Original article
In-hospital Mortality Due to Acute Myocardial Infarction. Relevance of Type of Hospital and Care Provided. RECALCAR StudyMortalidad intrahospitalaria por infarto agudo de miocardio. Relevancia del tipo de hospital y la atención dispensada. Estudio RECALCAR

https://doi.org/10.1016/j.rec.2013.06.006Get rights and content

Abstract

Introduction and objectives

To investigate the relationship between in-hospital mortality due to acute myocardial infarction and type of hospital, discharge service, and treatment provided.

Methods

Retrospective analysis of 100 993 hospital discharges with a principal diagnosis of myocardial infarction in hospitals of the Spanish National Health Service. In-hospital mortality was adjusted for risk following the models of the Institute for Clinical Evaluative Sciences (Canada) and the Centers for Medicare & Medicaid Services (United States).

Results

Hospital characteristics are relevant to explain the variation in the individual probability of dying from myocardial infarction (median odds ratio: 1.3561). The risk-adjusted in-hospital mortality in cluster 3 and especially in cluster 4 hospitals (500 beds to 1000 beds and medium-high complexity) was significantly lower than in hospitals with less than 200 beds. Cluster 5 (more than 1000 beds), which includes a diverse group of hospitals, had a higher mortality rate than clusters 3 and 4. The adjusted mortality in the groups with the best and worst outcomes was 6.74% (cluster 4) and 8.49% (cluster 1), respectively. Mortality was also lower when the cardiology unit was responsible for the discharge or when angioplasty had been performed.

Conclusions

The typology of the hospital, treatment in a cardiology unit, and percutaneous coronary intervention are significantly associated with the survival of a patient hospitalized for myocardial infarction. We recommend that the Spanish National Health Service establish health care networks that favor percutaneous coronary intervention and the participation of cardiology units in the management of patients with acute myocardial infarction.

Resumen

Introducción y objetivos

Investigar la relación entre mortalidad intrahospitalaria por infarto agudo de miocardio y tipología del hospital, servicio de alta y tratamiento dispensado.

Métodos

Análisis retrospectivo de 100.993 altas por infarto en los hospitales del Sistema Nacional de Salud. La mortalidad se ajustó por riesgo utilizando los modelos del Institute of Clinical Evaluative Sciences (Canadá) y de los Centers for Medicare & Medicaid Services (Estados Unidos).

Resultados

Las características de los hospitales son relevantes para explicar la variación de la probabilidad individual de morir por infarto (odds ratio mediana = 1,3561). La mortalidad intrahospitalaria ajustada por riesgo fue significativamente menor en los hospitales de los clusters 3 y 4 (500 a 1.000 camas y complejidad mediana-alta) que en hospitales de menos de 200 camas. El cluster 5 (más de 1.000 camas), que es muy heterogéneo, tenía mayor mortalidad que los clusters 3 y 4. Las diferencias de la mortalidad ajustada entre el grupo con mejores y peores resultados fueron del 6,74% (cluster 4) y el 8,49% (cluster 1) (p < 0,001). La mortalidad también fue menor cuando el servicio de cardiología se encargó del alta, así como cuando se practicó angioplastia.

Conclusiones

Las características del hospital, ser atendido por un servicio de cardiología y el intervencionismo coronario se asocian con la supervivencia intrahospitalaria del paciente con infarto. Se recomienda la creación de redes asistenciales en el Sistema Nacional de Salud que favorezcan el intervencionismo coronario y la participación de los servicios de cardiología en el manejo de pacientes con infarto agudo de miocardio.

Section snippets

INTRODUCTION

In Spain and the majority of the developed countries, heart disease1 constitutes a considerable health care burden as it is responsible for 22% of overall mortality and is the most common cause of in-hospital morbidity.1, 2, 3 Improvements in its treatment have contributed to the increase in life expectancy, with returns on the investment made in terms of cost-effectiveness.4 These achievements are due in large part to new therapies and management strategies and to good clinical administration

METHODS

For a more detailed description of the methodology used, the reader can consult the supplementary material.

RESULTS

Significant differences were observed between the means of the RSMR related to cluster type (Table 7), to the services responsible for discharging the patients (Table 8), and to the type of procedure performed (Table 9). The F statistic provided by analysis of variance was significant in every case (P<.05), and when differences in the error variances were detected, the Kruskall-Wallis test was applied and the null hypothesis rejected. Table 7, Table 8, Table 9 show the results obtained for the

DISCUSSION

This study demonstrates that, in the Spanish NHS, the probability of in-hospital survival after AMI is associated with the characteristics of the hospital, as well as with whether the discharge is carried out by the cardiology service and whether angioplasty has been performed (Fig. 2).

The recommendations of clinical practice guidelines24, 25, 26 and national agencies27, 28, 29, 30 have promoted the development of health care networks to guarantee access of patients with AMI to angioplasty as

CONCLUSIONS

The most relevant conclusion of this study is probably that, in the Spanish NHS, the differences between hospitals help to explain the variation in the individual probability of dying from AMI. The type of hospital, the provision of care by a cardiology service, and the performance of a percutaneous coronary intervention are variables that, in this study, are independently and significantly associated with the survival of AMI patients admitted to NHS hospitals. We recommend the creation of care

FUNDING

This work for this report was funded by an unconditional grant from Menarini.

CONFLICTS OF INTEREST

None declared.

Acknowledgements

The authors thank the Spanish Ministry of Health, Social Services, and Equality for the facilities it has made available to the Spanish Society of Cardiology for the development of the RECALCAR study, with special gratitude to the General Directorate of Public Health, Quality, and Innovation and to Dr. María Ángeles Gogorcena and Dr. Mercedes Álvarez of the Spanish Health Information Institute.

References (48)

  • M. Heras et al.

    Reducción de la mortalidad por infarto agudo de miocardio en un período de 5 años

    Rev Esp Cardiol

    (2006)
  • E.E. Álvarez-León et al.

    Recursos hospitalarios y letalidad por infarto de miocardio. Estudio IBERICA

    Rev Esp Cardiol

    (2004)
  • D. Bosch et al.

    Impacto de la apertura de un nuevo laboratorio de hemodinámica sobre la supervivencia a 30 días y a 2 años en los pacientes con infarto de miocardio

    Rev Esp Cardiol

    (2011)
  • I. Palanca Sanchéz et al.

    Unidades asistenciales del área del corazón: estándares y recomendaciones

    (2011)
  • S. Petersen et al.

    European cardiovascular disease statistics

    (2005)
  • Instituto de Información Sanitaria. Estadísticas comentadas. Carga de morbilidad y proceso de atención a las...
  • V. Ortún et al.

    Buen gobierno para conciliar la deseabilidad del Estado del Bienestar con la mejora de la productividad

  • E. Braunwald

    Shattuck lecture. Cardiovascular medicine at the turn of the millennium: triumphs, concerns, and opportunities

    N Engl J Med

    (1997)
  • H.M. Krumholz et al.

    Reduction in acute myocardial infarction mortality in the United States. Risk-standardized mortality rates from 1995-2006

    JAMA

    (2009)
  • Bradley E, Webster T, Baker D, La Pan K, Lipson D, Stone R, et al. Translating research into practice: Speeding the...
  • E.H. Bradley et al.

    Research in action: using positive deviance to improve quality of health care

    Implement Sci

    (2009)
  • H.M. Krumholz et al.

    Standards for statistical models used for public reporting of health outcomes: an American Heart Association scientific statement from the Quality of Care and Outcomes Research Interdisciplinary Writing Group

    Circulation

    (2006)
  • H.M. Krumholz et al.

    Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission

    Circ Cardiovasc Qual Outcomes

    (2009)
  • H.M. Krumholz

    Medicine in the era of outcomes measurement

    Circ Cardiovasc Qual Outcomes

    (2009)
  • Cited by (0)

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