Assessing the Quality of Care for Patients With Acute Myocardial Infarction in China

Acute coronary syndrome and its treatment outcomes in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Acute coronary syndrome (ACS) is the principal cause of death in developing countries including Ethiopia. No study reports the overall patterns of risk factors and burden of in-hospital mortality in Ethiopia. This study, therefore, aimed to assess the magnitude of risk factors, management, and in-hospital mortality of ACS in Ethiopia.

METHODS

Electronic searching of articles was conducted using PubMed, Science Direct, EMBASE, Scopus, Hinari, and Google Scholar to access articles conducted in Ethiopia. The Preferred Reporting Items for Systematic Reviews checklist was used for identification, eligibility screening, and selection of articles. Data were extracted with an abstraction form prepared with Microsoft Excel and exported to STATA for analysis. Funnel plot, Begg's test, and Egger's test were used to determine publication bias. Heterogeneity between the studies was checked by I2 statistic. The pooled prevalence of risk factors and in-hospital mortality of ACS were estimated using a random-effects meta-analysis model.

RESULTS

Most (59.367%) of the patients had ST-segment elevation myocardial infarction (STEMI). Hypertension (54.814%) was the leading risk factor for ACS followed by diabetes mellitus (38.549%). Aspirin (56.903%) and clopidogrel (55.266%) were most frequently used in patients with STEMI ACS, respectively. The pooled proportion of in-hospital mortality of ACS was 14.82% which was higher in patients with STEMI (16.116%).

CONCLUSION

The rate of in-hospital mortality is still high which was higher in patients with STEMI. Initiation of treatment must consider the heterogeneity of each patient's risk factor and reperfusion therapy should be implemented in our setting.

Assessment of Hospital Performance Using Quality of Care Indicators in Patients with Acute Coronary Syndrome

BACKGROUND: Global researchers have found a wide practice gap between the optimal care and actual care of patients with acute coronary syndrome (ACS). AIM: The main objective of the present study was to evaluate the quality of care provided to patients with ACS and compare our results to that of other similar studies and international standards. METHODS: A descriptive study was conducted using review of medical records and medical charts of new patients admitted and treated as ACS at the Department of Critical Care Medicine, Cairo University, from January 1, 2015, to December 31, 2020. For the purpose of the analysis, a set of highly predictive quality indicators was used. RESULTS: 967 patients were divided into two groups: 621 patients with acute ST-segment elevation myocardial infarction (STEMI) (mean age: 58.49 ± 11.45 years, 81.8% of males) and 34.9% presented to hospital in <4 h of symptom onset. Primary percutaneous coronary interventions (PCIs) were applied on 71.3% of cases (N = 443) and the mean “door-to-balloon” time was 78.8 min. In the first 24 h, acetylsalicylic acid (ASA), β-blockers, and angiotensin-converting enzyme inhibitors (ACE-I) or AR-blockers were administered in 100%, 65.9%, and 73.4% of the total eligible cases, respectively. At discharge, ASA, β-blockers, ACE-I/ARBs, and statins were prescribed in 90.8%, 78.3%, 82.8%, and 90.8%, respectively. 346 patients were with UA/NSTEMI (mean age 63±25.7 years, 69.4% male), while 21.7% of patients were presented to hospital after less than 4 hours of symptoms onset. Early PCIs were applied on 28.1% of cases (N = 97). In the first 24 h, ASA, β-blockers, and ACE-I or AR-blockers were administered in 100%, 78.3%, and 78.6% of the total eligible cases, respectively. At discharge, ASA, β-blockers, ACE-I/ARBs, and statins were prescribed in 93.4%, 83.2%, 81.2%, and 92.8%, respectively. In this study, a relation between different quality indicators with inhospital major adverse cardiac event and outcome was observed. CONCLUSION: There is still substantial work that lies ahead on the way to improve the uptake to evidence-based processes of care. We found some disparities between guidelines and clinical practice for ACS patients and a significant association between process indicators and inhospital outcomes. Our findings are potentially helpful for assessing and improving the quality of care for ACS patients in Egypt.

Prognostic Value of Circulating MG53 Levels in Acute Myocardial Infarction

Background: Mitsugumin 53 (MG53), a muscle-specific protein belonging to the TRIM family, has been demonstrated to protect the heart against oxidative injury. Although previous studies indicated that ischemic hearts released MG53 into circulation in mice, its effects in humans remains unknown. We aimed to evaluate the prognostic value of MG53 in patients with ST-segment elevation myocardial infarction (STEMI).

Methods: Serum levels of MG53 were measured in 300 patients with STEMI, all patients were followed for 3 years. The primary endpoint was major adverse cardiovascular events (MACE), defined as a composite of cardiovascular (CV) death, heart failure causing-rehospitalization, recurrent myocardial infarction (MI), and stroke.

Results: Patients with a higher concentration of serum MG53 tended to be older, with a history of diabetes. MG53 levels were also highly associated with indicators reflecting heart function, such as left ventricular ejection fraction (LVEF), N terminal pro B type natriuretic peptide (NT-pro-BNP), and cardiac troponin I (cTnI) at baseline. Kaplan-Meier survival curves demonstrated that patients with MG53 levels above the cutoff value (132.17 pg/ml) were more likely to have MACEs. Moreover, it was found to be a significant predictor of CV death (HR: 6.12; 95% CI: 2.10–17.86; p = 0.001). Furthermore, the C-statistic and Integrated Discrimination Improvement (IDI) values for MACEs were improved with MG53 as an independent risk factor or when combined with cTnI.

Conclusions: MG53 is a valuable prognostic marker of MACE in patients with AMI, independent of established conventional risk factors, highlighting the significance of MG53 in risk stratification post-MI.

Association between compliance with quality indicators and hospitalisation expenses in patients with heart failure: a retrospective study using quantile regression model in China

OBJECTIVE

To explore the association between compliance with quality indicators and hospitalisation expenses in patients with heart failure.

DESIGN

Generalised linear model and quantile regression model were used to examine the association between compliance with five quality indicators and hospitalisation expenses.

SETTING

Grade A hospital in Fujian Province, China.

PARTICIPANTS

Data on 2568 heart failure admissions between 2010 and 2015 were analysed.

RESULTS

The median (IQR) of hospitalisation expenses of 2568 patients was ¥10.9 (¥6.9-¥31.6) thousand. The rates of compliance with five quality indicators were 90.3% for evaluation of left ventricular function, 43.8% for diuretics, 62.0% for ACE inhibitors (ACEI) or angiotensin receptor blockers (ARB), 67.4% for beta-blockers, and 58.9% for aldosterone receptor antagonists. After adjustment for gender, age, residence, method of payment, number of diseases before admission, number of diseases at admission, number of emergency treatments during hospital stay and length of stay, patients who received evaluation for left ventricular function, diuretics, or ACEI or ARB had lower hospitalisation expenses, and patients who received beta-blockers had higher hospitalisation expenses, compared with their counterparts in generalised linear models. Differences in hospitalisation expenses between compliance and non-compliance with quality indicators became larger across quantile levels of hospitalisation expenses, and were found to be statistically significant when quantile level exceeded 0.80 (¥39.7 thousand) in quantile regression models.

CONCLUSIONS

The quality of care for patients with heart failure was below the target level. There was a negative relationship between compliance with quality indicators and hospitalisation expenses at the extreme quantile of expenses. More attention should be given to patients who may experience extreme expenses, and effective measures should be taken to improve the quality of care they receive.

Association between Adherence to Guideline-Recommended Preventive Medications and In-Hospital Mortality among Non-Reperfused ST-Elevation Myocardial Infarction Patients Admitted to a Tertiary Care Academic Center in a Developing Country

Background and aims

Acute ST-elevation myocardial infarction (STEMI) is a potentially fatal presentation of coronary artery disease (CAD). Evidence of the impact of acute pharmacological interventions in non-reperfused STEMI patients on subsequent events is limited. We aimed to assess the association between adherence to guideline-recommended preventive medications and in-hospital mortality among this high-risk patient population.

Methods

We conducted a cohort study using data obtained from the Jakarta Acute Coronary Syndrome (JAC) Registry database from a tertiary care academic hospital in Indonesia. We included 1132 of 2694 patients with STEMI recorded between 1 January 2014 and 31 December 2016 who did not undergo acute reperfusion therapy. Adherence to guideline-recommended preventive medications was defined as the combined administration of aspirin, clopidogrel, anticoagulants and statins after hospital admission. The main outcome measure was in-hospital mortality.

Results

Overall, 778 of 1132 patients (69%) received the combination of preventive medications. The guideline non-adherent group had significantly more patients with earlier onset of STEMI, higher Killip class and thrombolysis in myocardial infarction (TIMI) score. After adjustments for measured characteristics using logistic regression modeling, exposure to the combination of preventive therapies was associated with a statistically significant lower risk for in-hospital mortality (adjusted odds ratio: 0.46, 95% confidence interval: 0.30-0.70).

Conclusions

Adherence to guideline-recommended preventive medications was associated with lower risk of in-hospital mortality in non-reperfused STEMI patients. The predictors of not receiving these medications need to be confirmed in future research.

Quality of Care for Patients with Acute Myocardial Infarction (AMI) in Pakistan: A Retrospective Study

A wide variation exists in the practice patterns of acute myocardial infarction (AMI) care worldwide, leading to differences in clinical outcomes. This study aims to evaluate the quality of process care and its impact on in-hospital outcomes among AMI patients in Pakistan, as no such study has been conducted in Pakistan thus far based upon recommended guidelines. We investigated a sample of 2663 AMI patients across 11 territory hospitals in Punjab province of Lahore, Faisalabad, Multan, Rawalpindi, and Islamabad from January 1, 2016 to December 31, 2017, with an in-hospital mortality rate of 8.6%. We calculated compliance rates of quality indicators (QIs) for all eligible patients. The association between process care and in-hospital outcome was assessed using hierarchical generalized linear model that adjusted for patient and hospital characteristics. In addition, we examined the effect of patient composite scores on clinical outcomes. Aspirin (73.08%) and clopidogrel (67.86%) indicated relatively better conformance than other QIs. The percutaneous coronary intervention also showed significantly low adherence. All QIs showed no significant association with in-hospital mortality. In contrast, 4 out of 8 QIs were observed positively correlated with in-hospital length of stay (LOS). The overall patient composite score was found to be statistically significant with in-hospital LOS. The assessment of quality of care showed low adherence to clinical care recommendations, and increased adherence was associated with longer in-hospital LOS among AMI patients. Evaluation of valid QIs for AMI treatment and their impact on in-hospital outcomes is an important tool for improving health care delivery in the overall AMI population in Pakistan. Low adherence to performance measures strongly compel to focus on guideline-based tools for AMI in Pakistan.

Cardioprotective medication adherence among patients with coronary heart disease in China: a systematic review

In China, poor cardioprotective medication adherence is a key reason for the high mortality rate of coronary heart disease (CHD). The aims of this systematic review are to (1) describe and synthesise factors that influence medication adherence among Chinese people with CHD, (2) evaluate the current status of intervention studies, and (3) discuss directions of future research to improve medication adherence. A comprehensive search using PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Scopus, Global Health and PsycINFO was undertaken to describe poor adherence in China. Thirty-three eligible articles were included in the study. The review shows that there are multiple contributing factors to poor medication adherence, including patients' sociodemographic characteristics, health status and medication characteristics. In addition, from patients' perspective, lack of medication-related knowledge, such as the name, function, dosage and frequency, contributes to poor adherence. From physicians' perspective, a gap exists between CHD secondary prevention guidelines and clinical practice in China. Follow-up phone calls, educational lectures, booklets and reminder cards were common methods found to be effective in improving medication adherence. This systematic review indicates that cardioprotective medications were commonly prescribed as secondary prevention medication to patients with CHD in China, but adherence to these medications gradually decreased during a follow-up period. Therefore, more research should be conducted on how to establish high-quality health educational programmes aimed at increasing patients' medication adherence.

Association Between Medication Adherence and 1-Year Major Cardiovascular Adverse Events After Acute Myocardial Infarction in China

Background Secondary prevention after acute myocardial infarction ( AMI ) requires long-term guideline-directed medical therapy. However, the level of medication adherence, factors associated with poor adherence, and extent to which good adherence can reduce adverse events after AMI in China remain uncertain. Methods and Results In 2013 to 2014, 4001 AMI patients aged ≥18 years were discharged alive from 53 hospitals across China (mean age 60.5±11.7 years; 22.7% female). Good adherence was defined as taking medications (aspirin, β-blockers, statins, clopidogrel, or angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers) ≥90% of the time as prescribed. Cox models assessed the association between good adherence (a time-varying covariate) and 1-year cardiovascular events after AMI . The most common medications were aspirin (82.2%) and statins (80.5%). There were 243 patients who were not prescribed any medications during follow-up; 1-year event rates were higher for these patients (25.1%, 95% CI 19.7-30.6%) versus those taking ≥1 medications (6.6%, 95% CI 5.76-7.34%). The overall rate of good adherence was 52.9%. Good adherence was associated with lower risk of 1-year events (adjusted hazard ratio 0.61, 95% CI 0.49-0.77). The most common reason for poor adherence was belief that one's condition had improved/no longer required medication. More comorbidities and lower education level were associated with poor adherence. Conclusions Good adherence reduced 1-year cardiovascular event risk after AMI . About half of our cohort did not have good adherence. National efforts to improve AMI outcomes in China should focus on medication adherence and educating patients on the importance of cardiovascular medications for reducing risk of recurrent events. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT01624909.

Level and variation on quality of care in China: a cross-sectional study for the acute myocardial infarction patients in tertiary hospitals in Beijing

Background

Quality of care (QoC) attracts global concerns when unsafe and misuse of healthcare wastes resources and endangers people’s health, especially in low- and middle-income countries. However, little is known about quality of care delivered in China. This study was intended to gauge the quality of care for acute myocardial infarction (AMI) patients in Beijing and identify the quality gaps across tertiary hospitals.

Methods

One thousand two hundred twenty eight patients, covered by Employee Essential Health Insurance Scheme and diagnosed of AMI, was sampled from 14 large comprehensive hospitals in Beijing, China. Chart review study was conducted through the discharge data and medical records of inpatients to evaluate 6 quality outcomes of interest, including the use of aspirin, beta blocker, and statin at discharge; use of aspirin within 24 h at arrival; angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD); percutaneous transluminal coronary intervention (PCI) within 90 min at arrival.

Results

Of the 1228 subjects, the mean age was 60.8 (11.8 SD) years and 83.0% were male. The overall medication prescribed was highly compliant with the clinical guidelines (97.0% [95% CI 96.8–97.2] for aspirin and 96.3% [95% CI 96.0–96.5] for statin), except for beta-blocker (83.6% [95% CI 83.0–84.1]) and ACEI/ARB use (61.4% [95% CI 60.7–62.2]). More than half of eligible patients did not receive appropriate PCI therapy (44.0% [95% CI 42.5–45.4]). Great variations across hospitals was observed in aspirin within 24 h and beta-blocker at discharge (P < 0.001), and the risk-adjusted results remained robust.

Conclusion

Underuse of recommended treatment and significant variations of quality were found for AMI patients across tertiary hospitals in Beijing. It raised great concerns on poorer quality of care in other less-developed areas with less medical resources. Practical actions are needed in reducing quality gaps to ensure the delivery of quality care.

The development of indicator measure for monitoring the quality of patient-centered care in China's tertiary hospitals

OBJECTIVE

To develop a set of structure and process indicators to evaluate tertiary hospitals' performance in the Healthcare Improvement Initiative, a national program with a goal to improve quality of patient-centered care.

METHODS

A modified Delphi technique, including literature review, multidisciplinary panel meeting and anonymous rating, was used to generate a set of indicators. A practice test involving both general and special hospitals was conducted to ensure the feasibility of data collection for these indicators.

RESULTS

62 indicators were generated by literature review. The panel review procedure involving 39 panelists with diverse backgrounds resulted in a total of 59 indicators, which included 40 qualitative indicators and 19 quantitative indicators. In the practice test, six quantitative indicators were found unfeasible. According to the suggestion of the experts in the hospital evaluation committee, three of those indicators were kept by adjusting their data collection methods, while other three ones were discarded.

DISCUSSION

A set of 56 structure and process indicators was developed to evaluate hospitals' performance in the implementation of the Healthcare Improvement Initiative, which could be used in both general and special tertiary hospitals. Results of the indicator measurement could present a panorama of the quality of patient-centered care in tertiary hospitals nation-wide, and inform health administrators of the ways to attain the goal of the Initiative.

Factors that contribute to poor adherence to statin therapy in coronary heart disease patients from Chongqing and measures to improve their therapeutic outcomes

To assess the efficacy and short-term outcomes of adherence to statin therapy among coronary heart disease (CHD) patients following their hospital discharge, we enrolled 615 CHD patients who were prescribed statins from The First Affiliated Hospital of Chongqing Medical University in China between February 1st and October 31st of 2013. Statin adherence was evaluated by identifying the proportion of patients who remained adherent or became non-adherent to statin therapy over 4–8 months post-discharge from the hospital. The composite outcomes included all-cause mortality and re-hospitalization with cardiovascular disease. We found that 15.9% patients were non-adherent to their statin therapies and that coronary artery stenosis<75% (OR = 3.433, 95% CI: 2.191–5.380, p < 0.001) and adverse effects (OR = 2.542, 95% CI: 1.327–4.869, p = 0.005) both clearly contributed to poor adherence. The primary self-reported reasons for non-adherence included a lack of knowledge about the benefits of statin therapy (36.7%), the treatment being halted at the advice of their doctor (19.4%), and the difficulty in obtaining statins (12.2%). Non-adherence to statin therapy was significantly associated with an increased risk of cardiovascular events (OR = 1.741, 95% CI: 1.035–2.929, p = 0.037). In conclusion, CHD patients with moderate stenosis or adverse effects tended to have poor statin adherence, and this was significantly associated with increased cardiovascular events. We should strengthen education of the importance of statin therapy for both patients and doctors and facilitate the ability of patients to obtain their statin medication.

Clinical Study Register Code: ChiCTR-EPC-16007839.

Roles of ST2, IL-33 and BNP in predicting major adverse cardiovascular events in acute myocardial infarction after percutaneous coronary intervention

This study investigated roles of serum ST2, IL-33 and BNP in predicting major adverse cardiovascular events (MACEs) in acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI). Blood samples were collected from the included AMI patients (n = 180) who underwent PCI. All patients were divided into the MACEs and MACEs-free groups. Enzyme-linked immunosorbent assay was performed to measure serum levels of ST2, IL-33 and BNP. Severity of coronary artery lesion was evaluated by Gensini score. Pearson correlation analysis was used. A receiver operating characteristics curve was drawn to evaluate the potential roles of ST2, IL-33 and BNP in predicting MACEs, and Kaplan-Meier curve to analyse the 1-year overall survival rate. Logistic regression analysis was conducted to analyse the independent risk factors for MACEs. Compared with the MACEs-free group, the serum levels of ST2, IL-33 and BNP were significantly higher in the MACEs group. Serum levels of ST2, IL-33 and BNP were positively correlated with each other and positively correlated with Gensini score. The area under curves of ST2, IL-33 and BNP, respectively, were 0.872, 0.675 and 0.902. The relative sensitivity and specificity were, respectively, 76.27% and 85.92%, 69.49% and 58.68%, as well as, 96.61% and 77.69%. Serum levels of ST2, IL-33 and BNP were independent risk factors for MACEs. The 1-year overall survival rate was higher in AMI patients with lower serum levels of ST2, IL-33 and BNP. In conclusion, serum levels of ST2, IL-33 and BNP have potential value in predicting MACEs in AMI patients undergoing PCI.

The Contemporary Use of Angiography and Revascularization Among Patients With Non-ST-Segment Elevation Myocardial Infarction in the United States Compared With South Korea

BACKGROUND

Practice guidelines recommend an early invasive strategy for high-risk non-ST-segment elevation myocardial infarction (NSTEMI) patients, but international differences in the use of invasive strategies are unknown.

HYPOTHESIS

Profiling NSTEMI patient management in the United States (U.S.) and South Korea could provide insight into how patients are triaged for an early invasive strategy in different health care environments and geographical regions.

METHODS

We evaluated the use of angiography and revascularization for NSTEMI patients treated at revascularization-capable hospitals (2007-2010) in both the ACTION Registry-GWTG (U.S.: n = 133,835; 433 hospitals) and KAMIR/KorMI Registry (South Korea: n = 7,901; 72 hospitals).

RESULTS

Compared with South Korean patients, U.S. NSTEMI patients more commonly had established cardiovascular risk factors, disease, and prior cardiovascular events and procedures. From 2007-2010, the use of angiography for NSTEMI patients rose steadily in both countries, but the use of revascularization only rose in South Korea. Patients from South Korea more commonly underwent angiography and revascularization. Percutaneous coronary intervention was the most common type of revascularization in both countries, but coronary artery bypass grafting was less common in South Korea. The use of both angiography and revascularization was incrementally lower with a higher predicted mortality risk for patients from both countries, but greater differences between low- and high-risk patients occurred in the U.S.

CONCLUSIONS

The profile, characteristics, and use of angiography and revascularization for NSTEMI patients in the U.S. vs South Korea differed substantially from 2007-2010, underscoring the heterogeneity of NSTEMI patients and treatment selection among different countries.