This study provides a continuous evaluation of quality of AMI care in a patient centered outcome from in LMIS, a non-interventional center, with free of charge and universal access to state funded-health care system. Comparison will be made with registries from LMIS, giving priority, for those reports coming from a network where most patients are treated with thrombolytic instead primary percutaneous coronary intervention, as possible.
Delgado-Acosta et al7. applied a survey from National Center of Epidemiology, in Cienfuegos (110 km western of this center), in one month in 2013. They described a thrombolytic rate application of 72%, (16/22), which may be considered very high. Prescription of betablockers in admission, were not as high, just 63.7%. No data about ACE-I was recorded, and system delay was considerably lower compared with previous report in 2011. Despite these gaps, more than 92% of patients perceived the attention as good or better.
By the other hand, Lóriga-García et al.’s registry of AMI, in Pinar del Rio (most western district, 441 northwestern of this center), gives another result11. Of 644 patients admitted during 2011 and 2012 with STEMI, only 55,2% received thrombolytic, 96.4% aspirin, 49.3% atenolol, and 32.9% ACE-I, lower frequency than Delgado Acosta et al for all drugs. And, 50 (7.7%) patients died during hospital admission.
In General Hospital Camilo Cienfuegos of Sancti-Spirítus, in 251 patients with STEMI, during 2014–2016, thrombolytic were administered to 57%; betablockers, to 42.8%; ACE-I, to 95.2%; and statins to 94.82%. System delay was 112.7 ± 77.8 min and time from symptoms onset to needle was 354.5 ± 266.4 min in those who received thrombolytic. Mortality was very high, even for LMISs: 13.5%12.
Finally, there are the results of the REgistro CUbano de Infarto Agudo de Miocardio, where data of patients included in this report, are reported on it too. In order to perform an accurate analysis, common patients were excluded from this comparison. So, excluding data from General Hospital Camilo Cienfuegos, there were 638 patients remaining, of them 550 with STEMI, with a thrombolytic rate of 54.7% (301/550); Aspirin, Clopidogrel, Betablockers, ACE-I, and statin administration rate at admission of 97.2%, 99.1%, 58%, 79.2%, and 97.2% respectively. Mortality was 9.6%, system-to-needle time was 49.9 ± 47.1 min; and 85.7% of patients which received thrombolytic system delay time was shorter than 60 min13.
Since introduction of Estreptoquinase no major change has been produced to reperfuse STEMI in last 20 years (coronary intervention is only available in 5 hospitals in Cuba)14–16. Beyond economic burden, there are external political situations that may impact on it. However, with same resources, several improvements are presented, when comparing with older reports from the same center.
Rest of pharmacological treatment is highly fulfilled at top level centers in Europe and United States, except perhaps, for betablockers. However, result shown in Cuban studies, are for overall population. And guidelines are clear: “Oral treatment with beta-blockers is indicated in patients with heart failure < 40% unless contraindicated (Class I, Level of Evidence A)”9. When only patients with heart failure with blood pressure over 90 mmHg in General Hospital Camilo Cienfuegos are included, this rate, in first 24 hours increases up to 93.1% (54/58), but decreases until 85% (45/53) in patients discharged alive. This analysis was impossible to make for another published papers due to lack of necessary data.
In our area, in Trinidad and Tobago, in a similar setting17, 70% of women and 69.2% of men who received thrombolytic (70.5% of overall population with STEMI), received it within first hour after first medical contact. Just 30.3% of patients received betablockers within first day of admission, but this, increased up to 76.5% at discharge. Rest of drugs, such as, aspirin, Clopidogrel, ACE-I, and statins were administered at discharge to 79.8%, 79%, 70.6%, and 75.3%, respectively.
In the Caribbean too, in Barbados, results like found in this report, were only achievable in male, in a specific group of age. Women were undertreated, as well as elderly, at their admission, as well with their discharge treatment18.
Data of the RENASCA, from 177 hospitals in Mexico during March 1, 2014 to December 2017, shows that 71.39% of patients, after implantation of ‘‘Infarction Code’’, received reperfusion of any kind, 40.1% with fibrinolytic therapy and 31.3% with Primary PCI. Commonly used drugs couldn’t reach 90% of administration, and most of them were reduced during in-hospital stay19.
The ACCESS registry showed that treatment in Latin America is quite suboptimal, although high rate of reperfusion by any means were reported. However, as barriers to adopt a guideline recommended treatment are common as well, quality improvement initiatives may work as well everywhere, despite the place where they were designed20.
In Africa, results are even more heterogeneous. However, three patterns may be described. First, in northern, attention seems to be dependent on patient’s time for first medical contact, as technologies and human resources appear to be available21–23. Second, in sub-Saharan countries, attention looks to be really poor, based on absence of reperfusion treatment for most of patients, despite their delay time to seek for attention: few patients received thrombolytic, and a huge variation of system delay was observed, Betablockers and ACE-I administration didn’t reach a quarter of available population24–26. And finally, in southern more-wealthy countries, attention seems to be the best of the continent, as stated by their higher fraction of patients with reperfusion, and secondary prevention treatments27.
Translating into practice
The absence of official document or consensus, about quality of attention of AMI in Cuba, make reports about it, heterogeneous, and hard to compare each other. However, some QI are universal despite conditions of network. Efforts from physicians to increase value of care should be directed, precisely, to those universal ones: rate of reperfusion, in-hospital and discharge treatment, and patient experience.
However, basis of networks is known by policy makers. And, as economic conditions are unlikely to change, it seems that the cheapest and short-term most effective way to increase quality of attention is by monitoring its markers.
Generate specific guide lines according to the real possibilities in the local setting where they are going to be applied is a right step but, even when some resources may be unavailable, there is no reason for excluding them. One must consider when and where those technologies can be introduced. In first place this is an opportunity to continue improving local protocols, and second this will contribute to do proper comparisons with higher standards, thus acute cardiac care physicians from LMISs most not consider the quality metrics from high income countries as unachievable, because then the continuous battle for improving care will be lost before it’s started.
Limitations of the study
This study was made in a single center of Middle-Region in Cuba, an underdeveloped country with free of charge universal access to state funded-health care, which is not common in this kind of settings. Also, lack of coronary intervention, made its results hard to generalize for stings where this is present. Finally, this registry can’t be considered as representative for the national population until specific analysis have made.
However, its methodology may be considered as start point for futures evaluation of quality metrics, or descriptions of them.