The first European standards for the management of heart attack patients are launched today by the European Society of Cardiology-Acute Cardiac Care Association (ESC-ACCA). The quality indicators for acute myocardial infarction (AMI) are published in European Heart Journal: Acute Cardiovascular Care, ACCA’s official journal, and presented at ESC Congress together with the results of the inaugural implementation. (1,2)
“Evaluating quality of care is part of modern healthcare but measuring it is difficult and does not solely rely on patient outcomes,” said first author Professor François Schiele. “For this reason it has become common practice to use quality indicators (QIs).”
The first QIs in Europe for assessing the quality of care provided to patients admitted for AMI were developed by the ACCA, a registered branch of the ESC.
The 20 QIs are in seven domains which cover the entire patient pathway: centre organisation, reperfusion-invasive strategy, in-hospital risk assessment, antithrombotic treatment during hospitalisation, discharge treatments, patient satisfaction, and composite QIs (CQIs) and mortality. There are 12 main and eight secondary QIs.
Professor Schiele said: “The QIs are in line with current ESC guidelines3,4 and were designed with the goal of improving the quality of care for AMI patients across Europe. A second aim is to use them to evaluate how well centres are currently performing and which domains could be improved.”
The QIs were implemented for the first time in two French nationwide registries of AMI patients admitted to a coronary or intensive care unit within 48 hours of symptom onset. The analysis included 7839 patients, of whom 3670 participated in FAST-MI 2005 and 4169 participated in FAST-MI 2010.5
For each patient, data was identified that would enable the calculation of the 20 QIs. The researchers also investigated the association between the QIs and three-year mortality. Overall, 12 QIs could be calculated from existing data in FAST-MI 2005 and 14 in FAST-MI 2010. Professor Schiele said: “None of the QIs we calculated showed performance above 90%, which means there is room for improvement in all domains.”
The opportunity-based CQI was calculated by dividing the number of times particular care processes were performed by the number of opportunities to provide them. The average score was 52% in 2005 and 72% in 2010. Professor Schiele said: “This suggests that only half of the appropriate care processes were provided to patients admitted with a heart attack in 2005, which rose to 72% in 2010.”
Performance on the opportunity-based CQI was divided into quartiles: 0%, 0–40%, 40–80%, and above 80%. The investigators found a decrease in mortality with increasing quartiles of the CQI. Compared to those with a score of 0%, patients with a score between 0 and 40%, 40% to 80%, or above 80% had a 17%, 27%, and 32% lower risk of death, respectively.6
Centres with more than 20 patients in the study were benchmarked by comparing their opportunity-based CQI score to the national average in 2005 or 2010. Centres were classified as “low” (below national average), “intermediate” (not significantly different) or “high” quality (above). Twelve centres achieved “high” in 2005 and 22 in 2010, while 16 were classified “low” in 2005 and 17 in 2010.
Professor Schiele said: “The opportunity-based CQI was related to survival, which provides further justification for assessing quality of care. The CQI also made it possible to classify centres as having high, average or low quality of care.”
(1) Professor François Schiele has presented the quality indicators during the sessions:
- Registries coronary artery disease, stroke and intervention on 29 August at 16:30
- What is going on in acute cardiovascular care on 30 August at 14:00
(2) Schiele F, Gale CP, Bonnefoy E, Capuano F, Claeys MJ, Danchin N, Fox KAA, Huber K, Iakobishvili Z, Lettino M, Quinn T, Gimenez MR, Bøtker HE, Swahn E, Timmis A, Tubaro M, Vrints C, Walker D, Zahger D, Zeymer U, Bueno H. Quality indicators for acute myocardial infarction: A position paper of the Acute Cardiovascular Care Association. European Heart Journal: Acute Cardiovascular Care. 2016. DOI: 10.1177/2048872616643053
(3) 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal. 2016;37:267–315. doi:10.1093/eurheartj/ehv320
(4) ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal. 2012;33:2569–2619. doi:10.1093/eurheartj/ehs215
(5) FAST-MI: French Registry of Acute ST-Elevation or non-ST-elevation Myocardial Infarction
(6) The relationship between the opportunity-based CQI and three-year survival was adjusted for year of admission, centre volume of activity, centre capability to perform percutaneous coronary intervention (PCI), type of AMI, and GRACE risk score. The Global Registry of Acute Coronary Events (GRACE) risk score assesses future risk of death or myocardial infarction.