Determinants and patterns of utilization of primary percutaneous coronary intervention across 12 European countries: 2003–2008

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Abstract

Background

Important differences exist between European countries in the degree of implementation of primary percutaneous coronary intervention (PPCI) for patients with ST-elevation myocardial infarction (STEMI). To investigate whether health care-associated economic and demographic country-level characteristics were associated with differences in utilization of PPCI, we aimed to examine 5-year trends in the implementation of PPCI for STEMI across 12 EU countries.

Methods

An ecological study of aggregated data from national and international registries. Main outcome was the number of PPCI per 1,000,000 population, collected annually for the years 2003 to 2008. Impact of year on PPCI implementation was modeled using linear regression and mixed effects models used to quantify associations between PPCI use and country-level parameters.

Results

The annual growth in utilization of PPCI was 1.11 (1.03,1.20) per million. Country-level utilization rates varied from 0.82 (95% CI 0.52, 1.30) to 1.38 (95% CI 1.15, 1.64) per million per year. Number of physicians per 100,000 population, number of nurses and midwifes per 100,000 population, number of acute care beds per 100,000 population, population density per km2, and proportion of population under 50 years old were associated with PPCI utilization.

Conclusions

All 12 EU countries demonstrated evidence of PPCI implementation from 2003 to 2008. However, there was substantial variation in the use and rate of uptake of PPCI between countries. Differences in utilization rates of PPCI are associated with supply factors, such as numbers of beds and physicians, rather than healthcare economic characteristics. Further studies are needed to explore the influence of patient-level factors.

Introduction

International guidelines support the implementation of evidence-based clinical practice — to reduce variation in access to and quality of healthcare [1], [2], [3]. Primary percutaneous coronary intervention (PPCI) is recommended for patients with ST-elevation myocardial infarction (STEMI) [4]. Despite substantial evidence to support its effectiveness, international and national studies report large variation in access to PPCI both within and across countries [5], [6], [7], [8]. A study including data from 2007 or 2008 based partly on expert estimation suggested that only 40% to 60% of patients with STEMI in Europe received PPCI [7]. The factual level of variation in PPCI across countries is still unknown [7], and knowledge of the underlying causes of variation is sparse. Successful implementation likely calls for a multilevel action, with e.g. public campaigns in order to educate the population to recognize STEMI symptoms; and urge the society to establish PPCI service 24 h a day seven days a week with the formation of regional networks between hospitals, including emergency medical system, in order to minimize time delays [9], [10].

Studies on factors affecting PPCI implementation has so far mainly been based on surveys or expert opinions [9], [11], [12]. Modern health care systems are complex and factors affecting PPCI implementation may vary across countries. Studies based on aggregated health care data with countries as the unit of observation, will allow identification of determinants of variation in the economic, demographic and institutional context [11], [12], [13], [14], [15], [16], [17]. To our knowledge no such study exists within the field of PPCI diffusion across a large number of European countries.

Using aggregated data concerning patients hospitalized with a diagnosis of STEMI from national registries from 12 EU countries, we aimed to: 1) describe the temporal implementation of PPCI, 2) quantify variation in use of PPCI, and 3) investigate whether patient-level factors and country-level financial and healthcare system characteristics were associated with observed differences in the use of PPCI.

Section snippets

Methods

“The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology”.

Design and source population

We conducted an ecological study using aggregated data from the following European countries; Austria, Belgium, Denmark, England, Germany, Italy, Portugal, Spain, Sweden, Scotland, Northern Ireland and Wales.

Dependent variable

The primary outcome was utilization of PPCI per 1,000,000 population, which was defined as the annual number of patients (2003 to 2008) with a diagnosis of STEMI who underwent acute percutaneous coronary intervention (PCI). Data on the dependent variable were collected from national registries. Table 1 shows the data sources and time periods used for each country. Using the national population estimates on January 1st 2006 published by Eurostat we calculated the annual number of PPCI per

Explanatory variables

Eurostat was used as the main data source for the explanatory variables (http://epp.eurostat.ec.europa.eu/portal). Identification of factors potentially affecting the diffusion of PPCI was based upon a literature review and availability of data. Table 2 provides a list of potential explanatory variables by data source and their hypothesized influence on the implementation of PPCI. Computerized and validated information on the explanatory variables from Eurostat were available for 2006, with a

Eurostat

The statistical office of the European Union (Eurostat) was established in 1953. Eurostat collects and verifies national- and regional-level statistics from the statistical authorities of the member countries. Eurostat ensures comparable data across countries and regions over time. The European Statistical System undertakes quality reporting, which can be consulted at the Eurostat homepage (http://epp.eurostat.ec.europa.eu/portal/page/portal/about_eurostat/introduction).

The European Observatory

The European Observatory

Analysis

Individual countries' implementation curves were plotted. The annual change in implementation per country was modeled using linear regression. A multilevel random slope model of the rate and level of PPCI procedures within countries over years was built to study the relationship between growth in PPCI use per million population and country-level covariates (where covariates were included as grouped variables). A natural log (ln) transformation was used to correct for right skewness of PPCI per

Trends in PPCI implementation

Fig. 1 depicts the implementation of PPCI from 2003 to 2008 for each country. The three countries with the highest utilization levels were Germany, Austria and Denmark, while utilization was lowest in Wales — which like England and Sweden did not include PPCI over 12 h, rescue or facilitated PCI. By 2008, Germany and Austria performed about 700 PPCI per million inhabitants. These two countries performed roughly 4 times the number of PPCI as did, for instance, Wales. We found a year on year

PPCI patterns

This study describes substantial between-country variation in the numbers of patients with STEMI who received acute PCI per 1,000,000 population between 2003 and 2008. It agrees with the geographical variation reported by the OECD in 2003 [25] and Widimsky et al. in 2009 [7]. Moreover, these reports described high utilization rates in Germany and low utilization rates in the UK. In the OECD report, patterns of implementation were based on numbers of PCI. However, a study from the Technological

Number of physicians

We demonstrate an association between the availability of physicians and growth in PPCI utilization. Earlier studies of barriers to implementation of PPCI have reported heterogeneous results [12], [14], [15], [16], [23]. A sufficient cardiology workforce is necessary to ensure access to high quality cardiovascular care including PPCI. Our findings are particularly relevant for policy makers — they indicate that availability of physicians with the requisite skills is associated with the

Number of acute care beds

Perhaps the most striking result was the positive effect on utilization rates associated with number of acute care beds. International perspectives on this finding, however, are unclear. A negative association between the number of available hospital beds and implementation of complex medical innovations has been reported, indicating that the availability of more sophisticated medical equipment (in more mature medical systems), may in the long run prevent unnecessary hospital admissions and,

Population density

We found that countries with both low and high population density per km2 had a slower growth in PPCI utilization compared with countries with a medium population density. This result agrees with studies reporting that widespread adoption of PPCI is potentially limited by anticipated transport delays, and practicalities associated with transporting the patients to appropriate treatment facilities within the recommended timeframe [11], [33], [34], [35]. Different complexity of infrastructure in

Age

We found a significant positive relationship between growth in PPCI utilization and age less than 50 years. Ischaemic heart disease is an age related disease, so an age dimension on treatment utilization would be expected [37].

Supply and demand

Our study demonstrates a link between health care system supply-side incentives and the level of implementation of PPCI. Evidence suggests that supply-side characteristics have a stronger influence on treatment patterns than do demand-side characteristics [16], [23], [31]. Supply-side constraints reflect a complex interaction between financial and human capital that determines utilization levels. Given the universal health care coverage afforded to citizens in European countries, it is not a

Strengths and limitations

The main strength of our study is that STEMI is a relatively common and well-defined clinical condition worldwide, allowing international comparison of diagnoses and treatment. Second, most STEMI patients are initially hospitalized providing reliable inpatient data across countries. Third, uniform definitions of the explanatory variables were available through Eurostat. Fourth, PPCI implementation has changed rapidly in recent years, allowing the investigation of implementation patterns. With

Perspectives and conclusions

While making cross-country comparisons with these data is challenging, these results nevertheless are instructive in presenting a picture of the striking international variation in the use of and uptake of PPCI for STEMI across several European countries. Our study was designed to shed light on health care system level factors, whereas much remains to be answered about the influence of patient-level factors on variation. The results of our study should be seen as a preliminary step in exploring

Contributorship

KGL, TLL and SDK conceived the study idea and designed the study. KGL collected the data. KGL and SDK reviewed the literature. KGL and TLL directed the analyses, which were carried out by KGL and TLL. CPG revised the analysis. All authors participated in the discussion and interpretation of the results. KGL organized the writing and wrote the initial draft. All authors critically revised the manuscript for intellectual content and approved the final version.

Acknowledgments

We thank the European Critical Care Foundation for funding this project.

CPG is funded through the National Institute for Health Research (NIHR) [NIHR/CS/009/004].

We thank the following people for their support with data collection:

  • Austria: Dr. Gerhard Fülöp, Gesundheit Österreich GmbH/Geschäftsbereich ÖBIG (Austrian Health Institute) Responsible for working area “health care planning”, Stubenring 6, 1010 Wienna, Austria. Maria Hofmarcher-Holzhacker, Director Health and Care, European Centre for

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    Acknowledgement of grant support: This work was supported by the European Critical Care Foundation. CPG is funded through the National Institute for Health Research (NIHR) [NIHR/CS/009/004].

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