A Comparison of In-hospital Myocardial Infarction Management Between Portugal and the United States | 2000 – 2010Lobo MF • Azzone V • Azevedo LF • Teixeira-Pinto A • Pereira-Miguel J • Costa-Pereira A • Resnic F • Normand SLT

What is Known

Data Sources

// Inter- & intra-country variability in new medical technology diffusion exist

// International comparative studies provide an opportunity to assess technology effectiveness

Population & Statistical Approach Age-Sex Standardize AMI Hospitalizations Rates and 95% CI

Adults >19 with AMI

Age-Sex Standardize In-Hospital Mortality Rates and 95% CI2010, Adults >19 with AMIPOPULATION:

// Adults (> 19 yrs) inpatient discharged with a new AMI between Jan. 1, 2000 and Dec. 31, 2010

// Both patients discharged to hospice or left against medical advice and invalid discharges were excluded

STATISTICAL APPROACH

// ICD-9-CM codes identified new AMI (410.x, no 410.x2) admissions and in-hospital procedures; discharge status (alive vs dead); and length of stay

// Cohorts stratified by STEMI (410.0-410.6, 410.8) and Non-STEMI (410.7, 410.9) status

// Intra & inter-country age-sex standardized rates of AMI hospitalizations, procedures and mortality

// There is an increasing AMI hospital admission rate in Portugal over the past decade that contrasts with a decreasing rate in the U.S.// Utilization of in-hospital cardiac surgical procedures differs between the two countries, with the U.S. generally having higher use// Coronary artery bypass grafting surgery after AMI is surprisingly low in Portugal// The differences in procedure utilization, length of hospital stay, or a combination of these factors may explain the higher in-hospital mortality rate after a heart attack in Portugal compared to the U.S.

// U.S.: HCUP 20% inpatient sample

// Portugal: ACSS 100% inpatient data from public sector hospitals*

// Equivalent key variables in the two datasets: / Demographic information / Diagnosis and procedure codes classification (ICD-9-CM) / Principal diagnosis

// Differences in the datasets: / Different number of codes / No race information in PT / Discharge status categorical values / Billing information (Charges/DRGs)

// 2010 population census information

Abbv. HCUP – Health Cost and Utilization Project; ACSS – Administração Central do Sistema de Saúde; ICD-9-CM – International Classification of Diseases, 9th Revision, Clinical Modification. DRG – Diagnosis-Related Group*Corresponds to 84% of all inpatient discharges in Portugal (2000-2010)

To compare trends in in-hospital AMI treatment & outcomes between U.S.

and Portugal

Aim

Country U.S. Portugal

Year 2000 2010 2000 2010

# Discharges 145,185 114,915 9,021 12,037

# Hospitals 932 916 76 51

Male, % 59 61 68 65

Mean Age [SD]

Risk Factors/Comorbidities, %

68 [14] 67 [14] 67 [13] 69 [14]% Aged ≥ 80 24 24 14 22

Diabetes 2.8 2.8 1.3 3.3Hypertension 45 64 32 53PVD 7.7 11 2.2 4.4Renal Failure 8.9 17 5.3 4.2COPD 16 16 3.9 4.4VHD 11 11 6.3 12

Median Length of Stay, [IQR] days 5 [3,8] 4 [3,7] 9 [6,13] 7 [5,10]

Survivors 5 [3,8] 4 [3,7] 10 [7,13 ] 7 [5,10]

Non-Survivors 4 [2,8] 4 [2,7] 3 [2,7] 3 [2,8]

† Standardized to 2010 US

Country U.S. Portugal Portugal/U.S. In-HospitalProcedures

Crude rates, % 2010 Standardized Rate Ratio†Year

CathCABG Surgery

Off PumpPCI

Stenting

Revascularization

OtherHeart Proc.

0.87 [0.75,1.00]0.19 [0.14, 0.26]0.38 [0.26, 0.54]1.07 [0.93,1.24]0.95 [0.86, 1.04]

0.97 [0.85,1.12]

1.16 [0.80,1.67]

Rate

per

100

0 Po

pula

tion

All AMIs STEMI NSTEMI

020

4060

8010

012

0

29.1 62.1 40.1 77 29.4 41.4

All AMI STEMI NSTEMICrude

rates, % N Crude rates, % N Crude

rates, % N

U. S. 53.0 6,087 63.6 2,066 48.8 4,021Portugal 94.9 1,142 105.4 635 84.3 507

Standardized to 2010 U.S. Population

Disclosures: Nothing to disclose. Funded by FCT, QREN, COMPETE (HMSP-ICT/0013/2011)

What this Study Adds

Disclosures: Nothing to disclose. Funded by FCT, QREN, COMPETE (HMSP-ICT/0013/2011)

2000 2002 2004 2006 2008 2010

Discharge Year (Standardized to 2010 US Population)

Rate

Per

100

0 Po

pula

tion

04

812

1620

24

All AMI

STEMI

NSTEMI

All AMI

STEMI

NSTEMI

United StatesPortugalShading represents 95% confidence bands

www.cuteheart.com

marianalobo@med.up.pt

United StatesPortugalError bar represents 95% confidence bands