Data_Sheet_1_Current Status and Hospital-Level Differences in Care and Outcomes of Patients With Acute Non-ST-Segment Elevation Myocardial Infarction in China: Insights From China Acute Myocardial Infarction Registry.PDF

BackgroundWith the growing burden of non-ST-elevation myocardial infarction (NSTEMI), developing countries face great challenges in providing equitable treatment nationwide. However, little is known about hospital-level disparities in the quality of NSTEMI care in China. We aimed to investigate the variations in NSTEMI care and patient outcomes across the three hospital levels (province-, prefecture- and county-level, with decreasing scale) in China.
MethodsData were derived from the China Acute Myocardial Infarction Registry on patients with NSTEMI consecutively registered between January 2013 and November 2016 from 31 provinces and municipalities throughout mainland China. Patients were categorized according to the hospital level they were admitted to. Multilevel generalized mixed models were fitted to examine the relationship between the hospital level and in-hospital mortality risk.
ResultsIn total, 8,054 patients with NSTEMI were included (province-level: 1,698 patients; prefecture-level: 5,240 patients; county-level: 1,116 patients). Patients in the prefecture- and county-level hospitals were older, more likely to be female, and presented worse cardiac function than those in the province-level hospitals (P <0.05). Compared with the province-level hospitals, the rate of invasive strategies was significantly lower in the prefecture- and county-level hospitals (65.3, 43.3, and 15.4%, respectively, P <0.001). Invasive strategies were performed within the guideline-recommended timeframe in 25.4, 9.7, and 1.7% of very-high-risk patients, and 16.4, 7.4, and 2.4% of high-risk patients in province-, prefecture- and county-level hospitals, respectively (both P <0.001). The use of dual antiplatelet therapy in the county-level hospitals (87.2%) remained inadequate compared to the province- (94.5%, P <0.001) and prefecture-level hospitals (94.5%, P <0.001). There was an incremental trend of in-hospital mortality from province- to prefecture- to county-level hospitals (3.0, 4.4, and 6.9%, respectively, P-trend <0.001). After stepwise adjustment for patient characteristics, presentation, hospital facilities and in-hospital treatments, the hospital-level gap in mortality risk gradually narrowed and lost statistical significance in the fully adjusted model [Odds ratio: province-level vs. prefecture-level: 1.23 (0.73–2.05), P = 0.441; province-level vs. county-level: 1.61 (0.80–3.26), P = 0.182; P-trend = 0.246].
ConclusionsThere were significant variations in NSTEMI presentation and treatment patterns across the three hospital levels in China, which may largely explain the hospital-level disparity in in-hospital mortality. Quality improvement initiatives are warranted, especially among lower-level hospitals.

背景 随着非ST段抬高型心肌梗死（non-ST-elevation myocardial infarction, NSTEMI）的疾病负担日益加重，发展中国家在全国范围内提供公平可及的诊疗服务方面面临巨大挑战。然而，目前关于中国不同层级医院中非ST段抬高型心肌梗死诊疗质量的差异仍缺乏深入认识。本研究旨在探讨中国三类医院层级（按规模递减依次为省级、地市级、县级医院）的非ST段抬高型心肌梗死诊疗模式与患者临床结局的差异。

方法 研究数据来源于中国急性心肌梗死注册研究（China Acute Myocardial Infarction Registry），纳入2013年1月至2016年11月期间，来自中国大陆31个省、自治区、直辖市的连续注册登记的非ST段抬高型心肌梗死患者。根据患者就诊医院的层级进行分组。采用多水平广义混合模型（multilevel generalized mixed models）分析医院层级与患者住院死亡风险之间的关联。

结果 本研究共纳入8054例非ST段抬高型心肌梗死患者，其中省级医院就诊患者1698例，地市级医院5240例，县级医院1116例。与省级医院患者相比，地市级与县级医院的患者年龄更大、女性占比更高，且基线心脏功能更差（P<0.05）。与省级医院相比，地市级与县级医院的有创诊疗操作率显著更低，分别为65.3%、43.3%与15.4%（P<0.001）。在极高危患者中，省级、地市级、县级医院分别有25.4%、9.7%与1.7%的患者在指南推荐的时间窗内完成有创诊疗操作；高危患者中该比例分别为16.4%、7.4%与2.4%，组间差异均具有统计学意义（均P<0.001）。县级医院的双联抗血小板治疗（dual antiplatelet therapy）使用率为87.2%，仍低于省级医院（94.5%，P<0.001）与地市级医院（94.5%，P<0.001），治疗依从性不足。住院死亡率随医院层级降低呈递增趋势：省级、地市级、县级医院分别为3.0%、4.4%与6.9%（P趋势<0.001）。经逐步校正患者特征、就诊基线情况、医院设施及住院治疗措施后，医院层级间的死亡风险差异逐渐缩小，在完全校正模型中该差异不再具有统计学意义[比值比（Odds ratio）：省级vs地市级：1.23（95%置信区间0.73–2.05），P=0.441；省级vs县级：1.61（95%置信区间0.80–3.26），P=0.182；P趋势=0.246]。

结论 中国不同层级医院间的非ST段抬高型心肌梗死患者就诊特征与诊疗模式存在显著差异，该差异可在很大程度上解释住院死亡风险的医院层级差异。因此，有必要开展诊疗质量改进举措，尤其是针对低层级的基层医院。