key: cord-0964244-o0bdtobp
authors: Aktaa, Suleman; Yadegarfar, Mohammad E; Wu, Jianhua; Rashid, Muhammad; de Belder, Mark; Deanfield, John; Schiele, Francois; Minchin, Mark; Mamas, Mamas; Gale, Chris P
title: Quality of acute myocardial infarction care in England and Wales during the COVID-19 pandemic: linked nationwide cohort study
date: 2021-06-21
journal: BMJ Qual Saf
DOI: 10.1136/bmjqs-2021-013040
sha: d7821e489facab8bd4e4f6f7531dec35815fb11c
doc_id: 964244
cord_uid: o0bdtobp

BACKGROUND AND OBJECTIVE: The impact of the COVID-19 pandemic on the quality of care for patients with acute myocardial infarction (AMI) is uncertain. We aimed to compare quality of AMI care in England and Wales during and before the COVID-19 pandemic using the 2020 European Society of Cardiology Association for Acute Cardiovascular Care quality indicators (QIs) for AMI. METHODS: Cohort study of linked data from the AMI and the percutaneous coronary intervention registries in England and Wales between 1 January 2017 and 27 May 2020 (representing 236 743 patients from 186 hospitals). At the patient level, the likelihood of attainment for each QI compared with pre COVID-19 was calculated using logistic regression. The date of the first national lockdown in England and Wales (23 March 2020) was chosen for time series comparisons. RESULTS: There were 10 749 admissions with AMI after 23 March 2020. Compared with before the lockdown, patients admitted with AMI during the first wave had similar age (mean 68.0 vs 69.0 years), with no major differences in baseline characteristics (history of diabetes (25% vs 26%), renal failure (6.4% vs 6.9%), heart failure (5.8% vs 6.4%) and previous myocardial infarction (22.9% vs 23.7%)), and less frequently had high Global Registry of Acute Coronary Events risk scores (43.6% vs 48.6%). There was an improvement in attainment for 10 (62.5%) of the 16 measured QIs including a composite QI (43.8% to 45.2%, OR 1.06, 95% CI 1.02 to 1.10) during, compared with before, the lockdown. CONCLUSION: During the first wave of the COVID-19 pandemic in England and Wales, quality of care for AMI as measured against international standards did not worsen, but improved modestly.

The COVID-19 pandemic has impacted on the structure and organisation of services delivered through the National Health Service (NHS) with knock-on effects on the management of a number of acute cardiovascular conditions including acute myocardial infarction (AMI) in the UK. [1] [2] [3] [4] For patients admitted to hospital with AMI, guideline-indicated therapies such as invasive coronary angiography, timely reperfusion and secondary prevention medications improve survival, 5 and professional organisations in the UK recommended the perpetuation of these therapies during the pandemic. 6 7 Yet, an earlier study found an increase in 30-day mortality and a reduction in the proportion of invasive coronary angiography during the national lockdown for patients with non-ST segment elevation myocardial infarction (NSTEMI). 8 There has been, however, no comprehensive evaluation of the quality of AMI care during the first national lockdown and no study has used recognised standards for such an investigation.

Quality indicators (QIs) have been increasingly used as a mechanism to measure broad aspects of care, 9 identify unwanted variation 10 11 and drive quality improvement. 12 For AMI, a suite of QIs exist which are valid, 13 internationally recognised 14 and have built on earlier indicators that have an inverse association with mortality. [15] [16] [17] [18] [19] We used the UK national cardiovascular registries to investigate the quality of AMI care according to these indicators during the first national lockdown in the COVID-19 pandemic. This may help understand changes in the processes of AMI care during the time of national crisis and identify areas for improvement.

We used linked data from the UK national AMI and percutaneous coronary intervention (PCI) registries, namely the Myocardial Ischaemia National Audit Project (MINAP) 20 21 

Original research of Percutaneous Coronary Intervention (NAPCI), championed by the British Cardiovascular Intervention Society. 22 MINAP and NAPCI registries have been described previously. 20 

We included all adult patients (⩾18 years of age), discharged alive with ST-segment elevation myocardial infarction (STEMI) or NSTEMI from MINAP between 1 January 2017 and 27 May 2020. Data related to PCI were obtained from the NAPCI registry using each patient's unique NHS number to deterministically link patients between the two registries. Where multiple admissions for the same patient were recorded, the earlier admission was used to reduce potential bias from previous treatments. Patients with no valid NHS number were excluded.

We used the 2020 European Society of Cardiology (ESC) Association for Acute Cardiovascular Care (ACVC) QIs for AMI, which comprise 26 indicators. The eligibility criteria for each QI was determined according to the specifications provided in the ESC ACVC document. 14

The outcome was quality of AMI care. Care quality was quantified according to the degree to which eligible patients received the care outlined in the QIs prior to, compared with after, 23 March 2020 (up to 27 May 2020). This date was chosen for the time series comparison because it corresponded with the first national lockdown in England and Wales.

Patient baseline characteristics, comorbidities and treatments were reported according to the study period and type of AMI as percentages and numbers for categorical variables, means and SDs for parametric continuous variables, and medians and IQRs for non-parametric variables. Baseline differences between each diagnosis were tested using χ 2 test for categorical variables, t-test for continuous parametric and the Mann-Whitney U test for non-parametric variables. At the patient level, the likelihood of attainment for each QI compared with that before the COVID-19 pandemic was estimated using logistic regression.

All analyses were performed on complete cases. All tests were two-sided, and statistical significance was considered as p value <0.05. Statistical analyses were performed in Stata IC V.14.2 and R V.3.4.3.

Data for 236 743 patients admitted with AMI to one of 186 NHS hospitals were included. Of those, 152 109 (64.3%) patients had NSTEMI, and the median age was 69.0 (58-79) years with 75 918 (32.2%) patients being women. The cohort following lockdown (10 749) were compared with the period chosen before lockdown (225 994). Table 1 shows the demographics, comorbidities, in-hospital treatment and discharge details according to the study period. Data are presented according to the type of AMI in online supplemental table 1. Compared with before the lockdown, patients admitted with AMI during the first wave had similar age (mean 68.0 vs 69.0 years), similar baseline characteristics (history of diabetes (25% vs 26%), renal failure (6.4% vs 6.9%), heart failure (5.8% vs 6.4%) and previous myocardial infarction (22.9% vs 23.7%)) and less frequently had high Global Registry of Acute Coronary Events (GRACE) risk scores (43.6% vs 48.6%) (table 1).

Data from the national registries enabled the direct measurement of 16 (61.5%) of the 26 ESC ACVC QIs. The QIs that could not be assessed included the planned duration of dual anti-platelet therapy, the QIs within the patient satisfaction domain and the objective risk-stratification using validated tools. GRACE risk scores, however, were indirectly derived for 193 177 (81.6%) patients. In addition, while participating in a network for STEMI management, taking part in a registry and routine monitoring to reperfusion times in STEMI could not be directly measured, these form part of routine practice in the UK. The outcome QI (30-day mortality) may be obtained from data linkage with the Civil Registration of Deaths Register, but was not evaluated for this work because mortality had been previously investigated 8 and this study concerned processes of care.

During, compared with before, the national lockdown, in England and Wales there was an improvement in attainment for 10 (62.5%) QIs, with evidence for a slight reduction in attainment for the other QIs that could be measured using the datasets (table 2). Figure 1 shows the OR for QI attainment during the lockdown referenced to the pre-COVID period.

Overall, there was a slight increase in attainment for the composite QI after the first national lockdown (43.8% to 45.2%, OR 1.06, 95% CI 1.02 to 1.10) suggesting good overall adherence to Original research guidelines-indicated therapies for AMI during the COVID-19 pandemic.

This real-world naturalistic study evaluated the quality of AMI care in England and Wales before and during the COVID-19 pandemic using routinely collected nationwide registry data. We found that the NHS provided high-quality AMI care during the pandemic as measured against international standards. In particular, we found that early detection and timely invasive investigation for NSTEMI were delivered at much higher rates, while STEMI reperfusion was slightly delayed than prior to the UK lockdown. Such insights were gained by means of routinely collected cardiovascular data. These findings highlight the role that the UK national cardiovascular registries may play in the evaluation of processes of AMI care in times of need.

Others have described changes in the patterns of treatment for patients with AMI during the COVID-19 pandemic, 1-3 8 but no study has quantified the breadth or depth of AMI care on a national level using validated QIs. Similar findings of an overall improvement in the quality of care have recently been reported for patients with stroke in the UK. 24 Taken together, this emphasises the consequences of a national crisis on the delivery of processes of care for acute cardiovascular conditions and may help identify areas for improvement.

One may only speculate as to the reasons for improved care quality for AMI following the national lockdown. Given that there was a reported decline of between 16% and 40% in admissions with AMI to hospitals following the first UK lockdown, the modest improvement in attainment of the majority of the QIs during the pandemic could be explained by a relative increase in availability of cardiology staff and resources. 1 2 8 25 That is, a reduction in admissions for AMI, with the maintenance of a specialist emergency heart attack service, would provide greater opportunities for specialist staff to deliver higher quality care. 3 Indeed, at the time, the British Cardiovascular Society recommended the UK national heart attack service to continue as previously and not to revert to historical treatments for AMI such as thrombolysis. 6 7 This was in contrast to recommendations during the early stages of the pandemic to adopt a 'thrombolysis-first' approach. 26 Given the decline in admissions with AMI, our findings suggest that care quality could be further improved with appropriate staffing and resources.

However, it is possible that other factors were at play. This includes the preparedness of dedicated services (and with this additional staff availability and attention) and the prioritisation of hospital discharges 

(and therefore greater attention to the provision of care prior to leaving hospital). 27 Moreover, the 'shut down' of normal elective activity, 28 29 which spanned all services, would have enabled the NHS to be better equipped to receive and treat patients with AMI. It is also plausible that the recording of data into the national registries was more selective, with a bias towards patients who were lower risk, had better care and who were more likely to be discharged alive (previous work has suggested that missing data is associated with 30-day mortality for STEMI and NSTEMI). 30 The delay in STEMI reperfusion observed in our study is consistent with other UK 3 and international 31 studies, and may be related to the changes to STEMI service during the pandemic including the redeployment of catheter laboratory staff to other intensive care environments. 27 Furthermore, the slight reduction in the assessment of left ventricular ejection fraction prior to hospital discharge and the prescription of angiotensin converting enzyme inhibitors or angiotensin receptor blockers for those with a reduced ejection fraction, as well as the increase in radial access use after the lockdown, may be due to the fact that there was an imperative to make available hospital beds and therefore enable the early hospital discharge of stable patients following AMI.

Our study does emphasise an opportunity to integrate local efforts with those wider afield that aim to evaluate and improve the quality of AMI care. The ESC QIs have been designed to enable the assessment of care quality for AMI, according to international clinical practice guidelines. 32 Equally, MINAP and NAPCI are used as tools for audit and evaluation of NHS heart attack services. 33 Hitherto, we were only able to measure 61.5% of the ESC AMI QIs against these two national registers. We propose that routine national data collection aligns to and harmonises with national and international standards for the measurement of quality of care. 34 Equally, we recognise that while information such as health-related quality of life may be difficult to capture via national registries, 35 greater alliance may help enhance the comprehensiveness of data collection systems in the UK. 36 37 Our study has limitations. MINAP does not collect information pertaining to all admissions with AMI Original research across the NHS. 38 It is possible that care quality for those admissions recorded were systematically different from those not in the registry. Nonetheless, MINAP does collect detailed clinical information pertaining to the majority of admissions in England and Wales with AMI, and is the largest single healthcare system AMI registry. 20 We substituted statin therapy for high-intensity statin, serum cholesterol for lowdensity lipoprotein cholesterol, and balloon inflation time for arterial access time. While these are slightly different aspects of care to the ones proposed in the ESC ACVC QIs, they provide insights into current practice of pharmacotherapy following AMI. This was a retrospective cohort study which has bias inherent to its observational design.

The COVID-19 pandemic created a natural experiment for the NHS. During this period, quality of care for AMI as measured against international standards did not worsen, but improved modestly. Give the decline in admissions with AMI, our findings could suggest that care quality may be further improved with appropriate staffing and resources. Implicit in the study is the notion that routinely collected data in concert with standardised measures of care quality allow appropriate evaluation of care quality.

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Competing interests None declared.

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Suleman Aktaa http:// orcid. org/ 0000-0002-9854-481X Francois Schiele http:// orcid. org/ 0000-0003-4974-6551