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Disparities Abound in Chinese Heart Attack Care

Continued quality improvement in acute MI may be possible in the U.S. given lessons learned from another country with major geographic and other disparities in acute MI care and mortality: China.

Rural hospitals and those with fewer resources showed opportunities for improved care in China, according to findings from two registries now published online in JAMA Network Open.

“Many researchers believe that we have solved the STEMI [ST-segment elevation MI] problem, but the improvement in mortality has plateaued and we have made very little progress in reperfusion times for patients transferred from a non-PCI [percutaneous coronary intervention] center or outcomes for those with out-of-hospital cardiac arrest or cardiogenic shock,” wrote Timothy Henry, MD, of The Christ Hospital, Cincinnati, and James Jollis, MD, of Duke University School of Medicine in Durham, North Carolina, in an accompanying commentary.

The two studies suggest the U.S. still has a lead over China in acute MI care — but will it be able to keep it? The U.S. has been hurt by a fracturing of the national acute MI registry into multiple competing registries, which poses challenges to regional collaboration and quality improvement, Henry and Jollis suggested.

Meanwhile, they wrote, “China has rapidly embraced the best quality improvement models of the U.S.” and is even poised to surpass the collaborative systems of care in the States.

Geographic Variation

China saw persistent regional variations in the use of reperfusion and guideline-recommended medical therapy, one group reported from registry data.

Despite the launch of national health care reform in 2009, hospitals in the country’s center were 17% less likely to provide MI treatments to eligible patients than centers in western areas in 2011-2015 (adjusted OR 0.83, 95% CI 0.76-0.91), according to Yingling Zhou, MD, PhD, of Guangdong Provincial People’s Hospital.

“In the present study, we observed significant differences in the use of guideline-recommended treatments across China, with hospitals in the Western region having the best performance, particularly for clopidogrel [Plavix], ACEIs/ARBs [angiotensin-converting enzyme inhibitors/angiotensin receptor blockers], and statins,” the research group said.

Zhou’s team noted that the western region is the least economically developed region in China and has been subject to special government investment in public health starting in the year 2000.

Eastern China also improved processes of MI care from 2001-2006 to 2011-2015.

Across the board, use of guideline-recommended treatments increased from 2001-2006 to 2011-2015, and there was some improvement in care variation, study authors said.

“However, care delivery remains suboptimal and disparities remained across China when compared with that in the United States and United Kingdom where reperfusion therapy, β-blockers, and ACEIs/ARBs are used at much higher rates. Additional measures should be taken to further narrow regional care disparity across the country,” Zhou and colleagues urged.

Their cross-sectional study was based on the Patient-Centered Evaluative Assessment of Cardiac Events–Retrospective AMI project. A random sampling yielded 27,046 patients hospitalized for acute MI at 153 hospitals across China.

The country was divided into three geographic regions: eastern, central, and western. There were marked regional variations

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