Identifying Predictors of Acute Myocardial Infarction Care Improvement by Inter-Jurisdictional Comparison of Outcome, Cost, and Resource Use

• Author / Creator

  Tran, Dat T.

• Acute myocardial infarction (AMI) is a global health concern. Despite of a reduction in incidence and mortality in the last several decades, AMI is still the leading cause of mortality and morbidity in many parts of the world, especially high income countries including Canada. Because of continuing advancement in AMI care practice and change in patient risk profiles, continuing benchmark of AMI care practice, health outcomes as well as resource use and costs is needed to inform health policy and quality improvement initiatives. We conducted four retrospective cohort studies using (1) the Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD) which contains acute care inpatient abstracts in all Canadian provinces except for Quebec between April 2004 and March 2014 and (2) the province of Alberta inpatient, outpatient, practitioner claims, pharmaceutical information network, population registry and vital statistic databases between April 2004 and March 2016. We examined temporal trends and provincial variations in the use of reperfusion strategies and associated in-hospital mortality, cardiac care quality indicators, resource use and health care costs of patients with AMI (International Classification of Diseases, 10th revision, codes I21 and I22). Canadian Classification of Health Interventions was used to identify relevant reperfusion and cardiac procedures, Alberta Interactive Health Data Application was used to provide dollar values for inpatient and outpatient services and Alberta Drug Benefit List was used to provide drug price. Overall, there was a significant increase in the use of contemporary primary percutaneous coronary intervention (PCI) during the study period but there was generally no change in health outcomes, except for a modest improvement in 30-day in-hospital mortality and 30-day readmission after coronary artery bypass grafting (CABG). The stable trend may reflect an avoided mortality and readmission when accounting for increased risk burden among patients with AMI over time. In addition, there were large variations in both the use of revascularization strategies and health outcomes across Canadian provinces. Patients with ST-segment elevation MI receiving fibrinolysis and followed by PCI in a systematic manner had the best outcomes compared with patients who underwent other alternative reperfusion strategies. The health care costs for AMI are high. However, the annual costs for AMI decreased during the study period, possibly suggesting an efficiency improvement in AMI care. The combination of stable outcomes and decreased costs over time could indicate a success in AMI care in Canada. Resource use and costs in the long-term were modest compared with those during the first year after incident AMI. Hospitalization accounted for the largest share of total health care costs and the subgroup of non-ST-segment elevation MI patients appeared to be the biggest resource use and cost driver. The large variation in care practice and outcomes across Canadian provinces could be a potential area for a pan-Canadian collaboration and coordination initiative to improve AMI care in Canada. In addition, a set of standard quality indicators specifically for AMI care should be developed. The methodology and findings in this thesis could be a starting point for a larger discussion on development of such a set of national quality indicators.

• Subjects / Keywords

  • Cost
  • Resource use
  • Acute myocardial infarction
  • Health outcome
  • Inter-provincial comparison

• Graduation date

  Spring 2018

• Type of Item

  Thesis

• Degree

  Doctor of Philosophy

• DOI

  https://doi.org/10.7939/R3XP6VJ79

• License

  This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for non-commercial purposes. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.