Association of Hospital-Level Differences in Care With Outcomes Among Patients With Acute ST-Segment Elevation Myocardial Infarction in China

Key Points Question What are the differences in care and outcomes of patients with ST-segment elevation myocardial infarction among 3 vertical levels of hospitals in China? Findings In this cross-sectional study using data from the China Acute Myocardial Infarction Registry, which included 108 hospitals at the province, prefecture, and county levels, compared with patients in province-level hospitals, the rates of reperfusion therapy were lower among those in prefecture-level and county-level hospitals (69.4% vs 54.3% vs 45.8%). In-hospital mortality rates progressively increased among the 3 levels of hospitals, from 3.1% at the province level to 5.3% at the prefecture level to 10.2% at the county level. Meaning These findings suggest that more efforts should be made to address the gaps in care and outcomes of ST-segment elevation myocardial infarction for national quality improvement in China.

Name: Primary cause of death: 1. Cardiovascular death indicates cause of death was sudden cardiac death, MI, unstable angina, or other CAD; vascular death (e.g., stroke, arterial embolism, pulmonary embolism, ruptured aortic aneurysm, or dissection); CHF; or cardiac arrhythmia 2. Non-cardiovascular death indicates cause of death was respiratory failure, pneumonia, cancer, trauma, suicide, or any other already defined cause (e.g., liver disease or renal failure) Name: Heart Failure Coding Instructions: Indicate if there is physician documentation or report of either new onset or acute reoccurrence of heart failure.

Supporting Definitions: Heart Failure:
Heart failure is defined as physician documentation or report of any of the following clinical symptoms of heart failure described as unusual dyspnea on light exertion, recurrent dyspnea occurring in the supine position, fluid retention; or the description of rales, jugular venous distension, pulmonary edema on physical exam, or pulmonary edema on chest x-ray presumed to be cardiac dysfunction. A low ejection fraction without clinical evidence of heart failure does not qualify as heart failure.

Name: Re-infarction
Indicate if there are clinical signs and symptoms of a new infarction or repeat infarction.
Target Value: Any occurrence between arrival at this facility and discharge Supporting Definitions: Re-infarction: Re-infarction occurs when there are clinical signs and symptoms of ischemia that is distinct from the presenting ischemic event. In patients where recurrent myocardial infarction is suspected from clinical signs or symptoms following the initial infarction, an immediate measurement of the employed cardiac marker is recommended. A second sample should be obtained 3-6 h later. Recurrent infarction is diagnosed if there is a20% increase of the value in the second sample. A 20% change should be considered significant, i.e. over that expected from analytical variability itself. This value should also exceed the 99th percentile URL. The ECG diagnosis of re-infarction following the initial infarction may be confounded by the initial evolutionary ECG changes. Re-infarction should be considered when ST elevation >0.1 mV reoccurs in a patient having a lesser degree of ST elevation or new pathological Q waves, in at least two contiguous leads, particularly when associated with ischemic symptoms for 20 min or longer.

Name: Arrhythmia
Indicate if the patient has a new episode or acute recurrence of arrhythmia in your facility documented by 1 of the following.

Name: Cardiac Arrest H. In-Hospital Clinical Events
Coding Instructions: Indicate if the patient experienced an episode of cardiac arrest in your facility.

Name: Cardiogenic Shock
Coding Instructions: Indicate if the patient had a new onset or acute recurrence of cardiogenic shock in your facility.

Note(s):
Transient episodes of hypotension reversed with IV fluid or atropine do not constitute cardiogenic shock. The hemodynamic compromise (with or without extraordinary supportive therapy) must persist for at least 30minutes.

Supporting Definitions: Cardiogenic shock:
Cardiogenic shock is defined as a sustained (>30 minutes) episode of systolic blood pressure <90 mm Hg, and/or cardiac index <2.2 L/min/m 2 determined to be secondary to cardiac dysfunction, and/or the requirement for parenteral inotropic or vasopressor agents or mechanical support (e.g., IABP, extracorporeal circulation, ventricular assist devices) to maintain blood pressure and cardiac index above those specified levels.

Name: Mechanical Complication
Rupture of the ventricular myocardium, as documented by cardiac echocardiography, ventriculography, pericardiocentesis, cardiac surgery, and/or autopsy. Rupture could be of the free wall or the ventricular septum. Included in this category is frank papillary muscle rupture.
Name: CVA/Stroke H Coding Instructions: Indicate if the patient experienced a stroke or cerebrovascular accident (CVA) in your facility.

Supporting Definitions: Stroke
A stroke or cerebrovascular accident is defined as loss of neurological function caused by an ischemic or hemorrhagic event with residual symptoms at least 24 hours after onset or leading to death.
Type of stroke: 1. Hemorrhagic: A stroke with documentation on imaging (e.g., CT scan or MRI of hemorrhage in the cerebral parenchyma, or a subdural or subarachnoid hemorrhage). Evidence of hemorrhagic stroke obtained from lumbar puncture, neurosurgery, or autopsy can also confirm the diagnosis.
2. Ischemic: A focal neurological deficit that results from a thrombus or embolus (and not due to hemorrhage) that appears and is still partially evident for more than 24 hours 3. Ischemic with hemorrhagic conversion 4. Unknown: if the type of stroke could not be determined by imaging or other means (from lumbar puncture, neurosurgery, or autopsy)

Name: Peripheral Arterial Event
Indicate if the patient experienced a peripheral arterial event in your facility.