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

International Journal for Quality in Health Care, 2017, 29(5), 669–678 doi: 10.1093/intqhc/mzx092 Advance Access Publication Date: 28 July 2017 Article Article A comparison of in-hospital acute myocardial infarction management between Portugal and the United States: 2000–2010 MARIANA F. LOBO1, VANESSA AZZONE2, LUÍS FILIPE AZEVEDO1,3, BRUNO MELICA1,4, ALBERTO FREITAS1,3, LEONOR BACELAR-NICOLAU5, FRANCISCO N. ROCHA-GONÇALVES1,6, CLÁUDIA NISA1, ARMANDO TEIXEIRA-PINTO7, JOSÉ PEREIRA-MIGUEL5, FREDERIC S. RESNIC8,9, ALTAMIRO COSTA-PEREIRA1,3, and SHARON-LISE NORMAND2,10 1 Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal, 2Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA, 3Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal, 4Serviço de Cardiologia, Unidade de Diagnóstico e Intervenção Cardiovascular, Centro Hospitalar de Vila Nova de Gaia e Espinho, R. Conceição Fernandes 1079, Vila Nova de Gaia Portugal, 5Institute of Preventive Medicine and Public Health and ISAMB – Institute of Environmental Health, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisbon, Portugal, 6Portuguese Institute of Oncology Porto, R. Dr. António Bernardino de Almeida 62, 4200-162 Porto, Portugal, 7School of Public Health, Faculty of Medicine, Edward Ford Building (A27), The University of Sidney, NSW 2006, Australia, 8Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, MA 01805, USA, 9Tufts University School of Medicine, Boston, MA 02111, USA, and 10 Department of Biostatistics, Havard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA Address reprint requests to: Mariana F. Lobo, Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal. Tel: +351-225-513-622; Fax: +351-225-513-623; E-mail: Editorial Decision 29 June 2017; Accepted 4 July 2017 Abstract Objective: To compare healthcare in acute myocardial infarction (AMI) treatment between contrasting health systems using comparable representative data from Europe and USA. Design: Repeated cross-sectional retrospective cohort study. Setting: Acute care hospitals in Portugal and USA during 2000–2010. Participants: Adults discharged with AMI. Interventions: Coronary revascularizations procedures (percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery). Main Outcome Measures: In-hospital mortality and length of stay. Results: We identified 1 566 601 AMI hospitalizations. Relative to the USA, more hospitalizations in Portugal presented with elevated ST-segment, and fewer had documented comorbidities. Agesex-adjusted AMI hospitalization rates decreased in USA but increased in Portugal. Crude procedure rates were generally lower in Portugal (PCI: 44% vs. 47%; CABG: 2% vs. 9%, 2010) but only CABG rates differed significantly after standardization. PCI use increased annually in both © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: 669 Lobo et al. 670 countries but CABG decreased only in the USA (USA: 0.95 [0.94, 0.95], Portugal: 1.04 [1.02, 1.07], odds ratios). Both countries observed annual decreases in risk-adjusted mortality (USA: 0.97 [0.965, 0.969]; Portugal: 0.99 [0.979, 0.991], hazard ratios). While between-hospital variability in procedure use was larger in USA, the risk of dying in a high relative to a low mortality hospital (hospitals in percentiles 95 and 5) was 2.65 in Portugal when in USA was only 1.03. Conclusions: Although in-hospital mortality due to an AMI improved in both countries, patient management in USA seems more effective and alarming disparities in quality of care across hospitals are more likely to exist in Portugal. Key words: acute myocardial infarction, patient management, international comparison Different health systems have varying abilities to adopt new health technologies with potential impact on their healthcare performance. Particularly when these have been proven to be cost-effective compared to other therapeutic alternatives. Reasons for the differences are likely related to variations in regulatory processes that approve new technologies, in healthcare practice patterns, and in the organization and economic capacity of health systems to provide new treatments [1–5]. As such, differences may be even more apparent between the USA and countries in Europe, which significantly contrast in their gross domestic products, regulatory framework of new medical device approval, capacity to adopt and diffuse new health technology, and population epidemiological profiles [6–8]. Moreover, although controversial, the WHO ranked the health system of the US behind many of its counterparts in Europe, reflecting its incapacity to transform higher per capita expenditure in healthcare in proportional higher accessible quality of care when compared to most European countries [9]. Acute myocardial infarction (AMI) is a common, fatal and costly disease. Despite significant declines in mortality during the last decade notably as a result from the advent of new health technologies it remains a considerable societal burden [10–13]. Therefore, regular monitoring is of crucial importance. Several observational studies compared AMI management between the USA and European countries [1, 2, 4, 7, 11, 14, 15], however, little is known about how different countries compare regarding within-country disparities in healthcare quality in AMI treatment across hospitals. According to previous findings AMI patients in the USA are more frequently subject to invasive coronary procedures, face fewer in-hospital deaths, shorter hospital stays and more readmissions when compared to European countries. However, two studies observed no significant differences between USA versus Sweden in survival after an AMI in adults [1, 3], and vital statistics data indicate that AMI mortality per capita in the USA is comparable to European average. In this study, we sought to characterize AMI incidence, hospital management, and outcomes in the two sides of the Atlantic using comparable inpatient hospitalizations data covering the period between 2000 and 2010 from Portugal and the USA exploring for potential differences in inter-hospital disparities within countries. We chose this period because it encompassed important advances in AMI treatment [2]. We chose Portugal because performance of its health system has been ranked ahead of the health system of the USA (12th vs. 37th); [9] Portugal saw one of the most enthusiastic adoption rates of the drug-eluting s (...truncated)