Admission to county-level versus province-level hospitals was associated with higher unadjusted in-hospital mortality (6.9% vs 3.0%), but this lost significance after adjustment (OR 1.61, P=0.182).
Observational (n=8,054)
Yes
Does the level of admitting hospital affect the quality of care and in-hospital mortality in patients with NSTEMI in China?
Significant variations in NSTEMI presentation and treatment patterns across hospital levels in China largely explain the observed disparities in in-hospital mortality, highlighting the need for quality improvement in lower-level hospitals.
Odds Ratio: 1.61 (95% CI 0.8–3.26)
Absolute Event Rate: 6.9% vs 3%
p-value: p=0.182
Background With the growing burden of non-ST-elevation myocardial infarction (NSTEMI), developing countries face great challenges in providing equitable treatment nationwide. However, little is known about hospital-level disparities in the quality of NSTEMI care in China. We aimed to investigate the variations in NSTEMI care and patient outcomes across the three hospital levels (province-, prefecture- and county-level, with decreasing scale) in China. Methods Data were derived from the China Acute Myocardial Infarction Registry on patients with NSTEMI consecutively registered between January 2013 and November 2016 from 31 provinces and municipalities throughout mainland China. Patients were categorized according to the hospital level they were admitted to. Multilevel generalized mixed models were fitted to examine the relationship between the hospital level and in-hospital mortality risk. Results In total, 8,054 patients with NSTEMI were included (province-level: 1,698 patients; prefecture-level: 5,240 patients; county-level: 1,116 patients). Patients in the prefecture- and county-level hospitals were older, more likely to be female, and presented worse cardiac function than those in the province-level hospitals ( P 0.05). Compared with the province-level hospitals, the rate of invasive strategies was significantly lower in the prefecture- and county-level hospitals (65.3, 43.3, and 15.4%, respectively, P 0.001). Invasive strategies were performed within the guideline-recommended timeframe in 25.4, 9.7, and 1.7% of very-high-risk patients, and 16.4, 7.4, and 2.4% of high-risk patients in province-, prefecture- and county-level hospitals, respectively (both P 0.001). The use of dual antiplatelet therapy in the county-level hospitals (87.2%) remained inadequate compared to the province- (94.5%, P 0.001) and prefecture-level hospitals (94.5%, P 0.001). There was an incremental trend of in-hospital mortality from province- to prefecture- to county-level hospitals (3.0, 4.4, and 6.9%, respectively, P -trend 0.001). After stepwise adjustment for patient characteristics, presentation, hospital facilities and in-hospital treatments, the hospital-level gap in mortality risk gradually narrowed and lost statistical significance in the fully adjusted model Odds ratio: province-level vs. prefecture-level: 1.23 (0.73–2.05), P = 0.441; province-level vs. county-level: 1.61 (0.80–3.26), P = 0.182; P -trend = 0.246. Conclusions There were significant variations in NSTEMI presentation and treatment patterns across the three hospital levels in China, which may largely explain the hospital-level disparity in in-hospital mortality. Quality improvement initiatives are warranted, especially among lower-level hospitals.
Zhao et al. (Mon,) conducted a observational in Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) (n=8,054). Admission to lower-level hospitals (county-level) vs. Province-level hospitals was evaluated on In-hospital mortality (OR 1.61, 95% CI 0.80-3.26, p=0.182). Admission to county-level versus province-level hospitals was associated with higher unadjusted in-hospital mortality (6.9% vs 3.0%), but this lost significance after adjustment (OR 1.61, P=0.182).