Performance of hospitals according to the ESC ACCA quality indicators and 30-day mortality for acute myocardial infarction: national cohort study using the United Kingdom Myocardial Ischaemia National Audit Project (MINAP) register

Aims To investigate the application of the European Society of Cardiology Acute Cardiovascular Care Association quality indicators (QI) for acute myocardial infarction for the study of hospital performance and 30-day mortality. Methods and results National cohort study (n = 118,075 patients, n = 211 hospitals, MINAP registry), 2012-13. Overall, 16 of the 20 QIs could be calculated. Eleven QIs had a significant inverse association with GRACE risk adjusted 30-day mortality (all P < 0.005). The association with the greatest magnitude was high attainment of the composite opportunity-based QI (80-100%) vs. zero attainment (odds ratio 0.04, 95% confidence interval 0.04-0.05, P < 0.001), increasing attainment from low (0.42, 0.37- 0.49, P < 0.001) to intermediate (0.15, 0.13-0.16, P < 0.001) was significantly associated with a reduced risk of 30-day mortality. A 1% increase in attainment of this QI was associated with a 3% reduction in 30-day mortality (0.97, 0.97-0.97, P < 0.001). The QI with the widest hospital variation was ′fondaparinux received among NSTEMI′ (interquartile range 84.7%) and least variation ′centre organisation′ (0.0%), with seven QIs depicting minimal variation (<11%). GRACE risk score adjusted 30-day mortality varied by hospital (median 6.7%, interquartile range 5.4-7.9%). Conclusions Eleven QIs were significantly inversely associated with 30-day mortality. Increasing patient attainment of the composite quality indicator was the most powerful predictor; a 1% increase in attainment represented a 3% decrease in 30-day standardised mortality. The ESC QIs for acute myocardial infarction are applicable in a large health system and have the potential to improve care and reduce unwarranted variation in death from acute myocardial infarction

Guideline-indicated treatments and diagnostics, GRACE risk score, and survival for non-ST elevation myocardial infarction

Aim: To investigate whether improved survival from NSTEMI, according to GRACE risk score, was associated with guideline-indicated treatments and diagnostics, and persisted after hospital discharge. Methods and results: National cohort study (n=389,507 patients, n=232 hospitals, MINAP registry), 2003-13. The primary outcome was adjusted all-cause survival estimated using flexible parametric survival modelling with time-varying covariates over a median follow-up of 2.3-years. Receipt of all eligible treatments (optimal care) was inversely related to risk status: 25.6% in low, 18.6% in intermediate and 11.5% in high risk NSTEMI. At 30 days, the use of optimal care was associated with improved survival among high (adjusted hazard ratio [aHR]=0.66 [95% CI 0.53-0.86], difference in absolute mortality rate per 100 patients [AMR/100] –0.19 [95% CI –0.29 to –0.08]), and intermediate (aHR=0.74 [95% CI 0.62-0.92]; AMR/100 –0.15 [95% CI –0.23 to –0.08]) risk NSTEMI. At the end of follow-up (8.4 years), the significant association between the use of all eligible guideline-indicated treatments and improved survival remained only for high risk NSTEMI (aHR=0.66 [95% CI 0.50-0.96]; AMR/100= –0.03 [95% CI –0.06 to –0.01]). For low risk NSTEMI, there was no association between the use of optimal care and improved survival at 30 days (aHR=0.92 [95% CI 0.69-1.38] and at 8.4 years (aHR=0.71 [95% CI 0.39-3.74]). Conclusions: Optimal use of guideline-indicated care for NSTEMI was associated with greater survival gains with increasing GRACE risk, but its use decreased with increasing GRACE risk