This country-wide study shows that between 2001 and 2007, the treatment of AMI patients improved in the tertiary and secondary care hospitals in Estonia, although the rates of reperfusion and revascularization increased mainly in the tertiary care setting. At the same time, improvements in the treatment did not translate into significantly lower mortality within the hospital types even after accounting of the differences in the baseline characteristics. Instead, in 2007, a marked mortality gap can be observed between the tertiary and the secondary care hospitals.
The positive trend in AMI treatment during hospitalization has also been reported by previous studies [9–14, 17–19]. The observed improvements in Estonia are probably connected to better access to coronary intervention facilities, the release of new European and Estonian guidelines during the study period, and the launching of several training programs by the Estonian Society of Cardiology [3–7].
Still, in 2007, the mean use of beta-blockers and ACEI/ARB during hospitalization and for outpatient use remained below 83%, while the rates in the secondary care hospitals were even lower. The use of statins in the secondary care hospitals causes even more concern as although the rates increased markedly during the study period, their use is still below 38%. The fact that the quality of care of AMI patients in the secondary care hospitals lags behind that in their tertiary care counterparts may be due to the known slower implementation of guideline-recommended medications in secondary care hospitals . As the study demonstrated, patients in the secondary care hospitals tend to be older and have more co-morbidities, which may influence management decisions.
Better access to invasive coronary care facilities and recent research findings contributed to the wider use of PCI in the tertiary care hospitals. At the same time, in the secondary care hospitals transfer for further cardiac testing and revascularisation into tertiary care hospitals increased. Still, the transfer rates were low compared to previous studies [21, 22]. Although the mean age of transferred patients increased, transferred patients still tended to be younger than the non-transferred patients (data not presented).
While in the tertiary care hospitals reperfusion rates increased and primary PCI became the preferred method of reperfusion for STEMI patients, then in the secondary care hospitals reperfusion rates showed little change. It is possible that STEMI patients are usually transferred before receiving medical reperfusion. Still, a previous study revealed that the reasons for not receiving reperfusion may be unknown in up to 45% of cases .
Several studies have demonstrated that closer adherence to published guidelines for AMI management results in improved short-and long-term outcomes and this even despite the growing prevalence of risk factors (older age, history of hyperlipidaemia and diabetes mellitus) at presentation [10–14, 16, 24–26]. Although our study demonstrates a marked improvement in the treatment quality for AMI patients in 2007 compared to 2001, especially in tertiary care hospitals, it fails to show a significant decrease in 30-day and 3-year mortality. As the study sample of the secondary care hospitals demonstrated, this may largely be due to the higher age and cardiovascular risk among the study samples in 2007. For instance, the rates of diabetes had almost doubled in both types of hospitals. In order to further clarify this issue, we performed a sub-analysis to compare the baseline characteristics, quality of care provided, and mortality separately among patients < 75 and ≥ 75 years in 2001 and 2007 in tertiary care hospitals (data not presented). On the basis of this analysis we may hypothesize that in tertiary care hospitals the reason why short-and long-term mortality has not improved despite better overall quality of care is that firstly the improvement is more targeting those younger and healthier and secondly the rate of patients over 75 years with more co-morbidities has increased.
Interesting findings of the study were the differences in short and long-term mortality between the two hospital types in 2007. This can probably be explained by a combined effect of improved management possibilities in the tertiary care hospitals and different patient baseline characteristics in the two hospital types. The patients admitted to the secondary care hospitals are more likely to be older and have a higher cardiovascular risk. Moreover, as the elderly often present with atypical symptoms and have a greater burden of cardiac and non-cardiac co-morbidities, physicians are more reluctant to treat them aggressively, the more so when the outcomes of interventions and surgery may be poorer [27, 28].