Quality of Care in Chinese Hospitals: Processes and Outcomes After ST-segment Elevation Myocardial Infarction

Nicholas S Downing, Yongfei Wang, Kumar Dharmarajan, Sudhakar V Nuti, Karthik Murugiah, Xue Du, Xin Zheng, Xi Li, Jing Li, Frederick A Masoudi, John A Spertus, Lixin Jiang, Harlan M Krumholz, Nicholas S Downing, Yongfei Wang, Kumar Dharmarajan, Sudhakar V Nuti, Karthik Murugiah, Xue Du, Xin Zheng, Xi Li, Jing Li, Frederick A Masoudi, John A Spertus, Lixin Jiang, Harlan M Krumholz

Abstract

Background: China has gaps in the quality of care provided to patients with ST-elevation myocardial infarction, but little is known about how quality varies between hospitals.

Methods and results: Using nationally representative data from the China PEACE-Retrospective AMI Study, we characterized the quality of care for ST-elevation myocardial infarction at the hospital level and examined variation between hospitals. Two summary measures were used to describe the overall quality of care at each hospital and to characterize variations in quality between hospitals in 2001, 2006, and 2011. The composite rate measured the proportion of opportunities a hospital had to deliver 6 guideline-recommended treatments for ST-elevation myocardial infarction that were successfully met, while the defect-free rate measured the proportion of patients at each hospital receiving all guideline-recommended treatments for which they were eligible. Risk-standardized mortality rates were calculated. Our analysis included 12 108 patients treated for ST-elevation myocardial infarction at 162 hospitals. The median composite rate increased from 56.8% (interquartile range [IQR], 45.9-72.0) in 2001 to 80.5% (IQR, 74.7-84.8) in 2011; however, substantial variation remained in 2011 with defect-free rates ranging from 0.0% to 76.9%. The median risk-standardized mortality rate increased from 9.9% (IQR, 9.1-11.7) in 2001 to 12.6% (IQR, 10.9-14.6) in 2006 before falling to 10.4% (IQR, 9.1-12.4) in 2011.

Conclusions: Higher rates of guideline-recommended care and a decline in variation between hospitals are indicative of an improvement in quality. Although some variation persisted in 2011, very top-performing hospitals missed few opportunities to provide guideline-recommended care. Quality improvement initiatives should focus on eliminating residual variation as well as measuring and improving outcomes.

Clinical trial registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01624883.

Keywords: China; hospital performance; quality improvement; quality measurement; variation.

© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Figures

Figure 1
Figure 1
Variation (median odds ratio, median, and interquartile range) in rates of 6 process measures for ST‐elevation myocardial infarction in 2001, 2006, and 2011. ACEi indicates angiotensin converter enzyme inhibitor; ARB, angiotensin receptor blockers; n/a, not applicable.
Figure 2
Figure 2
Distribution of composite (A) and defect‐free (B) rates for ST‐elevation myocardial infarction in 2001, 2006, and 2011. **The composite rate was calculated by dividing the number of times each hospital successfully delivered each of the guideline‐recommended care processes to an ideal patient by the total number of opportunities that the hospital had to deliver such interventions. The defect‐free rate was defined as the proportion of patients at each hospital who received all treatments for which they were considered ideal.
Figure 3
Figure 3
Comparison of composite rate of aspirin, ACE inhibitor and beta‐blocker therapy for patients with ST‐elevation myocardial infarction treated in hospitals in China (CN) and the United States in 2006 and 2011. ACEi indicates angiotensin converter enzyme.
Figure 4
Figure 4
Risk‐standardized mortality rates for ST‐elevation myocardial infarction in 2001, 2006, and 2011, overall and stratified by hospital characteristics. AMI indicates acute myocardial infarction; n/a, not applicable; PCI, percutaneous coronary intervention.

References

    1. Bi Y, Gao R, Patel A, Su S, Gao W, Hu D, Huang D, Kong L, Qi W, Wu Y, Yang Y, Turnbull F. Evidence‐based medication use among Chinese patients with acute coronary syndromes at the time of hospital discharge and 1 year after hospitalization: results from the Clinical Pathways for Acute Coronary Syndromes in China (CPACS) study. Am Heart J. 2009;157(509–516):e501.
    1. Li J, Li X, Wang Q, Hu S, Wang Y, Masoudi FA, Spertus JA, Krumholz HM, Jiang L. ST‐segment elevation myocardial infarction in China from 2001 to 2011 (the China PEACE‐Retrospective Acute Myocardial Infarction Study): a retrospective analysis of hospital data. Lancet. 2015;385:441–451.
    1. China Society of Cardiology of Chinese Medical Association Editorial Board of Chinese Journal of Cardiology . Guideline for diagnosis and treatment of patients with ST‐elevation myocardial infarction. Zhonghua Xin Xue Guan Bing Za Zhi. 2010;38:675–690.
    1. O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis‐Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST‐elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78–e140.
    1. Krumholz HM, Wang Y, Mattera JA, Wang Y, Han LF, Ingber MJ, Roman S, Normand S‐LT. An administrative claims model suitable for profiling hospital performance based on 30‐day mortality rates among patients with an acute myocardial infarction. Circulation. 2006;113:1683–1692.
    1. Dharmarajan K, Li J, Li X, Lin Z, Krumholz HM, Jiang L. The China Patient‐Centered Evaluative Assessment of Cardiac Events (China PEACE) retrospective study of acute myocardial infarction: study design. Circ Cardiovasc Qual Outcomes. 2013;6:732–740.
    1. China Society of Cardiology of Chinese Medical Association Editorial Board of Chinese Journal of Cardiology . Guideline for diagnosis and treatment of patients with acute myocardial infarction. Zhongguo Xun Huan Za Zhi. 2001;16:407–422.
    1. Ministry of Health of the People's Republic of China . The qualification standard of secondary general hospital (version 2012). 2012. Available at: . Accessed June 16, 2016.
    1. Simms AD, Reynolds S, Pieper K, Baxter PD, Cattle BA, Batin PD, Wilson JI, Deanfield JE, West RM, Fox KAA, Hall AS, Gale CP. Evaluation of the NICE mini‐GRACE risk scores for acute myocardial infarction using the Myocardial Ischaemia National Audit Project (MINAP) 2003–2009: National Institute for Cardiovascular Outcomes Research (NICOR). Heart. 2013;99:35–40.
    1. Merlo J, Chaix B, Ohlsson H, Beckman A, Johnell K, Hjerpe P, Råstam L, Larsen K. A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena. J Epidemiol Community Health. 2006;60:290–297.
    1. Nuti SV, Wang Y, Masoudi FA, Bratzler DW, Bernheim SM, Murugiah K, Krumholz HM. Improvements in the distribution of hospital performance for the care of patients with acute myocardial infarction, heart failure, and pneumonia, 2006–2011. Med Care. 2015;53:485–491.
    1. Medical Administration Department of the National Commission for Health and Family Planning of the People's Republic of China . Notification on accreditation standards for secondary general hospitals. 2012. Available at: . Accessed July 11, 2016.
    1. Ministry of Health of the People's Republic of China . Hospital quality monitoring system (HQMS). 2009. Available at: . Accessed September 6, 2016.
    1. Du X, Gao R, Turnbull F, Wu Y, Rong Y, Lo S, Billot L, Hao Z, Ranasinghe I, Iedema R, Kong L, Hu D, Lin S, Shen W, Huang D, Yang Y, Ge J, Han Y, Lv S, Ma A, Gao W, Patel A. Hospital quality improvement initiative for patients with acute coronary syndromes in China: a cluster randomized controlled trial. Circ Cardiovasc Qual Outcomes. 2014;7:217–226.
    1. Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, Roumanis SA, Curtis JP, Nallamothu BK, Magid DJ, McNamara RL, Parkosewich J, Loeb JM, Krumholz HM. Strategies for reducing the door‐to‐balloon time in acute myocardial infarction. New Engl J Med. 2006;355:2308–2320.
    1. Krumholz HM, Bradley EH, Nallamothu BK, Ting HH, Batchelor WB, Kline‐Rogers E, Stern AF, Byrd JR, Brush JE Jr. A campaign to improve the timeliness of primary percutaneous coronary intervention: door‐to‐balloon: an alliance for quality. JACC Cardiovasc Interv. 2008;1:97–104.
    1. Zheng X, Curtis JP, Hu S, Wang Y, Yang Y, Masoudi FA, Spertus JA, Li X, Li J, Dharmarajan K, Downing NS, Krumholz HM, Jiang L; China PEACE Collaborative Group . Coronary catheterization and percutaneous coronary intervention in china: 10‐year results from the china peace‐retrospective cathpci study. JAMA Intern Med. 2016;176:512–521.
    1. Li J, Li X, Ross JS, Wang Q, Wang Y, Desai NR, Xu X, Nuti SV, Masoudi FA, Spertus JA, Krumholz HM, Jiang L; China PCG . Fibrinolytic therapy in hospitals without percutaneous coronary intervention capabilities in China from 2001 to 2011: China PEACE‐retrospective AMI study. Eur Heart J Acute Cardiovasc Care. 2016;6:232–243.
    1. Peterson ED, Roe MT, Mulgund J, DeLong ER, Lytle BL, Brindis RG, Smith SC Jr, Pollack CV Jr, Newby LK, Harrington RA, Gibler WB, Ohman EM. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA. 2006;295:1912–1920.
    1. Bradley EHHJ, Elbel B, McNamara RL, Magid DJ, Nallamothu BK, Wang Y, Normand SL, Spertus JA, Krumholz HM. Hospital quality for acute myocardial infarction: correlation among process measures and relationship with short‐term mortality. JAMA. 2006;296:72–78.

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