Lessons Learned From Acute Myocardial Infarction Care in China | Acute Coronary Syndromes | JAMA Network Open | JAMA Network
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Invited Commentary
October 23, 2020

Lessons Learned From Acute Myocardial Infarction Care in China

Author Affiliations
  • 1The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
  • 2Department of Medicine, Duke University, Durham, North Carolina
JAMA Netw Open. 2020;3(10):e2021768. doi:10.1001/jamanetworkopen.2020.21768

Over the last several decades, we have made remarkable progress in the treatment of ST-segment myocardial infarction (STEMI). There has been a dramatic increase in timely reperfusion with primary percutaneous coronary intervention (PCI), leading to substantial improvement in both morbidity and mortality, not only in the US but also in many regions of the world.1 On the basis of improvements in primary and secondary prevention, the incidence of STEMI has actually decreased as well.1 Many researchers believe that we have solved the STEMI problem, but the improvement in mortality has plateaued and we have made very little progress in reperfusion times for patients transferred from a non-PCI center or outcomes for those with out-of-hospital cardiac arrest or cardiogenic shock. Moreover, we lack a comprehensive national STEMI registry, and many patients are excluded from the measure in the existing registries. Therefore, the actual real-world outcomes remain unclear, and considerable variability exists across the US, with clear urban-rural disparities.2

Importantly, the incidence of STEMI is increasing in many parts of the world. For example, there has been a substantial increase in mortality associated with STEMI in both urban and rural populations in mainland China over the last 20 years.3,4 The articles by Zhong et al3 and Xu et al4 provide potential insights for US and Chinese cardiologists. Both studies3,4 include large numbers of patients from diverse regions of mainland China in collaboration with US investigators and quality initiatives.

As described by Zhong et al,3 the China PEACE-retrospective acute myocardial infarction (AMI) study followed a quality of care model established by the Cooperative Cardiovascular Project (CCP)5 to examine hospital treatment by medical record review for patients with an AMI discharge diagnosis. A random sample of hospitalizations for AMI (both STEMI and non-STEMI) in 2001, 2006, 2011, and 2015 from the 3 geographic regions of mainland China—Eastern, Central, and Western, subdivided into rural and urban—were examined, excluding patients who were transferred (in or out) and those discharged alive within 24 hours. Zhong et al3 evaluated the use of 6 evidence-based treatments (reperfusion therapy, aspirin, clopidogrel, and β-blockers within 24 hours, and angiotensin-converting enzyme or angiotensin II receptor blocker inhibitors and statin therapy during the hospitalization) in 27 046 patients with AMI in 153 hospitals across China who were considered ideal candidates for treatment and then calculated the proportion of ideal patients who received the treatment. This is a complex analysis with substantial assumptions, demonstrating regional differences with an improvement overall in health care delivery over time. Delivery of recommended treatments to an ideal patient was associated with decreased odds of mortality by 38% to 51% depending on the region.3 The challenges of interpreting data from large registries on the basis of discharge diagnosis and medical record review are illustrated by the fact that hospitals in the Central Region had lower mortality rates than those in the Western Region, despite having poorer performance of care delivery; the better guideline-recommended treatments in the Western Region were associated with higher in-hospital and 5-day mortality.3 Of note, the rates of cardiac arrest (1.0%-1.3%) and cardiogenic shock (5.2%-6.9%) across the regions were quite low.3 Although the overall composite of ideal treatments improved, it was based primarily on the use of statins and clopidogrel, and the use of reperfusion therapy actually declined, remaining approximately 50% for the ideal patient.3 In addition, the overall mortality rate did not change substantially over time, perhaps because the use of reperfusion therapy did not increase.

The China Acute Myocardial registry, as described by Xu et al,4 followed another successful model for quality improvement, the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry.6 Focusing on 12 695 patients with STEMI at 108 hospitals in 31 provinces throughout mainland China, the study4 describes variability in care and mortality according to 3 Chinese-specific definitions of hospital types. Considering catheterization laboratory availability, 100% of province-level hospitals, 93% of prefecture-level hospitals, and 44% of county-level hospitals have a catheterization laboratory.4 Patients presenting to province-level hospitals were more likely than patients presenting to prefecture-level or county-level hospitals to arrive by ambulance (19.4% vs 11.6% vs 12.0%), to present within 12 hours after symptoms onset (75.3% vs 70.8% vs 69.8%), and to receive reperfusion therapy (69.4% vs 54.3% vs 45.8%).4 County-level hospitals were fastest at fibrinolysis, whereas prefecture-level hospitals had the fastest PCI times. Patients treated at province-level hospitals were younger and had lower mortality rates than patients treated at prefecture-level and county-level hospitals (3.1% [95% CI, 2.6%-3.7%] vs 5.3% [95% CI, 4.8%-5.9%] vs 10.2% [95% CI, 8.9%-11.7%]; P for trend < .001), with mortality differences that remained significant after adjustment for available patient characteristics, presentation, hospital facility, and treatment differences.4 In particular, the availability of primary PCI and a cardiac intensive care unit were hospital characteristics associated with lower mortality.

What insights can be gained from the application of US quality improvement models to the Chinese health care system? First, AMI continues to be a major worldwide problem, with a particular burden on developed countries with increasing economic prosperity, longer life expectancies, and higher rates of hypertension, diabetes, and tobacco use. Despite the similarities of biology and pathology among patients, health care systems vary markedly by country and region, largely as a function of local and regional economics, political systems, and social norms. Although the US quality measurement models can be successfully applied to China, efforts at improving care must consider local resources, customs, and expertise to provide effective improvements. For example, the higher rates of ambulance presentation in the US and staffing with paramedics capable of diagnosing STEMI has provided a particularly effective process expediting reperfusion therapy. In the Chinese system, with 84.8% of patients self-presenting,4 interventions that focus on the hospital admission process including emergency medicine are more likely to accelerate care and improve outcomes. The data also highlight marked differences in care and outcomes according to rural and urban settings, whether viewed by region or hospital type in China, or referring or receiving hospitals in the US.2 In both countries, the greatest and most challenging opportunities for improved care reside in rural and less resourced regions and hospitals.

Collaboration and competition among countries and political systems in the spirit of advancing health care and reducing morbidity and mortality has great potential to benefit both countries. The successful application of the CCP5 and ACTION6 models in China demonstrates that both countries are capable of implementing large-scale and comprehensive quality improvement programs to benefit the most acutely ill patients. Going forward, the question remains which country will lead continued progress. These 2 registries3,4 represent large and successful efforts at describing AMI care at specific points in time, with the most recent data from 2015. The next iterations of these effort most likely to rapidly advance AMI care should mirror the principles of W. Edwards Deming, “plan-do-check-act,”7 establishing prespecified regional protocols, measuring care, and reporting comparative performance on an ongoing basis with credible time frames, and using these data to continue to improve care and lower mortality. In the US, the national AMI registry has devolved into multiple competing registries, with declines in hospital participation in a common registry within relevant regional systems. This fracture of the US system challenges efforts to improve care, where emergency medical services must transport patients to hospitals with differing or no data systems, impeding regional collaboration and improvement. China has rapidly embraced the best quality improvement models of the US and is poised to approach and surpass the high water mark of collaborative AMI regional systems of care in the US.8 The US health system has the identical opportunity, and the continued collaboration and competition would be welcomed by health care practitioners, patients, and their families.

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Article Information

Published: October 23, 2020. doi:10.1001/jamanetworkopen.2020.21768

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Henry TD et al. JAMA Network Open.

Corresponding Author: Timothy D. Henry, MD, The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, 2123 Auburn Ave, Ste 424, Cincinnati, OH 45219 (tim.henry@thechristhospital.com).

Conflict of Interest Disclosures: None reported.

Shah  RU, Henry  TD, Rutten-Ramos  S, Garberich  R, Tighouart  M, Bairey Merz  CN.  Increasing percutaneous coronary interventions for ST-segment elevation myocardial infarction in the United States: progress and opportunity.   JACC Cardiovasc Interv. 2015;8(1 pt B):139-146. doi:10.1016/j.jcin.2014.07.017PubMedGoogle ScholarCrossref
Henry  TD, Sharkey  SW, Burke  MN,  et al.  A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction.   Circulation. 2007;116(7):721-728. doi:10.1161/CIRCULATIONAHA.107.694141PubMedGoogle ScholarCrossref
Zhong  Q, Gao  Y, Zheng  X,  et al.  Geographic variation in process and outcomes of care for patients with acute myocardial infarction in China from 2001 to 2015.   JAMA Netw Open. 2020;3(10):e2021182. doi:10.1001/jamanetworkopen.2020.21182Google Scholar
Xu  H, Yang  Y, Wang  C,  et al; China Acute Myocardial Infarction Registry Investigators.  Association of hospital-level differences in care with outcomes among patients with acute ST-segment elevation myocardial infarction in China.   JAMA Netw Open. 2020;3(10):e2021677. doi:10.1001/jamanetworkopen.2020.21677Google Scholar
Marciniak  TA, Ellerbeck  EF, Radford  MJ,  et al.  Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project.   JAMA. 1998;279(17):1351-1357. doi:10.1001/jama.279.17.1351PubMedGoogle ScholarCrossref
Peterson  ED, Roe  MT, Rumsfeld  JS,  et al.  A call to ACTION (Acute Coronary Treatment and Intervention Outcomes Network): a national effort to promote timely clinical feedback and support continuous quality improvement for acute myocardial infarction.   Circ Cardiovasc Qual Outcomes. 2009;2(5):491-499. doi:10.1161/CIRCOUTCOMES.108.847145PubMedGoogle ScholarCrossref
Deming  WE.  Out of the Crisis. The MIT Press; 2018:74-75.
Jollis  JG, Al-Khalidi  HR, Roettig  ML,  et al.  Impact of regionalization of ST‐segment‐elevation myocardial infarction care on treatment times and outcomes for emergency medical services‐transported patients presenting to hospitals with percutaneous coronary intervention: mission—Lifeline Accelerator‐2.   Circulation. 2018;137(4):376-387. doi:10.1161/CIRCULATIONAHA.117.032446PubMedGoogle ScholarCrossref
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