Geographic Variations in In‐Hospital Mortality and Use of Percutaneous Coronary Intervention Following Acute Myocardial Infarction in China: A Nationwide Cross‐Sectional Analysis

Abstract

BackgroundPrevalence of acute myocardial infarction (AMI) is increasing in China, and AMI has become a major cause of mortality; however, information is very limited about the nationwide geographic and hospital variation in in‐hospital mortality (IHM) and the use of percutaneous coronary intervention (PCI) after AMI.Methods and ResultsFrom the Nationwide Hospital Discharge Database of China, we identified 242 866 adult admissions with AMI in 2015 from 1055 tertiary hospitals. We used multivariable logistic regressions to analyze the associations between geographic or hospital characteristics with IHM or PCI use. The national IHM rate was 4.71% (95% confidence interval, 4.62–4.79%). There was a greater risk of mortality in the Northeast (odds ratio [OR]: 1.86), West (OR: 1.73), South (OR: 1.32), and North (OR: 1.14) regions than in the East region of China. Non–teaching hospitals (OR: 1.18) and tertiary level B hospitals (OR: 1.06) were associated with higher IHM rates. The national PCI use rate was 45.3% (95% confidence interval, 45.1–45.5%). Compared with the East region of China, PCI use was lower in the Northeast (OR: 0.50), West (OR: 0.64), North (OR: 0.84), and South (OR: 0.88) regions. Non–teaching hospitals (OR: 0.83) and tertiary level B hospitals (OR: 0.55) were also associated with lower usage rates. There was a significant negative correlation between IHM and PCI use (r=−0.955), and IHM rates for patients with and without PCI both differed by geographic regions.ConclusionsThere were significant differences in IHM and PCI use among China's tertiary hospitals, linked to both geographic and hospital characteristics. More targeted intervention at national and regional levels is needed to improve access to effective health technologies and, eventually, outcomes following AMI.

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“…57 In China, a nationwide database study that included 1055 tertiary hospitals showed an in-hospital mortality of 3.6% and a PCI utilization rate of 37.2% in patients with NSTEMI (corresponding rates in patients with STEMI were 5.1% and 47.8%, respectively). 55 The study identified wide variations in the rates of in-hospital mortality across geographical regions, and the rates were significantly lower in patients who received PCI than in those who did not. 55 Geographical variation in care may be due to the lack of availability of cardiologists, catheterization laboratories, and medical treatments in rural areas compared with urban areas.…”

“…55 The study identified wide variations in the rates of in-hospital mortality across geographical regions, and the rates were significantly lower in patients who received PCI than in those who did not. 55 Geographical variation in care may be due to the lack of availability of cardiologists, catheterization laboratories, and medical treatments in rural areas compared with urban areas. 60 For example, a study assessing outcomes in patients with acute MI in New South Wales, Australia, showed that patients with NSTEMI presenting to a rural hospital were 70% less likely to undergo cardiac revascularization than patients presenting to an urban hospital.…”

“…In China, a nationwide database study that included 1055 tertiary hospitals showed an in‐hospital mortality of 3.6% and a PCI utilization rate of 37.2% in patients with NSTEMI (corresponding rates in patients with STEMI were 5.1% and 47.8%, respectively) . The study identified wide variations in the rates of in‐hospital mortality across geographical regions, and the rates were significantly lower in patients who received PCI than in those who did not . A separate registry study of patients with NSTEMI in China, including 142 hospitals, showed that angiography and PCI were performed in 63.1% and 58.2% of these patients, respectively, and that only 41.7% of patients with the highest risk underwent PCI …”

“…Optimal guideline‐indicated treatment of patients with NSTEMI is also affected by the availability of procedures, as well as governmental and hospital policies. Several studies have demonstrated wide geographical variation in the use of guideline‐indicated treatments for patients with NSTEMI, which is linked to hospital and geographical characteristics …”

“…Several studies have demonstrated wide geographical variation in the use of guideline-indicated treatments for patients with NSTEMI, which is linked to hospital and geographical characteristics. 30,[55][56][57] In the SNAPSHOT ACS study, assessing patients with chest pain admitted to hospitals in Australia and New Zealand, the proportion of patients with NSTEMI who were given a coronary angiogram varied from 56.5% to 68.9% across health jurisdictions, whereas the proportion of patients with STEMI/left bundle branch block given a coronary angiogram ranged from 81.1% to 100%. 30 Registry data from Arabian Gulf countries (Saudi Arabia, Bahrain, Qatar, Oman, United Arab Emirates, and Yemen) showed that only 26.8% of patients with NSTEMI received coronary angiography and 21.9% received revascularization with either PCI or CABG.…”