Twenty-Year Trends in Outcomes for Older Adults With Acute Myocardial Infarction in the United States | Acute Coronary Syndromes | JAMA Network Open | JAMA Network
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    1 Comment for this article
    Implied Cause and Effect - It Breaks My Heart
    David Buccigrossi, MD | Kaiser Permanente Southern California
    The article by Krumholz et al is full of useful and encouraging information regarding ischemic heart disease in the United States from 1995 - 2014. It is however reminiscent of a pair of articles in the New England Journal of Medicine in 2012, where the same bias of cause and effect is strongly implied (1), and a rebuttal was nicely rendered (2). In that case too, a set of generally expensive and impressive procedures are presented as the proximate cause of improved cardiovascular outcomes without proof. In the current article, hospital care, expensive procedures, process measures, and CMS programs are suggested as a principle source of benefit. I suspect the causes are much more pedestrian.

    They note that the average age of AMI presentation has increased by 2.7 years, implying progress in "delaying the onset of AMI." Curiously, they do not make a similar supposition of a far more profound statistic: that the rate of AMI per 100,000 beneficiary-years has decreased from 914 to 566. This extraordinary reduction is pre - event and cannot be attributed to any of the post - event interventions discussed in the article. Indeed, I think it most likely that hypertension control, lipid reduction, and smoking cessation contribute the lion's share to this decrease. Most of the other data improvements would follow, for these same outpatient interventions would decrease the average burden of each AMI, making them less lethal and leading to less of the many factors mentioned. There is no doubt that post - event care is wondrous, and has likely led to some benefit, but the data to support this is modest, and certainly the data to associate it with these extraordinary numbers - as if they were the chief contributors - is simply not there.

    Furthermore, the cost is of concern. The increase in cost per AMI hospitalization was only 19% over this time, but given that the 2014 hospitalizations were half as long (a good thing likely secondary to lesser burdens of disease and excellent hospital care), the per day cost increase was 138%. Catheterizations increased 36%, PCI increased 130%, and CABG decreased 29%. Again, the data that PCI improves outcomes is not robust, and whether this tremendous increase in PCI has led to a significant portion of the mortality and morbidity improvement is highly debatable.

    I applaud the brief look at inequality across counties, but the biggest factors in the 20 year differential in longevity between U.S. counties has much more to do with poverty, socioeconomic factors, and lack of medical insurance than PCI or advanced cardiovascular care. One of the best ways to bring medical insurance to those in need would be to reduce our very high cost of care, and thereby free up money for those uninsured patients.

    To that end, articles that emphasize glorious technology to the exclusion of the mundane and go even further by strongly implying cause and effect without proof do a disservice to what is known, and to where our precious medical dollars should be spent. Smoking cessation, hypertension control, and lipid reduction are the public health cornerstones which are most likely to affect cardiovascular disease incidence and outcome. These factors are indeed pedestrian, as millions of physicians, health care workers of all types, and patients, have led the charge in this regard. While they are much less exciting, they should be where the money is.

    1. N Engl J Med 2012;366:54-63.
    2. N Engl J Med 2012; 366:1258-1260
    Original Investigation
    March 15, 2019

    Twenty-Year Trends in Outcomes for Older Adults With Acute Myocardial Infarction in the United States

    Author Affiliations
    • 1Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
    • 2Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
    • 3Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
    • 4Department of Health Care Policy, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    • 5Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    JAMA Netw Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938
    Key Points español 中文 (chinese)

    Question  What are the patterns of hospitalizations, treatments, and outcomes for older patients with acute myocardial infarction (AMI) over a recent 20-year period in the United States?

    Findings  In this cohort study of data from more than 4.3 million Medicare fee-for-service beneficiaries aged 65 years and older discharged with AMI, declines were found in AMI hospitalizations (914 to 566 per 100 000 beneficiary-years), 30-day mortality (20.0% to 12.4%), and 30-day all-cause readmissions (21.0% to 15.3%). There were increases in the 2014 Consumer Price Index–adjusted median Medicare inpatient payment per AMI discharge ($9282 to $11 031) and 30-day inpatient catheterization (44.2% to 59.9%).

    Meaning  The last 2 decades were marked by large changes in the number of people hospitalized with AMI—and marked improvements in the short- and long-term outcomes along with increases in cost per hospitalization and number of procedures.


    Importance  Medicare and other organizations have focused on improving quality of care for patients with acute myocardial infarction (AMI) over the last 2 decades. However, there is no comprehensive perspective on the evolution of outcomes for AMI during that period, and it is unknown whether temporal changes varied by patient subgroup, hospital, or county.

    Objective  To provide a comprehensive evaluation of national trends in inpatient outcomes and costs of AMI during this period.

    Design, Setting, and Participants  This cohort study included analysis of data from a sample of 4 367 485 Medicare fee-for-service beneficiaries aged 65 years or older from January 1, 1995, through December 31, 2014, across 5680 hospitals in the United States. Analyses were conducted from January 15 to June 5, 2018.

    Main Outcomes and Measures  Thirty-day all-cause mortality at the patient, hospital, and county levels. Additional outcomes included 30-day all-cause readmissions; 1-year recurrent AMI; in-hospital mortality; length of hospital stay; 2014 Consumer Price Index–adjusted median Medicare inpatient payment per AMI discharge; and rates of catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery.

    Results  The cohort included 4 367 485 Medicare fee-for-service patients aged 65 years or older hospitalized for AMI during the study period. Between 1995 and 2014, the mean (SD) age of patients increased from 76.9 (7.2) to 78.2 (8.7) years, the percentage of female patients declined from 49.5% to 46.1%, the percentage of white patients declined from 91.0% to 86.2%, and the percentage of black patients increased from 5.9% to 8.0%. There were declines in AMI hospitalizations (914 to 566 per 100 000 beneficiary-years); 30-day mortality (20.0% to 12.4%; difference, 7.6 percentage points; 95% CI, 7.3-7.8 percentage points); 30-day all-cause readmissions (21.0% to 15.3%; difference, 5.7 percentage points; 95% CI, 5.4-6.0 percentage points); and 1-year recurrent AMI (7.1% to 5.1%; difference, 2.0 percentage points; 95% CI, 1.8-2.2 percentage points). There were increases in the 2014 Consumer Price Index–adjusted median (interquartile range) Medicare inpatient payment per AMI discharge ($9282 [$6969-$12 173] to $11 031 [$8099-$16 861]); 30-day inpatient catheterization (44.2% to 59.9%; difference, 15.7 percentage points; 95% CI, 15.4-16.0 percentage points); and inpatient percutaneous coronary intervention (18.8% to 43.3%; difference, 24.5 percentage points; 95% CI, 24.2-24.7 percentage points). Coronary artery bypass graft surgery rates decreased from 14.4% to 10.2% (difference, 4.2 percentage points; 95% CI, 3.9-4.3 percentage points). There was heterogeneity by hospital and county in the mortality changes over time.

    Conclusions and Relevance  This study shows marked improvements in short-term mortality and readmissions, with an increase in in-hospital procedures and payments, for the increasingly smaller number of Medicare beneficiaries with AMI.