Performance of hospitals according to the ESC
ACCA quality indicators and 30-day mortality
for acute myocardial infarction: national cohort
study using the United Kingdom Myocardial
Ischaemia National Audit Project (MINAP)
register
Owen Bebb1,2, Marlous Hall1, Keith A. A. Fox3, Tatendashe B. Dondo1,
Adam Timmis4, Hector Bueno5,6,7, Franc¸ois Schiele8, and Chris P. Gale1,2*
1Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK; 2York Teaching Hospital NHS Foundation Trust, York, UK; 3Centre for
Cardiovascular Science, University of Edinburgh, UK; 4NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, London; 5Centro Nacional de Investigaciones
Cardiovasculares (CNIC), Spain; 6Instituto de investigacion and Cardiology Department, Hospital Universitario, Spain; 7Universidad Complutense de Madrid, Spain; and
8Department of Cardiology, University Hospital Jean Minjoz, Besancon, France
Received 1 July 2016; revised 7 November 2016; editorial decision 3 January 2017; accepted 9 January 2017; online publish-ahead-of-print 20 February 2017
Aims To investigate the application of the European Society of Cardiology Acute Cardiovascular Care Association quality
indicators (QI) for acute myocardial infarction for the study of hospital performance and 30-day mortality.
...................................................................................................................................................................................................
Methods
and results
National cohort study (n = 118,075 patients, n = 211 hospitals, MINAP registry), 2012-13. Overall, 16 of the 20 QIs
could be calculated. Eleven QIs had a significant inverse association with GRACE risk adjusted 30-day mortality (all
P < 0.005). The association with the greatest magnitude was high attainment of the composite opportunity-based
QI (80-100%) vs. zero attainment (odds ratio 0.04, 95% confidence interval 0.04-0.05, P < 0.001), increasing attain-
ment from low (0.42, 0.37- 0.49, P < 0.001) to intermediate (0.15, 0.13-0.16, P < 0.001) was significantly associated
with a reduced risk of 30-day mortality. A 1% increase in attainment of this QI was associated with a 3% reduction
in 30-day mortality (0.97, 0.97-0.97, P < 0.001). The QI with the widest hospital variation was 0fondaparinux
received among NSTEMI0 (interquartile range 84.7%) and least variation 0centre organisation0 (0.0%), with seven
QIs depicting minimal variation (<11%). GRACE risk score adjusted 30-day mortality varied by hospital (median
6.7%, interquartile range 5.4-7.9%).
...................................................................................................................................................................................................
Conclusions Eleven QIs were significantly inversely associated with 30-day mortality. Increasing patient attainment of the compo-
site quality indicator was the most powerful predictor; a 1% increase in attainment represented a 3% decrease in 30-
day standardised mortality. The ESC QIs for acute myocardial infarction are applicable in a large health system and
have the potential to improve care and reduce unwarranted variation in death from acute myocardial infarction.
                                                                                                                                                                                                                   
Keywords Quality indicators • Acute myocardial infarction • Mortality • Hospital performance
* Corresponding author. Medical Research Council Bioinformatics Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, Level 11, Worsley Building, Clarendon
Way, University of Leeds, Leeds, LS2 9NL, UK. Tel: 44 (0)113 343 8916, Email: c.p.gale@leeds.ac.uk
VC The Author 2017. Published by Oxford University Press on behalf of the European Society of Cardiology.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unre-
stricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
European Heart Journal (2017) 38, 974–982 CLINICAL RESEARCH
doi:10.1093/eurheartj/ehx008 Acute coronary syndromes
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Introduction
Between and within European country variation in the delivery and
outcomes from acute myocardial infarction [AMI] suggest that the
potential to reduce the burden of cardiovascular disease has not been
realized.1–3 Measuring recognized standards of care is a mechanism by
which geographic variation in the use of guideline-indicated treatments
may be addressed and, therefore, cardiovascular outcomes improved.
The 2016 European Society of Cardiology [ESC] Acute Cardiovascular
Care Association [ACCA] quality indicators [QI] for the management
of AMI4 are based upon the ESC guidelines for the management of
AMI in patients presenting with ST-segment elevation5 and acute coro-
nary syndrome in patients presenting without persistent ST-segment
elevation.6 They comprise 7 domains across 20 QIs, including the eval-
uation of: (1) centre organization, (2) the reperfusion/invasive strategy,
(3) in hospital risk assessment, (4) antithrombotic treatment during
hospitalization, (5) secondary prevention discharge treatments, (6)
patient satisfaction, and (7) composite QIs and Global Registry of
Acute Coronary Events (GRACE) risk score adjusted 30-day mortality.
To date, there has been no investigation of within country provider
variation according to the ESC ACCA QIs or the relationship between
the QIs and 30-day mortality. To address this knowledge gap, providing
an external validation of the ESC ACCA QIs for AMI, we used data
from the United Kingdom national heart attack register (Myocardial
Ischaemia National Audit Project [MINAP]) which collects data from
one health system, the National Health Service of England and Wales.
Methods
Setting and design
The analyses were based on data from MINAP, a comprehensive registry
of ACS hospitalizations mandated by the United Kingdom Department of
Health.7 Each MINAP entry provides patient demographic data and clini-
cal details of the patient journey across 122 data items; details of MINAP
data collection and management have been described previously.7 The
analytical cohort (n= 118 075) was drawn from patients (n= 118 168)
with a discharge diagnosis of AMI admitted to one of 220 hospitals
between 1st January 2012 and 30th June 2013 ( see Supplementary mate
rial online, Figure S1). Patients were eligible for the study if they were >_18
years of age. For patients with multiple admissions the earliest record was
used (to reduce potential bias from previous treatments). We excluded
nine hospitals that treated <_30 patients within the 18-month period of
study. Patient-level data concerning demographics, cardiovascular risk
factors, medical history, and clinical characteristics at the time of
hospitalization were extracted from the registry. Unique patient identi-
fiers were used to link patients with the Office for National Statistics such
that vital status or date of death at 30 days could be ascertained. Data
used within the study were fully anonymized and, as such, ethical approval
was not required under NHS research governance arrangements. The
National Institute for Cardiovascular Outcomes Research (NICOR)
which includes the MINAP database (Ref: NIGB: ECC 1-06 (d)/2011) had
support, under section 251 of the National Health Service Act 2006, to
use patient information for medical research without consent. The study
was conducted in compliance with the Declaration of Helsinki.
ESC quality indicators
The ESC ACCA position statement defined 7 domains of care encom-
passing 12 main and 8 secondary QIs (see Supplementary material online,
Figure S2). All 20 QIs were mapped to each patient’s MINAP data to iden-
tify data fields that would enable their calculation. For each QI, we
included patients who were eligible for the treatment or intervention and
whose record had no missing data. As such, patients were classified as
ineligible if a treatment was contra-indicated, not indicated, not applica-
ble, if the patient declined treatment or treatment was deemed inappro-
priate due to co-morbidity.
Domain seven specifies the use of an opportunity-based composite
score and an all-or-none score (see Supplementary material online,
Appendix S1). For this study, we calculated the composite score for each
patient and subsequently each hospital, based on the number of times
particular care processes were performed (numerator) divided by the
number of chances a patient had to receive/hospital had to provide that
care (denominator). The composite score was calculated using an equal
weight method and included 9 measures (see Supplementary material
online, Appendix S1).
Statistical analyses
Baseline characteristics for the study population were described using
numbers and percentages for categorical data, and medians and IQR or
means and standard deviations (SD) for continuous non-normally and
normally distributed data. For the QIs, the proportion presented is of
those eligible for treatment.
We used a validated method for use with MINAP data to calculate
each patient’s GRACE risk score. This used the scoring system and coeffi-
cients described by the GRACE investigators, given that not all records
had information about Killip class and chronic renal failure, the ‘use of
loop diuretic’ (as a surrogate for Killip class II-IV), and creatinine concen-
tration, respectively, were added to each patient’s score.8,9
To estimate the GRACE risk score adjusted 30-day mortality, we used
the predicted probabilities derived from a logistic regression model
where the dependent variable was 30-day mortality and the independent
variable was each patient’s calculated GRACE risk score. Data were
summarized overall and at the hospital level. We used Spearman’s rank
test to investigate the relationship between all combinations of QIs,
except for the composite scores because they incorporated several single
QIs. We fitted a logistic regression model to assess the strength of associ-
ation between QI measures and 30-day mortality. For the composite
opportunity measure, the performance was split into 4 categories: (1) no
interventions received, (2) <40% of eligible interventions received,
(3) >_40% to <80% of eligible intervention received, and (4) >_80% of
interventions received.10,11 We excluded measures that had <_30 patients
with complete data for either aspect of the QI. All analyses were con-
ducted using Stata MP Version 14.0 (StataCorp LP, TX, USA), with statis-
tical significance determined at 5%.
Results
Patient characteristics
Across 211 hospitals in England and Wales, (47 341 [40.1%] STEMI
and 70 734 [59.9%] NSTEMI; mean age 68.5 (SD 14.0) years; 33.2%
female), there were 37 487 (34.2%) patients with a history of ischae-
mic heart disease, 24 068 (21.2%) with diabetes, 5,579 (5.1%) with a
history of heart failure, and 6678 (6.2%) with chronic renal failure
(Table 1). The mean GRACE score was 119.8 (SD 34.1). Following
hospitalization, 83 740 (78.2%) received coronary angiography and
2605 (2.5%) coronary artery bypass grafting [CABG]. Of STEMI,
21 567 (56.7%) received primary percutaneous coronary interven-
tion [PCI] and of NSTEMI, 23 172 (40.2%) received sub-acute or
QI and 30-day mortality for AMI 975
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Table 1 Baseline characteristics and their hospital variation of patients with acute myocardial infarction, MINAP
2012–13
Total cohort
(n5 118 075)
Missing data,
n, (%)
Hospital variation,
mean (SD) or median (IQR)
(n5 211 hospitals)
Demographics
Age in years, mean (SD) 68.5 (14.0) 63 (0.05) 69.5 (3.4)
Female 39 088 (33.2) 352 (0.30) 34.9 (30.4–38.6)
Medical history
History of ischaemic heart disease 37 487 (34.2) 8491 (7.2) 36.1 (29.4–40.9)
Hypertension 55 397 (50.6) 8522 (7.2) 49.7 (44.1–56.0)
Diabetes 24 068 (21.2) 4730 (4.01) 21.6 (17.7–24.4)
Dyslipidaemia 36 890 (34.2) 10 296 (8.72) 30.4 (22.6–40.6)
Family history of ischaemic heart disease 28 936 (30.5) 23 281 (19.7) 22.1 (16.3–30.8)
Smoker (current or previous) 67 670 (61.4) 7933 (6.7) 57.7 (50.4–63.5)
Peripheral vascular disease 4699 (4.3) 9659 (8.2) 3.9 (2.6–5.3)
Congestive cardiac failure 5579 (5.1) 9247 (7.8) 5.3 (2.93–8)
COPD 16 326 (15.0) 9323 (7.9) 15.1 (12.1–17.6)
Chronic kidney disease 6678 (6.2) 9854 (8.4) 6.1 (3.4–8.7)
Cerebrovascular disease 9070 (8.4) 9489 (8.0) 8.2 (5.7–10.9)
Clinical Presentation
Heart rate at hospitalization, median (IQR), b.p.m. 78 (66–91) 18 887 (16.0) 78 (76–80)
Systolic blood pressure at hospitalization, mean (SD), mmHg 136 (27.8) 18 794 (15.9) 139 (5.2)
Out of hospital cardiac arrest 3287 (2.9) 3737 (3.2) 1.9 (0.6–3.3)
Initial creatinine, median (IQR), mmol/L 86 (72–107) 11 622 (9.8) 87 (83–90)
ST-segment deviation on admission 61 439 (53.5) 3140 (2.7) 38.8 (25.8–57.3)
Killip classc 36 310 (30.8)
I 64 254 (78.6) 78.1 (70.6–86.6)
II 11 697 (14.3) 14.1% (6.2–21.0)
III 4424 (5.4) 5.0 (3.1–8.0)
IV 1390 (1.7) 0.6 (0–1.7)
GRACE risk score, mean (SD) 119.8 (34.1) 33 536 (28.4) 119.6 (114.3–123.7)
In hospital revascularization, (of those eligible)
Angiogramb 83 740 (78.2) 4210 (3.6) 67.5 (52.7–85.0)
PCI 67 740 (65.6) 15 388 (13.0) 45.9 (28.0–73.7)
CABG 2605 (2.5) 15 388 (13.0) 1.2 (0.2–3.5)
Medications at discharge,d
Aspirin 101 591 (98.1) 1374 (1.2) 98.7 (96.7–99.6)
P2Y12 inhibitor 92 501 (87.1) 1434 (1.2) 89.3 (83.9–93.5)
b-blocker 86 543 (95.6) 1412 (1.3) 96.5 (92.8–98.8)
Statin 84 421 (96.5) 1275 (1.14) 96.9 (93.1–98.9)
ACEi/ARB 84 681 (93.9) 1480 (1.33) 94.6 (89.5–98.2)
Lifestyle advice,
Cardiac rehabilitation 88 302 (81.7) 4340 (3.7) 85.5 (70.5–94.9)
Smoking cessation advice 27 848 (74.4) 2222 (3.3) 78.0 (54.7–90.5)
Dietary advice 81 745 (77.4) 7484 (6.3) 86.5 (55.3–95.9)
Values presented are given as number (percentage) unless stated.
SD, standard deviation; IQR, interquartile range; IHD, ischaemic heart disease; COPD, chronic obstructive pulmonary disease; GRACE, Global Registry Acute Coronary Events;
ACEi/ARB, angiotensin converting enzyme inhibitor/angiotensin II receptor blocker; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting.
aHistory of ischaemic heart disease refers to a history of CABG, MI, PCI, or angina.
bReceived angiography or PCI.
cKillip class; 1: No clinical signs of heart failure, 2: Rales/crackles within the lungs, present S3, elevated JVP, 3: frank pulmonary oedema, 4: cardiogenic shock.
dIncludes eligible patients who started mediations during admission.
976 O. Bebb et al.
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elective PCI. Hospital variation in patients’ characteristics was small,
compared with wider variation in QI attainment (Tables 1 and 2,
Figure 1). At 30 days, there were 7063 (7.1%) deaths.
Domains and quality indicators
Of the 7 QI domains, MINAP contained data fields for the assessment
of all, except the evaluation of patient satisfaction (Table 2). MINAP
allowed the assessment of care according to 16 of the 20 QIs; 12
derived directly from corresponding data fields and 4 ascertained
indirectly. The remaining 4 quality indicators including, the prescrip-
tion of high intensity statins at hospital discharge, the recording of the
GRACE and CRUSADE risk scores, and patient satisfaction could
not be evaluated because MINAP did not collect this information.
Figure 1 demonstrates the attainment and variation at a centre level
for those QIs measured.
Domain 1: Centre organization. Overall, 77.8% (n= 76 099) of eligible
patients had pre-hospital interpretation of an ECG, higher than the
median value for hospitals 74.8% (IQR 48.6–85.3%). For the remain-
ing components of the main QI and both of the secondary QIs, the
level of attainment for patients with AMI was 100% (n= 118 075)
(Table 2).
Domain 2: Reperfusion/invasive strategy. For STEMI, 89.3%
(n= 33 151) received reperfusion <12 h of onset of symptoms, and
74.6% (n= 20 815) received timely reperfusion. (Table 2) The median
time from first medical contact with STEMI to wire passage for the
whole cohort was 185 (IQR 135–284) min which was similar to the
median time for the hospitals, although variation was less (188 min,
IQR 170–210 min). For NSTEMI, the performance of coronary
angiography was low and varied between hospitals (median, 52.0%,
IQR 39.1–73.2%), and 61.3% (n= 17 895) received coronary
angiography <72 h of hospitalization.
Domain 3: In hospital risk assessment. Only one of the main QIs
could be assessed; the assessment of LVEF was recorded in 54.5%
(n= 56 680) of eligible patients, and demonstrated suboptimal attain-
ment which varied by hospital (median 54.5%, IQR 32.7–73.2%).
Domain 4: Antithrombotic treatment during hospitalization. The pre-
scription of adequate P2Y12 inhibition at discharge was achieved in
87.1% (n= 92 501), but varied across hospitals (median 89.3%, IQR
83.8–93.5). Fondaparinux use was low (50.3%, n= 30 737) and exhib-
ited the greatest hospital variation (median 66.8%, IQR 0.4–84.7%).
However, when fondaparinux or low molecular weight heparin was
considered, performance improved and variation reduced (median
90.3%, IQR 84.2–94.6%). The secondary QI found that 88.1%
(n= 89 488) of eligible patients with AMI were discharged on dual
antiplatelet therapy.
Domain 5: Secondary prevention discharge treatments. In total, 96.5%
(n= 84 421) of patients eligible for lipid lowering therapy were pre-
scribed a statin at time of discharge from hospital. For the two secon-
dary QIs, 94.2% (n= 31 569) of patients with AMI and heart failure or
a LVEF <_0.40 received an ACEi or ARB, and 95.8% (n= 32 728) with
AMI and heart failure or a LVEF <_0.40 received a b-blocker. Hospital
attainment was high, but varied between hospitals (IQR 89.1–98.4
and 92.0–99.0, respectively).
Domain 6: Patient Satisfaction. The MINAP registry recorded no
data about patient satisfaction during the period of study. However,
81.7% (n= 108 110) of patients were referred for cardiac rehabilita-
tion, 77.4% (n = 105 603) received dietary advice and 74.4%
(n= 37 443) of current smokers received cessation advice. Across
hospitals 85.5% of patients were referred for cardiac rehabilitation
(IQR 70.5–94.9), 86.5% of smokers received cessation advice (IQR
54.7–90.5%), and 86.5% were offered dietary advice (IQR 55.3–
95.9%).
Domain 7: Composite quality indicators and GRACE risk score adjusted
30-day mortality. According to the opportunity-based composite
score, patients received 83.3% (n= 118 071) of the interventions for
which they were eligible. Hospital attainment was high, but varied
between hospitals (median of 82.8%, IQR 77.5–88.7%). For the all-
or-none composite score, 83.1% of patients received all of the inter-
ventions for which they were eligible which varied more among
patients with heart failure or an ejection fraction <_0.40 than those
without (IQR 69.5–87.0 vs. 81.8–93.3). For the cohort, the median
GRACE risk score adjusted 30-day mortality was 2.7% (IQR 0.9–
8.1%). At the hospital level, variation was limited (median 6.7%, IQR
5.4–7.9%) (Figure 2).
Correlation of quality indicators
Overall 39 of the 45 QI to QI combinations demonstrated a weak
correlation (Spearman correlation coefficient <0.3), 4 had a signifi-
cant moderate correlation (0.4–0.7, all P< 0.001) and 2 had a signifi-
cant strong correlation (>_0.7, all P< 0.001) (Figure 3).
Quality indicators and mortality
Eleven QIs had a significant inverse association with 30-day mortality
(all P< 0.005) (Figure 4). The association with the greatest magnitude
was for high attainment vs. zero attainment of the composite
opportunity-based QI (odds ratio [OR] 0.04, 95% confidence interval
[CI] 0.04–0.05, P< 0.001). Increasing patient attainment of this indica-
tor from low (OR 0.42 CI 0.37–0.49, P< 0.001) to intermediate
(0.15, 0.13–0.16, P< 0.001) to high (0.05, 0.04–0.06, P< 0.001) was
significantly associated with a lower risk of 30-day mortality. On aver-
age, a unit increase in percentage attainment was significantly associ-
ated with a 3% decrease in 30-day mortality (0.97, 0.97–0.97,
P< 0.001).
Discussion
Using a nationwide clinical database, comprising an analytical cohort
of nearly 120 000 patients and over 200 hospitals between 2012–13,
we found that the ESC ACCA QIs for AMI allowed the thorough
evaluation of AMI care against international standards. The majority
of QIs assessed were significantly inversely associated with 30-day
mortality, the strongest being a composite indicator which, with
increasing attainment, was associated with decreasing rates of death
in a dose-response manner. Whilst we found high levels of perform-
ance with associated low levels of mortality, there was evidence for
between hospital variation in key metrics, which mapped to class 1
guideline-indicated care. As such, the ESC QIs for AMI are applicable
and valid, highlighting where in health systems there is potential to
improve care and that high levels of performance according to the
QIs is likely to reduce unwarranted variation and premature death
from AMI.
Data from the EUROASPIRE studies show that the use of
evidence-based treatments for AMI and associated outcomes vary
QI and 30-day mortality for AMI 977
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Table 2 Overall and hospital variation in performance according to the European Society Cardiology; Acute
Cardiovascular Care Association quality indicators for acute myocardial infarction
Domain Quality indicator Type of
quality
indicator
Total patients
eligible (n)
Proportion
receiving
care (%)
Hospital
variation
median %
(IQR) (n5 211
hospitals)
1: Centre organization 1.1 Centre organization: part of network Main 76 099 77.8 74.9 (48.6–85.3)
1.1a: Single emergency phone number to allow medical
triage
118 075 100 100 (100–100)
1.1b: Pre hospital interpretation of the ECG 76 099 77.8 74.9 (48.6–85.3)
1.1c: Pre hospital activation of the catheter lab 118 075 100 100 (100–100)
1.2: Routine assessment of times to reperfusion Secondary 118 075 100 100 (100–100)
1.3: Participate in regular registry Secondary 100 100 (100–100)
2: Reperfusion/invasive
strategy
2.1: Reperfusion within 12 h of presentation (STEMI) Main 33 151 89.3 76.7 (33.3–91.4)
2.2 Timely reperfusion (STEMI) Main 27 892 74.6 66.4 (35.8–78.8)
2.2a: Fibrinolysis received within 30 min (PPCI centres
and STEMI patients only)
547 55.0 33.3 (0–60.6)
2.2b: Primary PCI received within 60 min (PPCI centres
and STEMI patients only)
26 358 75.0 69.9 (54.6–80.8)
2.2c: Primary PCI received within 120 min (non-PPCI
centres and STEMI patients only)
672 93.9 40.0 (0–53.3)
2.2d: Door-in door-out time within 30 min (non-PPCI
centres and STEMI patients only)
538 23.8 5.7 (0–49.6)
2.3: Coronary angiography received within 72 h
(NSTEMI patients only).
Main 29 199 61.3 52.0 (39.1–73.2)
2.4: Time from diagnosis to wire passage (STEMI),
minutes (median, IQR)
Secondary 27 029 185 (135–284) 187.8 (169.8–210)
3: In Hospital risk
assessment
3.1: GRACE risk score recorded in notes Main N/A 0 N/A
3.2: CRUSADE risk score recorded in notes Main N/A 0 N/A
3.3: LV function recorded in notes Main 104 004 54.5 54.7 (32.7–73.2)
4: Anti thrombotics
during hospital
4.1: Adequate P2Y12 inhibition on discharge Main 106 157 87.1 89.3 (83.8–93.5)
4.2: Fondaparinux received (NSTEMI patients only) Main 61 152 50.3 66.8 (0.4–84.7)
Fondaparinux or LMWH received (NSTEMI patients
only)
61 185 85.2 90.3 (84.2–94.6)
4.3: DAPT received on discharge Secondary 101 582 88.1 90.5 (85.4–94.1)
5: Secondary
prevention
5.1: High intensity statins on discharge Main N/A 0 N/A
5.2: ACEi/ARB on discharge for those with HF or LVEF
<_40
Secondary 33 531 94.2 95.5 (89.1–98.4)
5.3: b-blocker on discharge for those with HF or LVEF
<_40
Secondary 34 150 95.8 96.8 (92.0–99.0)
6: Patient satisfaction 6.1 Not applicable Main N/A N/A N/A
7: Composite QI 7.1 Composite QI (opportunity-based) Main 118 071 83.3 (75.0–100) 82.8 (77.6–89.1)
7.2 Composite QI (all-or-none, overall score) Secondary 118 075 83.1 84.8 (76.7–90.5)
7.2a Composite QI (all-or-none, 3 measures) (%)
patients with no HF or LVEF<_40
Secondary 72 648 84.8 88.8 (81.8–93.3)
7.2b Composite QI (all-or-none, 5 measures) (%)
patients with HF or LVEF<_40
Secondary 45 427 80.2 79.9 (69.5–87.0)
7.3 Mortality rate adjusted for GRACE risk 84 539 6.9 S.D 10.4 6.7 (5.4–7.9)
Abbreviations: IQR, interquartile range; ECG, electrocardiogram; STEMI, ST-elevation myocardial infarction; PPCI, primary percutaneous coronary intervention; PCI, percutane-
ous coronary intervention; NSTEMI, non-ST elevation myocardial infarction; GRACE, Global Registry Acute Coronary Events; CRUSADE, Can Rapid Risk Stratification of
Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines); LV, left ventricular; LMWH, low molecular weight heparin;
eGFR, estimated glomerular filtration rate; DAPT, dual antiplatelet therapy; ACEi/ARB, angiotensin converting enzyme inhibitor/angiotensin II receptor blocker; QI, quality indi-
cator; HF, heart failure; LVEF, left ventricular ejection fraction; N/A, not applicable.
978 O. Bebb et al.
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widely between European countries.12–14 Other international com-
parisons provide evidence for variation both between and within
countries.1,3,15–17 When there are data to show that adherence to
guidelines improves clinical outcomes,3,18 variation in healthcare
performance against set standards serves as indirect evidence for the
potential to modify mortality. Results from our study show that
whilst there was variation between hospitals in baseline patient char-
acteristics, qualitatively this was less that that derived for the QIs,
Figure 2 Caterpillar plot of hospital rank of hospital mean unadjusted and mean GRACE risk score adjusted hospital 30-day mortality rates.
Figure 1 Distribution of hospitals’ performance according to the European Society Cardiology; Acute Cardiovascular Care Association quality
indicators for acute myocardial infarction.
QI and 30-day mortality for AMI 979
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Figure 4 Association between the European Society Cardiology; Acute Cardiovascular Care Association quality indicators for acute myocardial
infarction and crude 30-day mortality. The composite opportunity QI was divided into the following categories: zero–received no interventions out
of those eligible for, low–received <40% of interventions eligible for, intermediate–received >_40 to <80% of interventions eligible for and high–
received >_80% of interventions eligible for.
Figure 3 Scatter matrix of European Society Cardiology; Acute Cardiovascular Care Association quality indicators for acute myocardial infarction
showing pairwise correlations of all quality indicator pairs, presented alongside Spearman’s rank correlation coefficient (where * indicates P < 0.05,
** P < 0.01, ***P < 0.001).
980 O. Bebb et al.
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suggesting that the provision of treatments may have a greater role in
determining outcomes than case mix.19
The association between risk adjusted mortality and the ESC
ACCA QIs is consistent with previous findings.20,21 However, this
study evaluates a wider spectrum of QIs which map to guidelines and
transcend the pathway of AMI care as well as organization of services.
Four of the QIs were not associated with a significant reduction in
mortality. Coronary angiography <72 h for patients with NSTEMI
demonstrated a positive association with mortality. When further
investigated, however, the provision of PCI was inversely associated
with mortality (OR 0.58, 95% CI 0.51–0.65), in keeping with other
evidence.19
We noted many QIs did not correlate with each other, implying
they cover the spectrum of the AMI care pathway. The greatest cor-
relation was between the prescription of P2Y12 inhibitors and dual
antiplatelet therapy–given that the former is essential for the latter,
this is not unexpected. The weakest association was for centre
organization and timely angiography in NSTEMI; given that in the
United Kingdom centre organization was primarily arranged to treat
STEMI, it is not surprising that these two measures did not correlate.
Variation in the delivery of treatments is dependent upon many
factors, including the availability of sufficient hospital facilities,16,22
a skilled workforce,15,22 high levels of knowledge transfer from scien-
tific studies between healthcare professionals,23 the volume of cases
admitted to the hospital,24 differences in the extent to which care is
felt to be appropriate,25 as well as uniformity of recommendations
from guidelines from different countries.17 Regarding the latter, we
noted that the QI with the widest hospital variation was that for fon-
daparinux. We speculate this may be because the United Kingdom
(2010) guideline for the management of patients with AMI,26 recom-
mended fondaparinux only for cases of AMI who were not going for
angiography <24 h of hospitalization–therein differing from current
ESC recommendations. The QI with the least variation was centre
organization. This is because, in the United Kingdom, emergency care
for STEMI is institutionally operationalized as a result of the imple-
mentation of a national primary PCI service.22
In North America, there is a well-established program of quality
improvement that, for AMI is based upon the ACTION registry27
and allows benchmarking of performance comparisons of providers.
For the European community, the ESC AMI QIs offer an opportunity
to study and consequently address deficits in care for cardiovascular
disease. We demonstrate that this is possible only through a compre-
hensive clinical registry, as have others,27 but which for several
European countries is lacking.1
Although this study has many strengths, we recognize its limita-
tions. The findings are summary measures of performance grounded
on patient-level data and described at a hospital level. We followed
the ESC AMI QI specification for the calculation of adjusted mortal-
ity,4 being mindful that hospital-specific influences were not
accounted for in the modelling. Although we excluded hospitals
with <_30 patients recorded during the study period, for some hospi-
tals in the separate QI analytical cohorts had <_30 patients. For the
GRACE score, we used surrogates for both Killip class and creatinine
in keeping with previous validation work.8,9 MINAP does not record
the specific type of statins, so ‘statin prescription’ was used as a surro-
gate for high intensity statin. Similarly, because there was imperfect
recording of Ticagrelor, we used instead receipt of P2Y12 inhibitor.
The recoding, measurement, and reporting of within and between
country performance against validated QIs representing class 1 indi-
cated care is the critical next step in the international effort to reduce
the burden and variation in premature deaths due to cardiovascular
disease across Europe. This study provides good evidence for the
application of the ESC ACCA QIs for AMI to clinical registries for the
evaluation of cardiovascular care and outcomes; demonstrating their
significant inverse association with mortality. Furthermore, this study
identified potentially modifiable variation within a high performing
health system and sets a road map for the development of
standardized data collection in other ESC member countries.
Greater and more uniform adherence to guideline-indicated care will
result in improved and less varied mortality from AMI.
Supplementary material
Supplementary material is available at European Heart Journal online.
Acknowledgements
TBD and MH were funded by the British Heart Foundation (Project
Grant PG/13/81/30474). as a research assistant and research fellow,
respectively. The Myocardial Ischaemia National Audit Project
(MINAP) is commissioned by the Health Quality Improvement
Partnership (HQIP) as part of the National Clinical Audit and Patient
Outcomes Programme We gratefully acknowledge the contribution
of all hospitals and healthcare professions who participate in the
MINAP registry.
Funding
TBD and MH were funded by the British Heart Foundation (Project
Grant PG/13/81/30474) as a research assistant and research fellow,
respectively.
Conflict of interest: none declared.
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