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. 2022 May 4:377:e069164.
doi: 10.1136/bmj-2021-069164.

Variation in revascularisation use and outcomes of patients in hospital with acute myocardial infarction across six high income countries: cross sectional cohort study

Peter Cram  1   2   3 , Laura A Hatfield  4 , Pieter Bakx  5 , Amitava Banerjee  6   7 , Christina Fu  4 , Michal Gordon  8 , Renaud Heine  5 , Nicole Huang  9 , Dennis Ko  2   3   10 , Lisa M Lix  11   12 , Victor Novack  8 , Laura Pasea  6 , Feng Qiu  2 , Therese A Stukel  2   13 , Carin Uyl de Groot  5 , Lin Yan  11   12 , Bruce Landon  4   14
Affiliations

Variation in revascularisation use and outcomes of patients in hospital with acute myocardial infarction across six high income countries: cross sectional cohort study

Peter Cram et al. BMJ. .

Erratum in

Abstract

Objectives: To compare treatment and outcomes for patients admitted to hospital with a primary diagnosis of ST elevation or non-ST elevation myocardial infarction (STEMI or NSTEMI) in six high income countries with very different healthcare delivery systems.

Design: Retrospective cross sectional cohort study.

Setting: Patient level administrative data from the United States, Canada (Ontario and Manitoba), England, the Netherlands, Israel, and Taiwan.

Participants: Adults aged 66 years and older admitted to hospital with STEMI or NSTEMI between 1 January 2011 and 31 December 2017.

Outcomes measures: The three categories of outcomes were coronary revascularisation (percutaneous coronary intervention or coronary artery bypass graft surgery), mortality, and efficiency (hospital length of stay and 30 day readmission). Rates were standardised to the age and sex distribution of the US acute myocardial infarction population in 2017. Outcomes were assessed separately for STEMI and NSTEMI. Performance was evaluated longitudinally (over time) and cross sectionally (between countries).

Results: The total number of hospital admissions ranged from 19 043 in Israel to 1 064 099 in the US. Large differences were found between countries for all outcomes. For example, the proportion of patients admitted to hospital with STEMI who received percutaneous coronary intervention in hospital during 2017 ranged from 36.9% (England) to 78.6% (Canada; 71.8% in the US); use of percutaneous coronary intervention for STEMI increased in all countries between 2011 and 2017, with particularly large rises in Israel (48.4-65.9%) and Taiwan (49.4-70.2%). The proportion of patients with NSTEMI who underwent coronary artery bypass graft surgery within 90 days of admission during 2017 was lowest in the Netherlands (3.5%) and highest in the US (11.7%). Death within one year of admission for STEMI in 2017 ranged from 18.9% (Netherlands) to 27.8% (US) and 32.3% (Taiwan). Mean hospital length of stay in 2017 for STEMI was lowest in the Netherlands and the US (5.0 and 5.1 days) and highest in Taiwan (8.5 days); 30 day readmission for STEMI was lowest in Taiwan (11.7%) and the US (12.2%) and highest in England (23.1%).

Conclusions: In an analysis of myocardial infarction in six high income countries, all countries had areas of high performance, but no country excelled in all three domains. Our findings suggest that countries could learn from each other by using international comparisons of patient level nationally representative data.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from the US National Institute on Aging, ICES, Ontario Ministry of Health and Long term Care, Canadian Institute for Health Information for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1
Proportion of patients receiving cardiac catheterisation, percutaneous coronary intervention, and coronary artery bypass graft surgery in hospital and within 90 days of index hospital admission. Colour coding indicates proportion of 90 day care received during index admission. Rates standardised to age and sex distribution of US acute myocardial infarction population in 2017. 2013 data shown for the Netherlands; 2011-12 data unavailable. NSTEMI=non-ST elevation myocardial infarction; STEMI=ST elevation myocardial infarction. An interactive version of this graphic is available at https://bit.ly/3vBjtMh
Fig 2
Fig 2
Mortality within 30 days and one year of index hospital admission for acute myocardial infarction. Colour coding indicates proportion of deaths occurring within 30 days and 31-365 days of admission. Rates standardised to age and sex distribution of US acute myocardial infarction population in 2017. 2013 data shown for the Netherlands; 2011-12 data unavailable. NSTEMI=non-ST elevation myocardial infarction; STEMI=ST elevation myocardial infarction. An interactive version of this graphic is available at https://bit.ly/3v2W1bO
Fig 3
Fig 3
Measures of health system efficiency. Hospital length of stay and 30 day readmission rate for STEMI and NSTEMI by country. Rates standardised to age and sex distribution of US acute myocardial infarction population in 2017. 2013 data shown for the Netherlands; 2011-12 data unavailable. NSTEMI=non-ST elevation myocardial infarction; STEMI=ST elevation myocardial infarction. An interactive version of this graphic is available at https://bit.ly/3OGAFJd
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