study of 3236 patients with acute coronary syndrome and left ventricular ejection fraction ≥ 50%. We performed a propensity-matched analysis to draw up two groups of 555 patients paired according to whether or not they had been treated with beta-blockers. The prognostic value of beta-blockers to predict mortality during follow-up was analyzed using Cox regression.

RESULTS

During the follow-up (median, 5.2 years), 506 patients (15.6%) died. Patients treated with beta-blockers (n=2277 [70.4%]) had a lower mortality rate (11.6% vs 25.2%; P<.001). After propensity score matching, we found that mortality during follow-up was still lower in the beta-blocker group (14.4% vs 18.9%; P=.020). Therefore, this treatment was an independent protective factor after adjusting for confounding variables in the multivariate Cox regression analysis (hazard ratio=0.64; 95% confidence interval, 0.48-0.87; P=.004).

CONCLUSIONS

Beta-blocker treatment in patients with acute coronary syndrome and preserved left ventricular ejection fraction is associated with lower long-term mortality.