1. A Comparison of In-hospital Myocardial Infarction Management
Between Portugal and the United States | 2000 – 2010
Lobo 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% CI
2010, 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 3.3
Hypertension 45 64 32 53
PVD 7.7 11 2.2 4.4
Renal Failure 8.9 17 5.3 4.2
COPD 16 16 3.9 4.4
VHD 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-Hospital
Procedures
Crude rates, %
2010
Standardized
RateRatio†
Year
Cath
CABG Surgery
Off Pump
PCI
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]
Rateper1000Population
All AMIs STEMI NSTEMI
020406080100120
29.1 62.1 40.1 77 29.4 41.4
All AMI STEMI NSTEMI
Crude
rates, %
N
Crude
rates, %
N
Crude
rates, %
N
U. S. 53.0 6,087 63.6 2,066 48.8 4,021
Portugal 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)
RatePer1000Population
04812162024
All AMI
STEMI
NSTEMI
All AMI
STEMI
NSTEMI
United States
Portugal
Shading represents
95% confidence bands
www.cuteheart.com
marianalobo@med.up.pt
United States
Portugal
Error bar represents
95% confidence bands
![A Comparison of In-hospital Myocardial Infarction Management
Between Portugal and the United States | 2000 – 2010
Lobo 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% CI
2010, 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 3.3
Hypertension 45 64 32 53
PVD 7.7 11 2.2 4.4
Renal Failure 8.9 17 5.3 4.2
COPD 16 16 3.9 4.4
VHD 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-Hospital
Procedures
Crude rates, %
2010
Standardized
RateRatio†
Year
Cath
CABG Surgery
Off Pump
PCI
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]
Rateper1000Population
All AMIs STEMI NSTEMI
020406080100120
29.1 62.1 40.1 77 29.4 41.4
All AMI STEMI NSTEMI
Crude
rates, %
N
Crude
rates, %
N
Crude
rates, %
N
U. S. 53.0 6,087 63.6 2,066 48.8 4,021
Portugal 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)
RatePer1000Population
04812162024
All AMI
STEMI
NSTEMI
All AMI
STEMI
NSTEMI
United States
Portugal
Shading represents
95% confidence bands
www.cuteheart.com
marianalobo@med.up.pt
United States
Portugal
Error bar represents
95% confidence bands](https://image.slidesharecdn.com/2014qcor2baltimoreposterml-170126112355/85/Poster-2-presented-at-QCOR-Baltimore-2014-MLobo-1-320.jpg)
