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Clinical Trial
. 2015 Aug 7:351:h3913.
doi: 10.1136/bmj.h3913.

Comparison of hospital variation in acute myocardial infarction care and outcome between Sweden and United Kingdom: population based cohort study using nationwide clinical registries

Sheng-Chia Chung  1 , Johan Sundström  2 , Chris P Gale  3 , Stefan James  2 , John Deanfield  4 , Lars Wallentin  2 , Adam Timmis  5 , Tomas Jernberg  6 , Harry Hemingway  7 ; Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies/Register of Information and Knowledge about Swedish Heart Intensive care Admissions; National Institute for Cardiovascular Outcomes Research/Myocardial Ischaemia National Audit Project; CAardiovascular Disease Research Using Linked Bespoke Studies and Electronic Health Records
Affiliations
Clinical Trial

Comparison of hospital variation in acute myocardial infarction care and outcome between Sweden and United Kingdom: population based cohort study using nationwide clinical registries

Sheng-Chia Chung et al. BMJ. .

Abstract

Objective: To assess the between hospital variation in use of guideline recommended treatments and clinical outcomes for acute myocardial infarction in Sweden and the United Kingdom.

Design: Population based longitudinal cohort study using nationwide clinical registries.

Setting and participants: Nationwide registry data comprising all hospitals providing acute myocardial infarction care in Sweden (SWEDEHEART/RIKS-HIA, n=87; 119,786 patients) and the UK (NICOR/MINAP, n=242; 391,077 patients), 2004-10.

Main outcome measures: Between hospital variation in 30 day mortality of patients admitted with acute myocardial infarction.

Results: Case mix standardised 30 day mortality from acute myocardial infarction was lower in Swedish hospitals (8.4%) than in UK hospitals (9.7%), with less variation between hospitals (interquartile range 2.6% v 3.5%). In both countries, hospital level variation and 30 day mortality were inversely associated with provision of guideline recommended care. Compared with the highest quarter, hospitals in the lowest quarter for use of primary percutaneous coronary intervention had higher volume weighted 30 day mortality for ST elevation myocardial infarction (10.7% v 6.6% in Sweden; 12.7% v 5.8% in the UK). The adjusted odds ratio comparing the highest with the lowest quarters for hospitals' use of primary percutaneous coronary intervention was 0.70 (95% confidence interval 0.62 to 0.79) in Sweden and 0.68 (0.60 to 0.76) in the UK. Differences in risk between hospital quarters of treatment for non-ST elevation myocardial infarction and secondary prevention drugs for all discharged acute myocardial infarction patients were smaller than for reperfusion treatment in both countries.

Conclusion: Between hospital variation in 30 day mortality for acute myocardial infarction was greater in the UK than in Sweden. This was associated with, and may be partly accounted for by, the higher practice variation in acute myocardial infarction guideline recommended treatment in the UK hospitals. High quality healthcare across all hospitals, especially in the UK, with better use of guideline recommended treatment, may not only reduce unacceptable practice variation but also deliver improved clinical outcomes for patients with acute myocardial infarction. Clinical trials registration Clinical trials NCT01359033.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work other than those acknowledged above; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Hospital variation in use (median percentage and interquartile range) of treatment for ST elevation myocardial infarction (STEMI) and non- ST elevation myocardial infarction (NSTEMI) by year in Sweden and UK. Reperfusion percentage among STEMI patients was weighted by number of STEMI admissions to hospital. Primary percutaneous coronary intervention (PCI) rate was among hospitals that did ≥5 primary PCIs during year. Percentages of revascularisation and anticoagulant were weighted by NSTEMI admissions. Anticoagulant included heparin
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Fig 2 Hospital variation in use (median percentage and interquartile range) of discharge drugs for acute myocardial infarction (AMI) by year in Sweden and UK. Restricted to patients who survived beyond discharge and weighted by hospital AMI volume. ACEI=angiotensin converting enzyme inhibitor; ARB=angiotensin receptor blocker
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Fig 3 Variation in acute myocardial infarction (AMI), ST elevation myocardial infarction (STEMI), and non-ST elevation myocardial infarction (NSTEMI) 30 day mortality (median percentage and interquartile range) by year in Swedish and UK hospitals. Weighted by hospital volume of AMI, STEMI, and NSTEMI, respectively
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Fig 4 Hospital variation in case mix standardised 30 day mortality (%) in Sweden and UK, 2004-10
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Fig 5 Estimated case mix adjusted 30 day mortality for ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and acute myocardial infarction (AMI) patients and odds ratio by hospital treatment quarters, in Sweden and UK. STEMI mortality reported by hospital reperfusion treatment quarters; NSTEMI mortality reported by hospital revascularisation and anticoagulant use quarters; AMI mortality reported by hospital discharge drug use quarters. ACEI=angiotensin converting enzyme inhibitor; ARB=angiotensin receptor blocker
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