Article Text

Download PDFPDF

Global lessons for quality care: a tale of two countries
  1. Eugenia Y Lee1,
  2. Andrew T Yan1,2
  1. 1 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2 Division of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
  1. Correspondence to Dr Andrew T Yan, St. Michael’s Hospital, Division of Cardiology, Toronto M5B 1W8, Canada; yana{at}

Statistics from

With growing awareness of persistent care gaps and emerging evidence that improved care processes can influence patient outcomes,1–3 attention has been directed to evaluate quality of care to optimise the application of evidence-based therapies. Although international patterns of cardiovascular care have been the focus of previous research,4–9 comparisons have been hampered by disparities in data collection.10 Recently, both the American College of Cardiology and American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) have proposed respective sets of quality indicators (QI) for acute coronary syndrome (ACS).11 12Utilisation of these standardised measures appears to be the next logical step to investigate how different systems perform in ACS management, and to identify opportunities to improve the quality of cardiovascular care across the globe.

In this observational study involving two large national ACS databases from Israel (Acute Coronary Syndrome in Israel Survey, ACSIS) and UK (Myocardial Ischaemia National Audit Project, MINAP), Zusman et al compare the temporal changes in ACS care at three timepoints (2006, 2010 and 2013) using the ESC ACS QI, including composite QI scores calculated both by opportunity and all-or-none methodologies.13 Over time, both countries saw an increase in invasive coronary management, with a greater increase in the UK. There were significant improvements in reperfusion rates for ST-elevation myocardial infarction (STEMI) in the UK, and in the time to primary percutaneous coronary intervention (PCI). In comparison, the high rate of timely reperfusion for STEMI, and the time to primary PCI, remained relatively stable in Israel. The UK also noted a sharp increase in prescription of dual antiplatelet therapy on discharge (from 1.1% in 2006 to 93.5% in 2013), while the corresponding rate at baseline was high in Israel. With respect to the management of non-STEMI (NSTEMI), Israel consistently had a high proportion of timely angiography that surpassed the UK. Left ventricular functional assessment was performed more frequently in Israel, despite a significant temporal improvement in the UK.

Overall, between 2006 and 2013, both opportunity-based and all-or-none composite scores rose significantly in the UK, from 46.2% to 80.0% and 1.0% to 86.0%, respectively. On the other hand, in Israel, there was no change in opportunity-based composite score from 86.8% to 85.9%, and an increase in all-or-none score from 70.2% to 78.0%. Thirty-day and 1-year Global Registry of Acute Coronary Events (GRACE)-adjusted mortality rates declined similarly between Israel and UK, but overall a higher mortality was observed in the UK. In both countries, there was a stark inverse relationship between opportunity composite scores and crude 30-day mortality rates, at 2.0% (high attainment) vs 61.0% (low attainment) in Israel, and 2.9% vs 43.2% in the UK. This association remained significant after adjusting for GRACE risk score.

Some limitations of the study are inherent to its design, as discussed by the authors. The databases used were from two countries with their own methods of patient and hospital selection and data recording. Patients who declined treatment were deemed ineligible, and documented contraindications for specific treatments might vary between physicians, hospitals and countries. In addition, as with most studies involving existing large databases, missing data could introduce bias, and some pertinent QIs could not be examined in this study. The striking absolute reduction in 30-day mortality rates with higher QI attainment was likely partly attributable to residual confounding, rather than better treatment per se.

What can we learn from the study by Zusman et al? First, on a national scale, it offers both involved countries the valuable opportunity to recognise existing care gaps by reviewing the treatment and outcome data, in relation to the evolving characteristics of each healthcare system (manuscript appendix). As an example, the authors pointed out that the significant improvement in both opportunity-based and all-or-none composite scores in the UK coincided with an increased prescription of P2Y12 inhibitors after clopidogrel was approved by the National Health Service in 2007. There were also significant improvements in reperfusion QIs for STEMI, reflecting the establishment of streamlined treatment protocols targeted to shorten door-to-needle time for fibrinolysis and time-to-arterial access for primary PCI. In contrast, the lower rates of timely angiography in NSTEMI and left ventricular functional assessment might reflect less protocolised management of relatively less acute NSTEMIs and postrevascularisation care, as these patients are often managed by less specialised teams and not immediately referred to tertiary cardiac centres. This might also explain why Israel, with a higher density of PCI centres, achieved better QIs in these areas. These findings support more widespread implementation of effective care pathways in the management of NSTEMI.

Second, on a global scale, this study highlights the prospects of identifying potential solutions to bridge care gaps, by exploring standardised QIs across different healthcare settings. In addition to adherence to the ACC/AHA and ESC QI guidelines,11 12standardised data collection is crucial to enhance the comparability of international databases,14 thereby facilitating better assessment of the unique strengths and weaknesses of different healthcare systems. Changes, both at a micro level (individual practitioners and hospitals) and a macro level (regional and national), can be challenging and costly. Observational comparative studies may reveal the most promising healthcare interventions and policies that warrant more rigorous evaluation using randomised controlled trials15 which may not always be feasible in terms of cost and adequate sample size table 1.

Table 1

Observational comparisons of international healthcare systems

The observational study by Zusman et al illustrates the potential of availing standardised ACS QIs to analyse the impact of system changes over time and across countries. Future studies of other acute and chronic cardiovascular diseases, both in-hospital and postdischarge, may afford useful insight and complement randomised trials of healthcare delivery, in a concerted effort to reduce the global cardiovascular disease burden in a most cost-effective manner.



  • Contributors Drafting of the manuscript: EYL, ATY. Critical revision of the manuscript for important intellectual content: EYL, ATY.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • Patient consent for publication Not required.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles