Quality Evaluation Of The Application Of Renin-angiotensin-aldosterone System Inhibitors In Hospitalized Patients With Acute Myocardial Infarction In China From 2001 To 2011

Background:Cardiovascular disease(CVD)is the leading cause of deaths in China.Of all CVDs,acute myocardial infarction(AMI)is the most severe condition,which leads to high incidence,high rate of disability,high mortality,and high care cost.Moreover,the growth in the number of individuals with AMII is predicted to continue,which indicates that China is facing increasing burden on health services.Therefore,high quality of AMI care is crucial to meet the health needs of individuals with CVD.In addition to timely reperfusion therapy,appropriately applying evidence-based medications that have been proven to improve AMI prognosis is also an important element for AMI treatment.Renin-angiotensin-aldosterone system(RAAS)inhibitors,which includes angiotensin-converting enzyme inhibitors/angiotensin receptor blockers(ACEI/ARB)and aldosterone antagonist(AA),is an important category of drugs for AMI treatments.They have been shown to improve outcomes for AMI in selected patients,and were recommended by both China and U.S.guidelines.Left ventricular ejection fraction(LVEF)assessment is a critical component in the use of these drugs because it guides the indication for ACEI/ARB and AA.The benefit beyond indicated group is not established,and inappropriate use may even expose patients to significant risk.Little is known about the RAAS inhibitors use among patients with AMI in China.Objectives:To evaluate treatments patterns and trends for ACEI/ARB use,spironolactone use(the only AA in China),and LVEF assessment after AMI in China from 2001 to 2011;identify both patient and hospital factors associated with their use,and explore variations across different hospitals and regions.Methods:From a nationally representative sample of AMI patients(2001,2006,and 2011)in the China PEACE retrospective study,we identified patients eligible for the evaluations of ACEI/ARB,spironolactone,and LVEF assessment,respectively.We firstly assessed their use patterns and used multivariable logistic regression model with generalized estimating equations to determine factors associated with their use;and then did in-depth hospital-level analysis-employed a hierarchical logistic regression model to calculate the risk-standardized non-use rate(RSNUR)and 95%confidence interval(CI)for each hospital,and classified hospitals into 3 mutually exclusive groups:(1)worse,if the lower limit of a hospital's 95%CI is higher than the average,(2)better,if the upper limit of a hospital's 95%CI is less than the national average RSNUR,and(3)as expected,if a hospital's 95%CI overlaps with the average.We also identified hospital factors associated with non-use.Results:From 2001 to 2011,the rates of ACEI/ARB use increased from 62.0%in 2001 to 71.4%in 2006,decreasing to 67.6%in 2011(P for trend=0.01).Conversely,the use rates decreased from 2001 to 2006(40.1%to 34.5%,P for trend<0.001),but then increased to 50.4%in 2011.The mean RSNUR for ACEI/ARB was 33.6%(Standard Deviation[SD]14.1),with a range of 4.5%to 74.1%nationwide.Of all hospitals,37.2%performed worse,which means they had their lower limit of 95%(Confidence Interval,CI)for RSNUR significantly higher than the national average.Across regions,central China had the lowest proportion of worse-performed hospitals(32.4%)and the highest of well-performed hospitals(64.7%).There were no hospital-level factors significantly associated with RSNUR for ACEI/ARB.From 2001 to 2011,the proportion of patients whose eligibility for spironolactone was not assessed(i.e.LVEF assessment)decreased(66.9%in 2001 to 32.8%in 2011).Spironolactone use significantly increased among indicated patients over this period(28.6%to 72.4%,P for trend<0.001),but also in contraindicated patients(11.4%to 27.5%)and in other patients groups(not indicated:27.5%to 38.3%,unknown indications:21.3%to 35.1%,all P for trend<0.01).In all 4 groups,patients presenting with heart failure on admission were more likely to receive spironolactone.Since the sample sizes for each group were small,we did not conduct hospital-level analysis due to lack of statistical power.The rate of LVEF assessment increased significantly from 2001 to 2011(23.2%,46.9%,68.1%,respectively;P for trend<0.001).Female,those with coronary artery disease,patients with acute stroke on admission,and those with heart rate>90/min had a lower likelihood to receive LVEF assessment.The RSNUR for LVEF was 38.4%(SD 16.9),with a range of 8.9%to 78.4%.Of all hospitals,48.3%performed worse,with the lower limit of 95%CI for RSNUR significantly higher than the national average.Across regions,central China had the highest proportion of worse-performed hospitals(56.3%)and the lowest of well-performed hospitals(31.3%).Conclusions:Over the past decade,the appropriate use of spironolactone and LVEF assessment increased significantly in China;however,little improvement was observed in ACEI/ARB use.The inappropriate use of ACEI/ARB and spironolactone among contraindicated patients was concerning.Moreover,substantial variation existed across hospitals in ACEI/ARB use and LVEF assessment,indicating inequalities in health care performance.There remain marked opportunities for improvement.Future study should conduct in-depth interview to explore underlying mechanism.Quality improvement initiatives are needed to increase the application of RAAS inhibitors use for patients with AMI,and eliminate inequalities in health performance across hospitals.