Hospitals with UCIC seem to treat more effectively Ischemic

Coronary patients than hospitals without UCIC

Ischemic Coronary Disease (ICD) [1]

Angina Pectoris

Obstruction

Decrease of blood irrigation

Acute Myocardial Infarction

(almost) Total occlusion

Cellular necrosis

[1]

[1] Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction. Eur Heart J 2007;28:2525–2538

Symptoms [2]

Sudden chest pain/squeezing sensation of the chest, which extends to the upper back, jaw, head or left arm - most

frequent symptom

Pain with variable intensity (from mild to severe)

Tightness, burning or a heavy weight

Strong heart beating/palpitation

Dyspnoea/shortness of breath

Fatigue

Intermittent angina pectoris

Anxiety

Epigastric discomfort

Sweating or cold

Nausea

Vomiting

Loss of consciousness

[2] World Health Organization – http://www.who.int/mediacentre/factsheets/fs317/en/index.html, in 29/10/2009

Causes and Risk FactorsGenetic predisposing [3]

Age [4]

Gender [5], [6], [7]

Stress [8]

Psychological factors [8]

Non-modifiable

Intense exertion

[3] ] Grassi M, Assanelli D, Mozzini C, et al, Modeling premature occurrence of acute coronary syndrome with atherogenic and thrombogenic risk factors and gene markers in extended families, J Thromb Haemost, 2005 Oct; 3(10):2238-44[4] Hamm C, Heeschen C, Falk E, Fox KAA. Acute coronary syndromes: pathophysiology, diagnosis and risk stratification. In: Camm AJ, Luescher TF, Serruys PW, ed. The ESC Textbook of Cardiovascular Medicine. Oxford: UK, Blackwell Publishing; 2006. p 333–366[5] Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. Am Heart J 2002; 144:1012–1017[6] Schenk-Gustafsson K, Risk factors for cardiovascular disease in women, Maturitas, 2009 Jul 20; 63(3):186-90[7] Shaw LJ, Bugiardini R, Merz CN, Women and ischemic heart disease: evolving knowledge, J Am Cardiol., 2009 Oct 20; 54(17):1561-75[8] Hansel B, Thomas F, Relationship between alcohol intake, health and social status and cardiovascular risk factors in the urban Paris-Ile-De-France Cohort: is the cardioprotective action of alcohol a myth?, Eur J Clin Nutr., 2010 May 19

Diabetes [9]

Hypercholesterlemia [10]

High blood pressure [11]

Obesity [12], [13]

Tobacco smoking [14]

Alcohol [15]

Causes and Risk Factors

Socioeconomic [16]

Diseases

[9] Dresslerová I, Voiácek J, Diabetes mellitus and ischemic heart disease, Vnitr Lek, 2010 Apr; 56(4):301-6[10] Zamaklar M, Vascular inflammation: effect of proatherogenic dyslipidemic trio or quartet, Med Pregl., 2009; 62 Suppl 3:37-42[11] Martins e Silva J, Saldanha C, Cardiovascular risk factors: hemorheology and hemostatic components, Rev Port Cardiol., 2007 Feb; 26(2):161-82[12] Dentali F, Squizzato A, The metabolic syndrome as a risk factor for venous and arterial thrombosis, Semin Thromb Hemost, 2009 Jul; 35(5):415-7[13] Menotti A, Food patterns and health problems: health in Southern Europe, Ann Nutr Metab., 1991; 35 Suppl 1: 69-77[14] Wang Y, Li J, Prevalence of peripheral arterial disease and correlative risk factors among natural population in China, Zhonghua Xin Xue Guan Bing Za Zhi., 2009 Dec; 37(12):1127-31[15] Holm JE, Vogeltanz-Holm N, Assessing health status, behavioral risks, and health disparities in American Indians living on the northern plains of the U.S., Public Health Rep, 2010 Jan-Feb; 125(1):68-78[16] Eller NH, Work-related psychosocial factors and the development of ischemic heart disease: a systematic review, Cardiol Ver., 2009 Mar-Apr; 17(2):83-97

Medicine:

Antiplatelet agents

Anticoagulants

Nitro-glycerine

β-blockers

Metabolism modifiers

Inhibitor of cardiac frequency

Angiostensin converting enzyme inhibitor

Intervention Surgery:

Coronary catheterization and angioplasty

Coronary Surgery (bypass)

Secondary Prevention:

Initial patient risk assessment

Pharmacologic therapy

Therapeutic lifestyles and intervention

Psychosocial evaluation

[17]

[18], [19], [20]

Treatment

[17] Carneiro AV, Costa J, Borges M (2004 Jan), Statins for primary and secondary prevention of coronary heart disease.A[18] Arshad A, Mandava A (2008 May-Jun), Sudden cardiac death and the role of medical therapy, Prog Cardiovasc Dis, 50(6):420-38 scientific review, Rev Port Cardiol., 26(2):161-82[19] Derby RC, Office care of patients after myocardial infarction, Postgrad Med., 2008 Apr; 120(1): 11-7[20] Chummum H, Reducing the incidence of coronary heart disease, Br J Nurs., 2009 Jul 23-Aug 12; 18(14):865-70

Cardiovascular diseases are the first cause of death on developed countries as well as on the underdeveloped ones. The decline in death rates from coronary heart disease amongst developed economies in Europe, North America, Australia, and New Zealand (between 39 and 52% fall in age-adjusted death rates in men and women from 1989–1999) is contrasted with an increase in mortality in several countries of Eastern and Central Europe, most notably countries of the former USSR. Despite the decreasing age-adjusted mortality for myocardial infarction, the disease prevalence for non-fatal components of acute coronary syndromes remains high and the economic costs are immense. In Portugal, recent data published in the annual report from Alto Comissariado da Saúde revealed an increase of patients admitted on coronary units, from 2004 to 2008. On the other hand, the rate of mortality has consistently declined, with a higher mortality rate in men than in women.

[21]

[22]

Relevance

[21] Murray CJ, Lopez AD, Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet, 1997; 349: 1498–1504[22] Liu JL, et al. The economic burden of coronary heart disease in the UK. Heart 2002; 88: 597–603

Aims• To analyse the outcomes – fatality rate and length of stay - of ischemic coronary

patients admitted (including transferred cases) in three types of Portuguese hospitals:

Central hospitals (with UCIC)▫Hospitals with UCIC

District hospitals with UCIC

▫Hospitals without UCIC District hospitals without UCIC

• To determine if there are aspects of the included population, such as gender and/or age, that influence the outcomes defined and if these may be considered as prognosis markers.

Methods• Type of study, based on administrative Portuguese hospitals’ data:

▫ Observational▫ Retrospective▫ Analytical

• Target population

▫ All ICD patients admitted in the three types of hospitals considered, between January 1st 2000 and December 31st 2007

• Study variables analysed

▫ Gender▫ Type of hospital where the admission occurred▫ Distance of patient’s residence to the hospital▫ Length of stay▫ Fatality Rate▫ Transfer

Study participantsThe target population consists in all patients, admitted with ischemic coronary disease, defined by ICD9 as Ischemic Heart Disease, with the subgroups of:

• Acute myocardial infarction• Other acute and subacute forms of ischemic heart disease• Angina pectoris• Other forms of chronic ischemic heart disease

Study participants

7 Central Hospitals42 District with UCIC Hospitals37 District without UCIC Hospitals

Fig. 1 – Geographic distribution of participant Hospitals

TYPE OF HOSPITAL NUMBER OF ADMISSIONS

Central 78051

District without UCIC 140264

District with UCIC 25490

Total=243805

Study participants

Fig. 2 – Number of admissions in each type of hospital

Study Design, Variables Description and Statistical Analysis

Data used in statistical analysis (SPSS17®)

gender (nominal categorical variable) length of stay (discrete quantitative variable) type of hospital where the admission occurred (nominal categorical variable)mortality – deceased/not deceased (nominal categorical variable)distance of patient’s residence to the hospital (continuous quantitative

variable) transfer – yes/no (nominal categorical variable)

Results Comparison of fatality rate in different types of hospitals (all patients)

2000 2001 2002 2003 2004 2005 2006 20070

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Centralwith UCICwithout UCIC

Fata

lity

Rat

e (%

)

Fig. 3 – Graphic relating the fatality rate in each year within each type of hospital for all patients (p-value of chi-square<0.05)

Results

Central District with UCIC District without UCIC0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Fig. 4 – Graphic relating the deceased variable (all patients) with the type of hospital, using CI 95%

2000 2001 2002 2003* 2004* 2005 2006 20070

1

2

3

4

5

6

7

CENTRAISUCICSEM UCIC

Fata

lity

Rat

e (%

)Results Comparison of fatality rate in different types of hospitals (only

transferred patients)

Fig. 5 – Graphic relating the fatality rate in each year within each type of hospital for transferred patients (p-value of chi-square<0.05 except in 2003 and 2004)

Results

Central District with UCIC District without UCIC

0

1

2

3

4

5

6

Fig. 6 – Graphic relating the deceased variable (only transferred patients) with the type of hospital, using CI 95%

Comparison of the length of stay in each type of hospital

TYPE OF HOSPITAL PERCENTILE 5 MEDIAN PERCENTILE 95

Central 0 5 19

District with UCIC 0 5 19

District without UCIC 1 7 21

Fig. 7 – Table relating the length of stay among the three types of hospitals. Kruskal-Wallis p = 0

Results

Type of Hospital

Fatality Rate (%)

Male Female

Central 2,4 2,2

District With UCIC 2,7 2,7

District Without UCIC 3,9 3,7

Fig. 8 – Table relating fatality rate with gender among the three types of hospitals (p > 0.05)

Results Comparison of fatality rate according to gender in different types of hospitals

There are no significant diferences

TYPE OF HOSPITAL PERCENTILE 5 PERCENTILE 95

Central 0 180

District with UCIC 0 151

District without UCIC 0 48

The distance seems inversly related with fatality rate

Results

Fig. 9 – Table relating distance to Hospital with different types of Hospitals.

Comparison of the distance to Hospital with the type of Hospital

Results After concluding that hospitals with UCIC seem to treat more effectively Ischemic Coronary patients, it is interesting to calculate the number of deaths that could be avoided if patients who died in district without UCIC hospitals had been treated in central or district with UCIC hospitals.

To perform this analysis, it is important to remember that the number of admissions to district without UCIC hospitals in the studied period was 140264.

TYPE OF HOSPITAL NUMBER OF ADMISSIONS

Central 78051

District without UCIC 140264

District with UCIC 25490

Total=243805Fig. 10 – Number of admissions in each type of hospital

In district without UCIC hospitals: 3,8% x 140264 = 5330 patients died

In district with UCIC hospitals… 2,7% x 140264 = 3787 patients would die

So, 5330 – 3787 = 1543 patients would not have died

In central hospitals… 2,4% x 140264 = 3366 patients would die

So, 5330 – 3366 = 1964 patients would not have died

TYPE OF HOSPITAL FATALITY RATE (%)

Central 2,4

District with UCIC 2,7

District without UCIC 3,8Fig. 11 – Table relating the deceased variable with the type of hospital (p-

value of chi-square<0.05)

Results

Conclusion/Discussion

•The percentage of deceased patients is higher in district with no UCIC hospitals and lower in central hospitals;

•There are no significant differences in fatality rate, considering the variable “gender”, within the same type of hospital;

•A greater distance to the hospital could lead to higher fatality rate, but that's not what happens. In fact, the distance, seems inversely related to fatality rate.

• It was expected to find differences in the outcomes among the three types of hospitals included, and the differences really exist.

•Central hospitals seems to have better resources and greater success in the treatment of individuals with IC associated diseases, because, besides having a lower proportion of dead [23] (even taking into account the transfer), patients are still less time in hospital, indicating that they are treated more quickly and efficiently.

[23] Chukmaitov AS, et al. Variations in inpatient mortality among hospitals in different system types, 1995 to 2000. Med Care., 2009 Apr ;47(4):466-73.

• It was expected that fatality rate could be higher in central hospitals, once these hospitals receive transferred patients from other facilities, which usually corresponds to the most serious cases. However, there was an opposite result: a lower fatality rate in central hospitals, due to the advanced equipments, best financial capabilities [24, 25, 26] and better facilities.

•Finally, it is also important to refer the number of deaths that would probably be avoided if patients were treated in hospitals with UCIC; in fact, it was found that 1543 of the 5330 patients who died in district without UCIC hospitals would probably not have died if they had been admitted in district with UCIC hospitals and 1964 of those 5330 patients would not have died if they had been admitted in central ones.

Conclusion/Discussion

[23] Chukmaitov AS, et al. Variations in inpatient mortality among hospitals in different system types, 1995 to 2000. Med Care., 2009 Apr ;47(4):466-73.[24] Noiseux N, Bracco D, Do patients after off-pump coronary artery bypass grafting need the intensive care unit? A prospective audit of 85 patients, Interact Cardiovasc Thorac Surg., 2008 Feb; 7(1):32-6[25] Langa KM, Sussman EJ, The effect of cost-containment policies on rates of coronary revascularization in California, N Engl J Med., 1993 Dec 9; 329(24):1784-9[26] Abbott BG, Jain D, Impact of myocardial perfusion imaging on clinical management and the utilization of hospital resources in suspected acute coronary syndromes, Nucl Med Commun., 2003 Oct; 24(10):1061-9

• It was impossible to follow transferred patients after leaving the first hospital where they were admitted because when transferred they receive a new ID number, so that analysis was impossible to perform.

• It was found no variables concerning complications and type of treatment.

•The data about distance to hospital was not suitable for an explicit box plot, that we considered to be the best way to show this data.

•Once the database was too big, we had to change SPSS workspace in order to be able to perform a Kruskal-Wallis test.

Limitations

References:• [1] Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction.

Eur Heart J 2007;28:2525–2538• [2] World Health Organization

-http://www.who.int/mediacentre/factsheets/fs317/en/index.html, in 29/10/2009• [3] Grassi M, Assanelli D, Mozzini C, et al, Modeling premature occurrence of acute

coronary syndrome with atherogenic and thrombogenic risk factors and gene markers in extended families, J Thromb Haemost, 2005 Oct; 3(10):2238-44

• [4] Hamm C, Heeschen C, Falk E, Fox KAA. Acute coronary syndromes: pathophysiology, diagnosis and risk stratification. In: Camm AJ, Luescher TF, Serruys PW, ed. The ESC Textbook of Cardiovascular Medicine. Oxford: UK, Blackwell Publishing; 2006. p 333–366

• [5] Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. Am Heart J 2002; 144:1012–1017

• [6] Schenk-Gustafsson K, Risk factors for cardiovascular disease in women, Maturitas, 2009 Jul 20; 63(3):186-90

• [7] Shaw LJ, Bugiardini R, Merz CN, Women and ischemic heart disease: evolving knowledge, J Am Cardiol., 2009 Oct 20; 54(17):1561-75

• [8] Hansel B, Thomas F, Relationship between alcohol intake, health and social status and cardiovascular risk factors in the urban Paris-Ile-De-France Cohort: is the cardioprotective action of alcohol a myth?, Eur J Clin Nutr., 2010 May 19

• [9] Dresslerová I, Voiácek J, Diabetes mellitus and ischemic heart disease, Vnitr Lek, 2010 Apr; 56(4):301-6

• [10] Zamaklar M, Vascular inflammation: effect of proatherogenic dyslipidemic trio or quartet, Med Pregl., 2009; 62 Suppl 3:37-42

• [11] Martins e Silva J, Saldanha C, Cardiovascular risk factors: hemorheology and hemostatic components, Rev Port Cardiol., 2007 Feb; 26(2):161-82

• [12] Dentali F, Squizzato A, The metabolic syndrome as a risk factor for venous and arterial thrombosis, Semin Thromb Hemost, 2009 Jul; 35(5):415-7

• [13] Menotti A, Food patterns and health problems: health in Southern Europe, Ann Nutr Metab., 1991; 35 Suppl 1: 69-77

• [14] Wang Y, Li J, Prevalence of peripheral arterial disease and correlative risk factors among natural population in China, Zhonghua Xin Xue Guan Bing Za Zhi., 2009 Dec; 37(12):1127-31

• [15] Holm JE, Vogeltanz-Holm N, Assessing health status, behavioral risks, and health disparities in American Indians living on the northern plains of the U.S., Public Health Rep, 2010 Jan-Feb; 125(1):68-78

• [16] Eller NH, Work-related psychosocial factors and the development of ischemic heart disease: a systematic review, Cardiol Ver., 2009 Mar-Apr; 17(2):83-97

• [17] Carneiro AV, Costa J, Borges M (2004 Jan), Statins for primary and secondary prevention of coronary heart disease.A

• [18] Arshad A, Mandava A (2008 May-Jun), Sudden cardiac death and the role of medical therapy, Prog Cardiovasc Dis, 50(6):420-38 scientific review, Rev Port Cardiol., 26(2):161-82

• [19] Derby RC, Office care of patients after myocardial infarction, Postgrad Med., 2008 Apr; 120(1): 11-7

• [20] Chummum H, Reducing the incidence of coronary heart disease, Br J Nurs., 2009 Jul 23-Aug 12; 18(14):865-70

• [21] Murray CJ, Lopez AD, Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet, 1997; 349: 1498–1504

• [22] Liu JL, et al. The economic burden of coronary heart disease in the UK. Heart 2002; 88: 597–603

• [23] Chukmaitov AS, et al. Variations in inpatient mortality among hospitals in different system types, 1995 to 2000. Med Care., 2009 Apr ;47(4):466-73.

• [24] Noiseux N, Bracco D, Do patients after off-pump coronary artery bypass grafting need the intensive care unit? A prospective audit of 85 patients, Interact Cardiovasc Thorac Surg., 2008 Feb; 7(1):32-6

• [25] Langa KM, Sussman EJ, The effect of cost-containment policies on rates of coronary revascularization in California, N Engl J Med., 1993 Dec 9; 329(24):1784-9

• [26] Abbott BG, Jain D, Impact of myocardial perfusion imaging on clinical management and the utilization of hospital resources in suspected acute coronary syndromes, Nucl Med Commun., 2003 Oct; 24(10):1061-9