Posted on September 9, 2015
Population based longitudinal cohort study using nationwide clinical registries. In Sweden 119 786 patients were compared with 391 077 patients from the UK. Age: >30 years; admitted between 1 January 2004 and 31 December 2010. The 17 case mix measures were analyzed and compared. Patients admitted with acute myocardial infarction were assessed for variation in 30 day mortality.
30 day mortality from acute myocardial infarction was lower in Swedish hospitals and amounted to 8.4%. In UK hospitals 9.7% of admitted patients did not survive. Guideline based care explained the difference. Volume of primary PTCA weighed in with an inverse relationship between number of primary PCI’s and 30 day mortality rate. Comparing the lowest quarter with the highest quarter for use of primary PTCA; myocardial infarction varied between 10.7% v 6.6% in Sweden and 12.7% v 5.8% in the UK. The adjusted odds ratio 0.70 (95% confidence interval 0.62 to 0.79) in Sweden and 0.68 (0.60 to 0.76) in the UK. Differences for secondary prevention drugs for all discharged acute myocardial infarction patients were smaller than for reperfusion treatment in both countries.
Variation in the Guideline recommend treatment for AMI was associated with higher 30 day mortality rate. This variation was greater in UK hospitals compared with Swedish hospitals. The implementation of a nationwide quality improvement program, modelled after the Swedish design, could potentially reduce this variation and reduce 30 day mortality.
Strengths – Weakness
Adequate sample size from an international, multi-center registry with standardized protocol. The multivariate analyses, were adjusted for numerous potential confounders. However bias could be introduced by variables not included in the mix of the 17 chosen; differences in care before admission; using only the index admission; not all individuals admitted for an AMI are registered, this is more frequently encountered in the UK and finally the missing values in this large registry
“High quality healthcare across all hospitals, especially in the UK, with better use of guideline recommended treatment, may not only reduce unacceptable practice variation but also deliver improved clinical outcomes for patients with acute myocardial infarction.”
Better survival after a life-threatening AMI is closely linked to the quality of care provided. This again reflects how well guidelines are followed and implemented. Not the difference between guidelines in Sweden and UK are relevant but the difference between guideline implemented care in the individual hospitals. A lesson that applies not only to hospitals but more importantly on individual doctors and patients
Comparison of hospital variation in acute myocardial infarction care and outcome between Sweden and United Kingdom: population based cohort study using nationwide clinical registries. Chung SC, Sundstrom J, Gale CP et al. BMJ 2015; 351:h3913 PMID: 26254445.