Study Emphasizes Need for Substantial Improvement in Heart Attack Outcomes Across High-Income Nations

Efforts to decrease hospital readmissions may have been misguided because the United States are already doing better than other high-income nations in this area.

A new study highlights significant differences in myocardial infarction outcomes that illustrate a lack of consistency in the quality and type of care patients receive in 6 high income nations.

The investigation, conducted by researchers at Harvard Medical School (HMS) and The University of Texas Medical Branch as part of the International Health System Research Collaborative, noted that all 6 countries in the study (Canada, England, Israel, Netherlands, Taiwan, and the United States) excelled in certain measures, while also showing that no country achieved excellence in all categories.

The highest risk of death within 1 year of hospitalization was seen in the United States for the most serious type of heart attack, despite high scores in the use of effective interventions encouraged by evidence-based guidelines, such as revascularization. The United States also lead in a key measure of efficiency, which is low hospital readmission rates for patients treated for heart attacks.

The findings of this study emphasize the gaps in applying universally accepted standards of cardiac care and should help guide countries in focusing their efforts toward improving the effectiveness and efficiency of their heart attack care, according to the study authors.

The study was created to help analyze the impact of the differences across health systems, which meant that the research team would need to compare similar patients across populations in very different genetic, social, and environmental contexts.

The investigators sought to compare treatments and outcomes for patients 66 years of age and older who were admitted to the hospital with acute myocardial infarction in 6 high-income countries between 2011 and 2017.

The outcomes were then assessed separately for patients with 2 different types of heart attack as characterized by appearance on an electrocardiogram, ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI).

The data show that the proportion of patients admitted to the hospital in 2017 with STEMI heart attacks administered the recommended blood vessel-opening procedure for this type of cardiac episode ranged from 37% in England to 79% in Canada, with higher use being generally considered better.

There were notable differences observed across countries for all outcomes. For example, death within 1 year of admission for STEMI in 2017 ranged from 19% in the Netherlands to 28% in the United States and 32% in Taiwan.

The average hospital stay in 2017 for STEMI was lowest in the Netherlands and the United States (5 and 5.1 days, respectively) and highest in Taiwan (8.5 days), whereas 30-day readmission for STEMI was lowest in Taiwan (11%) and the United States (12%) and highest in England (23%).

The study authors said that many providers and researchers in the United States have expressed concern regarding high rates of readmission and the slow progress the country has made in improving these numbers despite consistent efforts over the past decade. However, they noted that efforts to decrease hospital readmissions may have been misguided because the United States are already doing better than other high-income nations in this area.

“This kind of international perspective is important both for finding ways to improve care, and for knowing how well you’re already doing,” said Bruce Landon, professor of health care policy at HMS, in the press release. “It was revealing to see that, in spite of the common perception that the US does a poor job on preventing readmissions, we’re already doing quite well compared to our international peers.”

Landon also noted that the high rates of death in the United States indicate that higher mortality rates might be related to social determinants of health, such as racial and income inequality, stress, and environmental conditions.

“This study gives us a crucial piece of the puzzle, but we need to take a hard look at the whole picture to understand what’s driving these excess deaths,” Landon said in the press release.

REFERENCE

Room for improvement. Harvard Medical School. May 11, 2022. Accessed May 16, 2022. https://hms.harvard.edu/news/room-improvement