Regional density of cardiologists and rates of mortality for acute myocardial infarction and heart failure

Geographic Variation in Mortality of Acute Myocardial Infarction and Association With Health Care Accessibility in Beijing, 2007 to 2018

Background Little is known about geographic variation in acute myocardial infarction (AMI) mortality within fast-developing megacities and whether changes in health care accessibility correspond to changes in AMI mortality at the small-area level. Methods and Results We included data of 94 106 AMI deaths during 2007 to 2018 from the Beijing Cardiovascular Disease Surveillance System in this ecological study. We estimated AMI mortality for 307 townships during consecutive 3-year periods with a Bayesian spatial model. Township-level health care accessibility was measured using an enhanced 2-step floating catchment area method. Linear regression models were used to examine the association between health care accessibility and AMI mortality. During 2007 to 2018, median AMI mortality in townships declined from 86.3 (95% CI, 34.2-173.8) to 49.4 (95% CI, 30.5-73.7) per 100 000 population. The decrease in AMI mortality was larger in townships where health care accessibility increased more rapidly. Geographic inequality, defined as the ratio of the 90th to 10th percentile of mortality in townships, increased from 3.4 to 3.8. In total, 86.3% (265/307) of townships had an increase in health care accessibility. Each 10% increase in health care accessibility was associated with a -0.71% (95% CI, -1.08% to -0.33%) change in AMI mortality. Conclusions Geographic disparities in AMI mortality among Beijing townships are large and increasing. A relative increase in township-level health care accessibility is associated with a relative decrease in AMI mortality. Targeted improvement of health care accessibility in areas with high AMI mortality may help reduce AMI burden and improve its geographic inequality in megacities.

Driving Time to the Nearest Percutaneous Coronary Intervention-Capable Hospital and the Risk of Case Fatality in Patients with Acute Myocardial Infarction in Beijing

Timely arrival at a hospital capable of percutaneous coronary intervention (PCI) is critical in treating acute myocardial infarction (AMI). We examined the association between driving time to the nearest PCI-capable hospital and case fatality among AMI patients. A total of 142,474 AMI events during 2013-2019 from the Beijing Cardiovascular Disease Surveillance System were included in this cross-sectional study. The driving time from the residential address to the nearest PCI-capable hospital was calculated. Logistic regression was used to estimate the risk of AMI death associated with driving time. In 2019, 54.5% of patients lived within a 15-min drive to a PCI-capable hospital, with a higher proportion in urban than peri-urban areas (71.2% vs. 31.8%, p < 0.001). Compared with patients who had driving times ≤15 min, the adjusted odds ratios (95% CI, p value) for AMI fatality risk associated with driving times 16-30, 31-45, and >45 min were 1.068 (95% CI 1.033-1.104, p < 0.001), 1.189 (95% CI 1.127-1.255, p < 0.001), and 1.436 (95% CI 1.334-1.544, p < 0.001), respectively. Despite the high accessibility to PCI-capable hospitals for AMI patients in Beijing, inequality between urban and peri-urban areas exists. A longer driving time is associated with an elevated AMI fatality risk. These findings may help guide the allocation of health resources.

Pre-left Ventricular Assist Device Cognition: A Comparison of Rural and Urban Implant Recipients

Mild cognitive impairment (MCI) is common in patients before left ventricular assist device (LVAD) placement. The consequences of these deficits may differentially impact groups of patients with limited access to postimplantation resources, such as those in rural areas. However, to date, no studies have examined preimplantation cognition in rural and urban patients. Therefore, the purpose of this study was to compare cognition in rural and urban patients before LVAD implantation. This observational cohort study is a secondary analysis of 265 patients undergoing LVAD implantation between July 2004 and June 2019. Preimplantation cognitive function was assessed. Rural-Urban Commuting Area Codes designated rural and urban. Independent-samples Mann-Whitney U tests were used to compare rural and urban cohorts. Subjects were 75.8% (201/265) male, 75.4% (200/265) urban, and 56.6% (±13.2) years old. Rural subjects scored significantly lower on the Mini Mental Status Exam (MMSE) (27 ± 2.20) and Wide Range Achievement Test (WRAT) (32 ± 22.9) compared with urban counterparts (MMSE, 27.6 ± 2.7) (p = 0.009); WRAT (44.4 ± 26.2) (p = 0.02) pre-LVAD. These findings suggest rural patients may have greater MCI before LVAD implantation. Rural LVAD recipients with MCI may require additional intensive education and tailored resource identification before discharge.

Differences in Hospitalization Outcomes of Kidney Disease between Patients Who Received Care by Nephrologists and Non-Nephrologist Physicians: A Propensity-Score-Matched Study

The influence of physician specialty on the outcomes of kidney diseases (KDs) remains underexplored. We aimed to compare the complications and mortality of patients with admissions for KD who received care by nephrologists and non-nephrologist (NN) physicians. We used health insurance research data in Taiwan to conduct a propensity-score matched study that included 17,055 patients with admissions for KD who received care by nephrologists and 17,055 patients with admissions for KD who received care by NN physicians. Multivariable logistic regressions were conducted to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for 30-day mortality and major complications associated with physician specialty. Compared with NN physicians, care by nephrologists was associated with a reduced risk of 30-day mortality (OR 0.29, 95% CI 0.25–0.35), pneumonia (OR 0.82, 95% CI 0.76–0.89), acute myocardial infarction (OR 0.68, 95% CI 0.54–0.87), and intensive care unit stay (OR 0.78, 95% CI 0.73–0.84). The association between nephrologist care and reduced admission adverse events was significant in every age category, for both sexes and various subgroups. Patients with admissions for KD who received care by nephrologists had fewer adverse events than those who received care by NN physicians. We suggest that regular nephrologist consultations or referrals may improve medical care and clinical outcomes in this vulnerable population.

Trelagliptin ameliorates oxygen-glucose deprivation/reperfusion (OGD/R)-induced mitochondrial dysfunction and metabolic disturbance of endothelial cells

Acute myocardial infarction (AMI) is a severe cardiovascular disease with high mortality. It is reported to be closely related to the mitochondrial dysfunction and metabolic disturbance on endothelial cells under a chronic hypoxic state. Significant declined mitochondrial respiration, ATP production, and metabolic changes are the main characteristics of endothelial injury in the disease. Trelagliptin is a DPP-4 inhibitor applied for the treatment of type II diabetes and has been recently reported to exert various pharmacological properties. In this investigation, we examined whether Trelagliptin possessed a protective effect against mitochondrial dysfunction and metabolic disturbance in human aortic valvular endothelial cells (HAVECs) under oxygen-glucose deprivation/reperfusion (OGD/R) conditions. We found that both the cytotoxicity and mitochondrial oxidative stress in HAVECs induced by OGD/R stimulation were greatly alleviated by Trelagliptin. In addition, the declined mitochondrial respiration and ATP production decreased secretion of cystathionine and creatine, and the increased production of triglyceride and adiponectin in OGD/R-challenged HAVECs was dramatically reversed by Trelagliptin, accompanied by the upregulated expression level of PGC-1α and CPT-1. Lastly, the AMPK pathway was observed to be significantly activated in OGD/R-challenged HAVECs by Trelagliptin treatment. After co-administration of the inhibitor of the AMPK pathway, the effects of Trelagliptin on mitochondrial function and metabolic alterations were significantly abolished. Taken together, our data indicate that Trelagliptin ameliorated OGD/R-induced mitochondrial disturbance and metabolic changes by activating the AMPK pathway.

Impact of Physician Volume and Specialty on In-Hospital Mortality of Ischemic and Hemorrhagic Stroke

BACKGROUND

The degree of association between mortality and case volume/physician volume is well known for many surgical procedures and medical conditions. However, the link between physician volume and death rate in patients hospitalized for stroke remains unclear. This study analyzed the correlation between in-hospital stroke mortality and physician volume per hospital, considering board certification status.Methods and Results:For this retrospective registry-based cohort study, data were obtained from the Japanese nationwide registry on patients hospitalized for ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) between 2010 and 2016. The number of stroke care physicians and relevant board-certified physicians was also obtained. Odd ratios (ORs) of 30-day in-hospital mortality were estimated after adjusting for institutional and patient differences using generalized mixed logistic regression. From 295,150 (ischemic stroke), 98,657 (ICH), and 36,174 (SAH) patients, 30-day in-hospital mortality rates were 4.4%, 16.0%, and 26.6%, respectively. There was a correlation between case volume and physician volume. A higher number of stroke care physicians was associated with a reduction in 30-day mortality after adjusting for stroke case volume and comorbidities for all stroke types (all P for trend<0.05).

CONCLUSIONS

An increased number of stroke care physicians was associated with reduced in-hospital mortality for all types of stroke. The volume threshold of board-certified physicians depends on the specialty and stroke type.

Time-to-reperfusion in patients with acute myocardial infarction and mortality in prehospital emergency care: meta-analysis

BACKGROUND

People living in rural areas usually suffer comparatively disadvantaged emergency health care than those living in urban areas, reasons including long transit time due to geographic factors. As for many time critical diseases, it is necessary to obtain treatment as quickly as possible.

METHODS

Screening of eligible studies were conducted based on inclusion an exclusion criteria. A comprehensive search was conducted by using following database: EMBASE, Medline, Cochrane library and Scopus. Quality assessment tool for observational cohort and cross-sectional study is used for assessing the risk of bias. The time group were defined based on the median or mean transit time among patients. In symptom onset-balloon time, we take 120 min transit time as the standard so patients in included studies are divided into two groups:less than 120 min (group A) and more than 120 min (group B). The collected data were used for quantitative analysis, they were inputted into Review Manager Software (v5.3) to produce summary results.

RESULTS

Ten studies representing 71,099 patients were included in the meta-analysis. All studies were retrospective and prospective observational studies and RCTs in which patients experienced ST-elevation myocardial infarction (STEMI) and were treated with percutaneous coronary intervention (PCI). Random effects meta-analysis of the point estimate was 0.69 (CI 0.60, 0.79). Heterogeneity between study results was evaluated via examination of the forest plots and quantified by using I2 statistic. Heterogeneity in two stage time was moderate among studies (I2 = 29%, P = 0.23).

CONCLUSION

The meta-analysis for included studies report less mortality in less than 120 min symptom onset-balloon and door-balloon time than that in more than 120 min. It is necessary to optimize the prehospital system for rapid decision making and logical destination and mode of transport with prehospital notification of the cath lab so that the hospital is ready to optimize door to balloon time.

European Society of Cardiology: Cardiovascular Disease Statistics 2019

AIMS

The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets.

METHODS AND RESULTS

In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5-23.1%] vs. 15.7% (IQR 14.5-21.1%)}, diabetes [7.7% (IQR 7.1-10.1%) vs. 5.6% (IQR 4.8-7.0%)], and among males smoking [43.8% (IQR 37.4-48.0%) vs. 26.0% (IQR 20.9-31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0-10.8) vs. 16.7% (IQR 13.9-19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655-8115)] compared with high-income [2235 (IQR 1896-3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures.

CONCLUSION

A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest.

Association between the number of board-certified cardiologists and the risk of in-hospital mortality: a nationwide study involving the Japanese registry of all cardiac and vascular diseases

OBJECTIVES

Although there are 14 097 board-certified cardiologists in Japan, it is unknown whether the number of institutional board-certified cardiologists is related to the prognosis of cardiovascular disease patients.

DESIGN

Cross-sectional analysis.

SETTING

Data were collected from the nationwide database of acute care hospitals in Japan (2371 hospitals) between 2012 and 2013.

PARTICIPANTS

A total of 1 422 703 consecutive patients were initially included in this study, but 518 610 patients were excluded due to age <18 years, missing data or prior hospitalisations; therefore, 896 171 patients comprised the final sample population.

MAIN OUTCOME MEASURES

The primary outcome was in-hospital mortality due to any cause. For the per-hospital analysis, Poisson regression models were used to estimate the association of board-certified cardiologists with in-hospital mortality, adjusted for hospital facilitation. For the per-patient analysis, hierarchical logistic regression models were used to estimate the ORs of the number of institutional board-certified cardiologists, adjusted for patient demographics, diagnoses, therapies and hospital facilities.

RESULTS

The regression model of the per-hospital analysis indicated that the number of board-certified cardiologists was associated with a lower rate ratio of in-hospital mortality (rate ratio, 0.988; 95% CI 0.983 to 0.993; p<0.01). The per-patient analysis indicated that the median age was 73 years and the in-hospital mortality rate was 11.7%. The regression model indicated that the presence of more board-certified cardiologists was associated with a lower risk of in-hospital mortality (OR, 0.980; 95% CI 0.975 to 0.986; p<0.01) after adjustments for hospital facilities, patient characteristics and treatments.

CONCLUSIONS

Among cardiovascular disease patients admitted to acute care hospitals in Japan, the presence of more board-certified cardiologists was associated with a lower risk of in-hospital mortality. These results have implications for national and institutional strategies for determining the required number of board-certified cardiologists.

On- Versus Off-Hours Presentation and Mortality of ST-Segment Elevation Myocardial Infarction Patients Treated With Primary Percutaneous Coronary Intervention

OBJECTIVES

The authors sought to assess the association between admission time with patient's care, procedure characteristics, and clinical outcomes within a contemporary ST-segment elevation myocardial infarction (STEMI) network of patients referred for primary percutaneous coronary intervention (PCI).

BACKGROUND

The effect of admission time on STEMI patient's outcomes remains controversial when primary PCI is the preferred reperfusion strategy.

METHODS

Characteristics and clinical outcomes of 2,167 consecutive STEMI patients admitted in a tertiary PCI-capable center were collected. On-hours were defined as admission from Monday through Friday between 8 am and 6 pm and off-hours as admission during night shift, weekend, and nonworking holidays. In-hospital and 1-year all-cause mortality were assessed as well as key time delays.

RESULTS

A total of 1,048 patients (48.3%) were admitted during on-hours, and 1,119 patients (51.7%) during off-hours. Characteristics were well-balanced between the 2 groups, including rates of cardiac arrest (7.9% vs. 8.8%; p = 0.55) and cardiogenic shock (12.3% vs. 14.7%; p = 0.16). Median symptom-to-first medical contact time and median first medical contact-to-sheath insertion time did not differ according to on- versus off-hours admission (120 min vs. 126 min; p = 0.25 and 90 min vs. 93 min; p = 0.58, respectively), as well as the rate of radial access for catheterization (85.6% vs. 87.5%; p = 0.27). There was no association between on- versus off-hours groups and in-hospital (8.1% vs. 7.0%; p = 0.49) or 1-year mortality (11.0% vs. 11.1%; p = 0.89), respectively.

CONCLUSIONS

In a contemporary organized STEMI network, patients admitted in a high-volume tertiary primary PCI center during on-hours or off-hours had similar management and 1-year outcomes.

Long Distance Tele-Robotic-Assisted Percutaneous Coronary Intervention: A Report of First-in-Human Experience

BACKGROUND

Robotic-assisted percutaneous coronary intervention (R-PCI) has been successfully employed in the United States since 2011. Performing R-PCI from a remote location has never been reported but if feasible would extend availability of treatment to many patients with coronary artery disease (CAD) who would otherwise go without.

OBJECTIVE

To assess the feasibility of remote tele-R-PCI with the operator 20 miles away from the patients.

METHODS

Five patients with single, type A coronary artery lesions treatable by PCI consented to participate. The primary endpoint was procedural success with no major adverse cardiac events (MACE) before discharge. Procedural success was defined as achieving < 10% diametric stenosis of the occluded target vessel utilizing tele-R-PCI balloon angioplasty and stent deployment (CorPath GRX®, Corindus Vascular Robotics, USA) without converting to in-lab manual PCI by an on-site standby team. Procedural, angiographic, and safety data were collected as were questionnaire scores from the remote operator evaluating the robot-network composite, image clarity, and overall confidence in the procedure.

RESULTS

The primary endpoint was achieved in 100% of patients. No procedural complications or adverse events occurred, and all patients were discharged the following day without MACE. The operator scores were favorable with the operators rating the procedure as equivalent to an in-lab procedure.

CONCLUSIONS

Performing long distance tele-R-PCI in patients with CAD is feasible with predictably successful outcomes if reliable network connectivity and local cardiac catheterization facilities are available.

Geographic Distribution of Hand Surgeons Throughout the United States

The purpose of this study was to evaluate the geographic distribution of hand surgeons in the United States. We assessed the states and congressional districts (CDs) for optimal numbers of surgeons, determined whether there is an even distribution, and identified factors influencing practice location. Hand surgeon practice location data from the American Association for Hand Surgery and American Society for Surgery of the Hand (2015) and both state and CD population data from the US Census (2014) were assessed. CDs each contain approximately the same population. Furthermore, select hand surgeons were asked to fill out a survey to identify how 6 factors influence practice location. A total of 2,707 American Association for Hand Surgery active and American Society for Surgery of the Hand active and candidate US members were included. The mean number of hand surgeons per state was 53 (range: 3-298). The most hand surgeons were in California, Texas, New York, and Florida and least were in Wyoming and Alaska. There were 16, 11, and 24 states with suboptimal, optimal, and greater-than-optimal density, respectively. There were 436 CDs. We found 231, 30, and 175 CDs with suboptimal, optimal, and greater-than-optimal density, respectively. There were weak correlations between hand surgeons and CD populations and between CD population densities and CD hand surgeons per capita. Twenty hand surgeons were included in the survey resulting in no difference of any 1 factor compared with the other 5 factors. There was a difference in the factor "population size" between hand surgeons from greater-than-optimal and suboptimal CDs. The findings of our study indicate that hand surgeon proportions do not correlate with population proportions, and distribution is not skewed toward areas of higher population density. Many areas are not optimally served, and hand surgeons may be choosing where to practice based on a combination of factors beyond population need.

Association between number of institutions with coronary computed tomography angiography and regional mortality ratio of acute myocardial infarction: a nationwide ecological study using a spatial Bayesian model

Background

Coronary computed tomography angiography (CTA) has demonstrated high diagnostic accuracy for detection of coronary artery stenosis, and healthcare providers can detect coronary artery disease in earlier stages before it develops into more serious clinical conditions such as acute myocardial infarction (AMI). We hypothesized that the mortality ratio of AMI in regions with a higher density of coronary CTA is lower than that in regions with a lower density of coronary CTA.

Methods

This ecological and cross-sectional study using secondary data targeted all secondary medical service areas (SMSAs) in Japan (n = 349). We obtained the numbers of cardiologists, institutions with coronary CTA, and institutions with a cardiac catheterization laboratory (CCL) as medical resources, socioeconomic factors, lifestyle factors, exercise habit factors, and AMI mortality data from a Japanese national database. We evaluated the association between the number of these medical resources and the standardized mortality ratio (SMR) of AMI in each SMSA using a hierarchical Bayesian model accounting for spatial autocorrelation (i.e., a conditional autoregressive model). We assumed a Poisson distribution for the observed number of AMI-related deaths and set the expected number of AMI-related deaths as the offset variable.

Results

The number of institutions with coronary CTA was negatively and significantly associated with the SMR of AMI (relative risk [RR] 0.900; 95% credible interval [CI] 0.848–0.953), while the SMR in each SMSA was not significantly associated with the number of either cardiologists (RR 0.997; 95% CI 0.988–1.004) or institutions with a CCL (RR 1.026; 95% CI 0.963–1.096).

Conclusions

We observed a significant association between the number of institutions with coronary CTA and the SMR of AMI. Effective allocation of coronary CTA in each region is recommended, and it would be important to clarify the standing position of coronary CTA in regional networking for AMI treatment in the future.

Electronic supplementary material

The online version of this article (10.1186/s12942-018-0133-0) contains supplementary material, which is available to authorized users.

Off-hours presentation does not affect in-hospital mortality of Japanese patients with acute myocardial infarction: J-MINUET substudy

BACKGROUND

The association between patients with acute myocardial infarction (AMI) who present during off-hours and clinical outcomes has not been fully elucidated.

METHODS

We investigated 3283 consecutive patients with AMI who were selected from a prospective, nationwide, multicenter registry (J-MINUET) database comprising 28 institutions in Japan between July 2012 and March 2014 to determine the current impact of off-hours presentation on in-hospital mortality among Japanese patients with AMI.

RESULTS

Among the patients, 52% presented in off-hours. Baseline characteristics were comparable, although those who presented during off-hours were younger and had a higher incidence of ST-elevation myocardial infarction and advanced Killip Class. The time from symptom onset to presentation time was shorter in off-hour patients (120min, interquartile range 60 to 256 vs. 215min, interquartile range 90 to 610, p<0.0001). In contrast, 85% of patients underwent primary percutaneous coronary intervention (PCI) and door to balloon time was comparable between the groups (74min, interquartile range 52 to 113 vs. 75min, interquartile range 52 to 126, p=0.34). The rates of in-hospital mortality were comparable (6.2% vs 6.8%, p=0.39). Multivariate logistic regression analysis revealed that off-hours presentation was not significantly associated with in-hospital mortality [odds ratio (OR) 0.94; 95% CI, 0.68-1.30, p=0.70].

CONCLUSION

The clinical impact of presenting during off-hours or regular hours on AMI patients in Japan is comparable in contemporary practice.

TRIAL REGISTRATION

UMIN Unique trial Number: UMIN000010037.

The Supply and Demand of the Cardiovascular Workforce: Striking the Right Balance

As the burden of cardiovascular disease in the United States continues to increase, uncertainty remains on how well-equipped the cardiovascular workforce is to meet the challenges that lie ahead. In a time when health care is rapidly shifting, numerous factors affect the supply and demand of the cardiovascular workforce. This Council Commentary critically examines several factors that influence the cardiovascular workforce. These include current workforce demographics and projections, evolving health care and practice environments, and the increasing burden of cardiovascular disease. Finally, we propose 3 strategies to optimize the workforce. These focus on cardiovascular disease prevention, the effective utilization of the cardiovascular care team, and alterations to the training pathway for cardiologists.

In-hospital mortality and treatment patterns in acute myocardial infarction patients admitted during national cardiology meeting dates

BACKGROUND

Many hospitals experience a reduction in the number of available physicians on days when national scientific meetings are conducted. This study investigates the relationship between in-hospital mortality in acute myocardial infarction (AMI) patients and admission during national cardiology meeting dates.

METHODS

Using an administrative database, we analyzed patients with AMI admitted to acute care hospitals in Japan from 2011 to 2013. There were 3 major national cardiology meetings held each year. A hierarchical logistic regression model was used to compare in-hospital mortality and treatment patterns between patients admitted on meeting dates and those admitted on identical days during the week before and after the meeting dates.

RESULTS

We identified 6,332 eligible patients, with 1,985 patients admitted during 26 meeting days and 4,347 patients admitted during 52 non-meeting days. No significant differences between meeting and non-meeting dates were observed for in-hospital mortality (7.4% vs. 8.5%, respectively; p=0.151, unadjusted odds ratio: 0.861, 95% confidence interval: 0.704-1.054) and the proportion of percutaneous coronary intervention (PCI) performed on the day of admission (75.9% vs. 76.2%, respectively; p=0.824). We also found that some low-staffed hospitals did not treat AMI patients during meeting dates.

CONCLUSION

Little or no "national meeting effect" was observed on in-hospital mortality in AMI patients, and PCI rates were similar for both meeting and non-meeting dates. Our findings also indicated that during meeting dates, AMI patients may have been consolidated to high-performance and sufficiently staffed hospitals.

Geographic Variation in Trends and Disparities in Acute Myocardial Infarction Hospitalization and Mortality by Income Levels, 1999-2013

IMPORTANCE

During the past decade, the incidence and mortality associated with acute myocardial infarction (AMI) in the United States have decreased substantially. However, it is unknown whether these improvements were consistent across communities of different economic status and geographic regions since efforts to improve cardiovascular disease prevention and management may have had variable impact.

OBJECTIVE

To determine whether trends in US county-level, risk-standardized AMI hospitalization and mortality rates varied by county-based median income level.

DESIGN, SETTING, AND PARTICIPANTS

In this observational study, county-level risk-standardized (age, sex, and race) hospitalization and 1-year mortality rates for AMI from January 1, 1999, to December 31, 2013, were measured for Medicare beneficiaries 65 years or older. Data analysis was performed from June 2 through December 1, 2015. Counties were stratified by median income percentile using 1999 US Census Bureau data adjusted for inflation: low- (<25th), average- (25th-75th), or high- (>75th) income groups.

MAIN OUTCOMES AND MEASURES

The effect of income on the slope of AMI hospitalizations and mortality, measured as differences in the rate of change in AMI hospitalizations and mortality by county income and by the 4 US geographic regions, and a possible lag effect among low-income counties.

RESULTS

In the 15-year study period, AMI risk-standardized hospitalization and mortality rates decreased significantly for all 3 county income groups. Mean hospitalization rates were significantly higher among low-income counties compared with high-income counties in 1999 (1353 vs 1123 per 100 000 person-years, respectively) and in 2013 (853 vs 648 per 100 000 person-years, respectively). One-year mortality rates after hospitalization for AMI were similar across county income groups, decreasing from 1999 (31.5%, 31.4%, and 31.1%, for high-, average-, and low-income counties, respectively) to 2013 (26.2%, 26.1%, and 25.4%, respectively). Income was associated with county-level, risk-standardized AMI hospitalization rates but not mortality rates. Increasing 1 interquartile range of median county consumer price index-adjusted income ($12 000) was associated with a decline in 46 and 37 hospitalizations per 100 000 person-years for 1999 and 2013, respectively; interaction between income and time was 0.56. The rate of decline in AMI hospitalizations was similar for all county income groups; however, low-income counties lagged behind high-income counties by 4.3 (95% CI, 3.1-5.9) years. There were no significant differences in trends across geographic regions.

CONCLUSIONS AND RELEVANCE

Hospitalization and mortality rates of AMI declined among counties of all income levels, although hospitalization rates among low-income counties lag behind those of the higher income groups. These findings lend support for a more targeted, community-based approach to AMI prevention.

Toward phase 4 trials in heart failure: A social and corporate responsibility of the medical profession

Congestive heart failure (CHF) is a chronic condition, requiring polypharmacy, allied health supports and regular monitoring. All these factors are needed to ensure compliance and to deliver the positive outcomes demonstrated from randomized controlled trials. Unfortunately many centers around the world are unable to match trial level support. The outcomes for many communities are thus unclear. Research design factors in post-marketing surveillance to address this issue. Phase 4 studies is the name given to trials designed to obtain such community level data and thus address issues of external validity. CHF phase 4 studies are relatively underutilized. We feel the onus for this research lies with the health profession. In this commentary we provide arguments as to why phase 4 studies should be viewed as a social and corporate responsibility of health professional that care for clients with CHF.

Strategies to reduce hospital 30-day risk-standardized mortality rates for patients with acute myocardial infarction: a cross-sectional and longitudinal survey

Background

Survival rates after acute myocardial infarction (AMI) vary markedly across U.S. hospitals. Although substantial efforts have been made to improve hospital performance, we lack contemporary evidence about changes in hospital strategies and features of organizational culture that might contribute to reducing hospital AMI mortality rates. We sought to describe current use of several strategies and features of organizational culture linked to AMI mortality in a national sample of hospitals and examine changes in use between 2010 and 2013.

Methods

We conducted a cross-sectional survey of 543 hospitals (70% response rate) in 2013, and longitudinal analysis of a subsample of 107 hospitals that had responded to a survey in 2010 (67% response rate).

Results

Between 2010 and 2013, the use of many strategies increased, but the use of only two strategies increased significantly: the percentage of hospitals providing regular training to Emergency Medical Service (EMS) providers about AMI care increased from 36% to 71% (P-value < 0.001) and the percentage of hospitals using computerized assisted physician order entry more than doubled (P-value < 0.001). Most, but not all, hospitals reported having environments conducive to communication, coordination and problem solving.

Conclusions

We found few significant changes between 2010 and 2013 in hospital strategies or in key features of organizational culture that have been associated with lower AMI mortality rates. Findings highlight several opportunities to help close remaining performance gaps in AMI mortality among hospitals.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2261-14-126) contains supplementary material, which is available to authorized users.

Off-hour presentation and outcomes in patients with acute myocardial infarction: systematic review and meta-analysis

OBJECTIVE

To assess the association between off-hour (weekends and nights) presentation, door to balloon times, and mortality in patients with acute myocardial infarction.

DATA SOURCES

Medline in-process and other non-indexed citations, Medline, Embase, Cochrane Database of Systematic Reviews, and Scopus through April 2013.

STUDY SELECTION

Any study that evaluated the association between time of presentation to a healthcare facility and mortality or door to balloon times among patients with acute myocardial infarction was included.

DATA EXTRACTION

Studies' characteristics and outcomes data were extracted. Quality of studies was assessed with the Newcastle-Ottawa scale. A random effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I(2).

RESULTS

48 studies with fair quality, enrolling 1,896,859 patients, were included in the meta-analysis. 36 studies reported mortality outcomes for 1,892,424 patients with acute myocardial infarction, and 30 studies reported door to balloon times for 70,534 patients with ST elevation myocardial infarction (STEMI). Off-hour presentation for patients with acute myocardial infarction was associated with higher short term mortality (odds ratio 1.06, 95% confidence interval 1.04 to 1.09). Patients with STEMI presenting during off-hours were less likely to receive percutaneous coronary intervention within 90 minutes (odds ratio 0.40, 0.35 to 0.45) and had longer door to balloon time by 14.8 (95% confidence interval 10.7 to 19.0) minutes. A diagnosis of STEMI and countries outside North America were associated with larger increase in mortality during off-hours. Differences in mortality between off-hours and regular hours have increased in recent years. Analyses were associated with statistical heterogeneity.

CONCLUSION

This systematic review suggests that patients with acute myocardial infarction presenting during off-hours have higher mortality, and patients with STEMI have longer door to balloon times. Clinical performance measures may need to account for differences arising from time of presentation to a healthcare facility.