A comparison of in-hospital acute myocardial infarction management between Portugal and the United States: 2000-2010

Institutional Variance in Mortality after Percutaneous Coronary Intervention for Acute Myocardial Infarction in Korea, Japan, and Taiwan

BACKGROUND

Although there have been studies that compared outcomes of patients with acute myocardial infarction (AMI) across countries, little focus has been placed on institutional variance of outcomes. The aim of the present study was to compare institutional variance in mortality following percutaneous coronary intervention (PCI) for AMI and factors explaining this variance across different health systems.

METHODS

Data on inpatients who underwent PCI for AMI in 2016 were obtained from the National Health Insurance Data Sharing Service in Korea, the Diagnosis Procedure Combination (DPC) Study Group Database in Japan, and the National Health Insurance Research Database (NHIRD) in Taiwan. Multilevel analyses with inpatient mortality as the outcome and the hierarchical structure of patients nested within hospitals were conducted, adjusting for common patient-level and hospital-level variables. We compared the intraclass correlation coefficient (ICC) and the proportion of variance explained by hospital-level characteristics across the three health systems.

RESULTS

There were 17 351 patients from 160 Korean hospitals, 29 804 patients from 660 Japanese hospitals, and 10 863 patients from 104 Taiwanese hospitals included in the analysis. Inpatient mortality rates were 6.3%, 7.3%, and 6.0% in Korea, Japan, and Taiwan, respectively. After adjusting for patient and hospital characteristics, Taiwan had the lowest variation in mortality (ICC, 1.8%), followed by Korea (2.2%) and then Japan (4.5%). The measured hospital characteristics explained 38%, 19%, and 9% of the institutional variance in Korea, Taiwan, and Japan, respectively.

CONCLUSION

Korea, Japan, and Taiwan had similarly uniform outcomes across hospitals for patients undergoing PCI for AMI. However, Japan had a relatively large institutional variance in mortality and a lower proportion of variation explainable by hospital characteristics, compared with Korea and Taiwan.

Myocardial perfusion scintigraphy in myocardial infarction - impact of ST-segment elevation and of Diabetes mellitus

Myocardial perfusion scintigraphy (MPS) is frequently used in the evaluation of patients with coronary artery disease, either stable or with the prior remote acute coronary syndrome. The goal of the present work was to evaluate changes in MPS according to the nature of the infarction (ST-elevation vs non-ST elevation status) as well as according to the presence or absence of Diabetes mellitus. A prospective study of 124 consecutive patients with myocardial infarction (MI) was carried out using MPS. Patients with ST-segment elevation MI (STEMI) had significantly larger values both for percentage and absolute areas of perfusion defects, both at rest and in a stress situation, when compared to patients without ST-segment elevation (NSTEMI). These patients had significantly lower values for left ventricular ejection fractions (EF), in a similar comparison. The values for perfusion defects at rest for STEMI patients were more than double the values for NSTEMI patients (17.1 ± 14.6% vs 6.5 ± 7.8%, P < .001). Concerning resting left ventricular EF, STEMI patients had a mean value of 47.6 ± 13.6% and NSTEMI patients had a mean value of 53.2 ± 12.4% (P.026). Regarding the comparison between patients with and without Diabetes mellitus, none of the parameters under study showed significant differences. Linear regression analysis, taking the percentage of perfusion defect, as the dependent variable, yielded an overall significant result, however, only ST-segment elevation was shown to have an individually significant result. We conclude that the presence of ST-segment elevation but not the presence of Diabetes mellitus is associated with different patterns of MPS in patients with MI.

Understanding the large heterogeneity in hospital readmissions and mortality for acute myocardial infarction

This study aims to investigate the variation in two acute myocardial infarction (AMI) outcomes across public hospitals in Portugal. In-hospital mortality and 30-day unplanned readmissions were studied using two distinct AMI cohorts of adults discharged from all acute care public hospital centers in Portugal from 2012-2015. Hierarchical generalized linear models were used to assess the association between patient and hospital characteristics and hospital variability in the two outcomes. Our findings indicate that hospitals are not performing homogeneously-the risk of adverse events tends to be consistently larger in some hospitals and consistently lower in other hospitals. While patient characteristics accounted for a larger share of the explained between-hospital variance, hospital characteristics explain an additional 8% and 10% of hospital heterogeneity in the mortality and the readmission cohorts respectively. Admissions to hospitals with low AMI caseloads or located in Alentejo/Algarve and Lisbon had a higher risk of mortality. Discharges from larger-sized hospitals were associated with increased risk of readmissions. Future health policies should incorporate these findings in order to incentivize more consistent health care outcomes across hospitals. Further investigation addressing geographical disparities, hospital caseload and practices is needed to direct actions of improvement to specific hospitals.