Quality evaluation in delivering care of Acute Myocardial Infarction in Sancti-Spirítus, Cuba.

Aim: This study assesses the quality of care for patients admitted with diagnosis of acute myocardial infarction (AMI) in a secondary general hospital located in Sancti-Spiritus, Cuba, in a low/middle income scenario (LMIS), using the 2017 European Society of Cardiology (ESC) Quality of Care Working Group’s guideline. Methods: Observational retrospective of admitted AMI in Sancti-Spiritus Camilo Cienfuegos General Hospital. An implemented electronic registry was used for data collection. Each patient was considered for eligibility for each of the eight domains of quality. A set of quality measures was derived from ESC guidelines. Organizational information was assessed by administrative review and interview. Results: Between 2017 and 2019, 660 patients with AMI were admitted to Camilo Cienfuegos General Hospital, most of them (72%), presented with features of ST-elevation myocardial infarction (STEMI). Thrombolytic were administered to 268 (72.4%) patients, 43 (16%) of them in less than 30 minutes of diagnosis. Dual Antiplatelet Therapy was administered to 98.1% of patients on admission. However, only 163 (34.8%) were enrolled in secondary prevention programs. No information regarding Patient Experience, nor 30-day adjusted mortality, was collected. Secondary prevention was accomplished, around 90%. a chance to modify some performance which are not with this doubtful situation.


Introduction
Cardiac conditions are a major burden for health systems, worldwide [1][2] . And, low and middle-income settings (LMISs), especially in Latin America, are not strange to this reality 3 . One of the most common cardiac conditions, that require intensive care, is Acute Myocardial Infarction (AMI). Assessing the quality of care provided to patient with this condition may in uence their outcome 4 . Therefore it is imperative to achieve a high-quality cardiovascular disease care.
It may be economically challenging for these countries, in every level of attention 5 . In Cuba, patients have free of charge universal access to state-funded health care, with no private practices 6 . And the case of AMI is not different than the rest of the world.
In this country with 110000 km 2 with 11millions inhabitants, are three well established regional networks, leaded by a tertiary center, where coronary interventions (on hours) and cardiac surgery take place. Yet, AMI attention is mostly provided in general hospitals (leaders of the district network). These centers are responsible for short, middle and long-term assistance of most cases; they also stratify patients to be transferred to a tertiary center for interventionist procedures.
Also, no national clinical guideline or quality metrics consensus has been achieved or published, so far. Despite data regarding number of patients and treatment been collected by statistics system, o cial publication is still lacking 7 . Therefore is still a challenge for healthcare providers to compare results from different institutions.
To identify gaps in proper medical attention may lead to a better care. In "Camilo Cienfuegos" General Hospital, Sancti-Spirítus, Cuba, a digital system with continuous evaluation of care was established 8 , with several improvements after updating its protocols. Current research in this particular topic includes evaluation of performance measures, and creation of set of speci c quality markers for our settings. AIM This paper evaluates the quality of care for patients admitted with AMI in a secondary General Hospital in Sancti-Spirítus, Cuba. Structural data and internal protocols (Domain 1) will be further discussed. Compliance was reported as a percentage of the eligible population, and for Domain 5 (secondary prevention discharge treatment), compliance with prescribed treatment will be addressed only on patients who were discharged alive, as previously reported.

Methods
The study was conducted in full conformance with principles of Declaration of Helsinki, and approved by institutional board review. Neither patients, nor the public were involved in the design of this study.
Setting: This evaluation comes from patients between 2017 and 2019 of the at Camilo Cienfuegos General Hospital, Sancti-Spirítus; a Cuban medical center lacking on-site percutaneous coronary intervention (PCI), which also lacks the capacity to transfer its patients to a PCI-capable center.

Results
Demographics, risk factors and clinical presentation. Between 2017 and 2019, 660 patients with AMI presented to Coronary Intensive Care Unit of Camilo Cienfuegos general Hospital of Sancti-Spirítus (CUBA). The majority of patients, 475 (72%) admitted through the registry, presented with features of STEMI.Mean age was 66.6 years (± 12.1) and 443 (67.1%) were male. On admission 87 (13.2%) patients had a Killip classi cation of heart failure of 1.Clinical presentation and the prevalence of comorbidities and other risk factors for AMI are described in Table 2.
Evaluation of quality of care according domains (Table 3) -Domain 1: Centre organization and system level structures of AMI care. An internal protocol exists which asserts that every patient with STEMI and no contraindications to receive thrombolytic therapy, which symptoms started within 12 h should receive it. In this center (as in Cuba), thrombolysis with Recombinant Streptokinase (Heberkinase, CIGB, Cuba) is standard therapy in patients with STEMI. Its administration after 12 hour was not suggested, despite clinical characteristic of patients, due to increasing adverse effects without any clinical bene t. Patients can be assisted wherever they decide.
There are 23 clinics, and 4 general hospitals (among them, Camilo Cienfuegos General Hospital, is the leader of the Cardiology network), it serves a population of 466000 inhabitants around 6744 km2. Management of AMI can be done everywhere, however, diagnosis of NSTEMI, can be done only in the General Hospital, given that cardiac biomarkers are not available in any other medical facility. Though direct emergency phone number exists for patient with chest pain, emergency system can be activated by attending physicians or by patients themselves. According to symptoms, an electrocardiogram can be done, which is widely available in the district. Though not widely used there are several attempts to perform a trans-telephonic evaluation of electrocardiograms, to supervise treatment. If STEMI is diagnosed, patient's transfer to proper setting on time is attempted. However, as it usually takes more time than recommended (given low number of available properly equipped vehicles), most patients, arrived by personal means. (Air transfer is not available in Cuba).Since 2014, time of initial medical contact is routinely recorded for this network, and periodical audits for quality assessment are often performed.
-Domain 2: Reperfusion strategy: As stated, almost no patient was transferred to interventional setting (although patients with mechanical complications that require surgical treatment may be transferred). For NSTEMI, due to lack of effective procedure ofreperfusion, only conservative treatment is provided.
Globally, median time for rst medical contact was 120 min (Interquartile range: 120 min), and delay system for those who received thrombolytic was 60 min (Interquartile range: 60 min). As several patients with STEMI arrived more than 12 hours after symptoms initiation (17.7%), they usually, don't receive thrombolytic (available thrombolytic has no indication after this time).
.Those patients with indication, who arrived within the correct time frame, only 72.4% received thrombolytic therapy, and in barely 30 patients, electrical signs of reperfusion were observed(50% decrease in initial level of ST segment deviation, and no Q wave). This may condition other QI which will be discussed, such as rate of complications, and in-hospital mortality.
-Domain 3: In-hospital risk assessment. One of the advantages of the designed electronic AMI registry is that, parameters to calculate risk strati cation tools, such as TIMI, GRACE, and CRUSADE are of mandatory inclusion. Therefore, the system itself determines the score and issues a warning message if one of these parameters is missing.
Besides, in hand-written reception of patients, is mandatory to determine them. Mean GRACE score was 112 (IQ: 18.5), CRUSADE score was 37.2 (IQ: 10), and TIMI score was 1.7 (IQ: 1.1), which means that most patients admitted in this center had a low or intermediate risk of death of major complications, which does not truly re ect the reality of those parameters.
-Domain 4: In-hospital antithrombotic drugs. Tough antiplatelets drugs as aspirin and heparins, are available, the only P 2 Y 12 inhibitor offered in Cuba is Clopidogrel. Antiplatelet treatment is administered in most patients with AMI, reaching a very good 97% of dual antiplatelet treatment administration. This fraction increases until an excellent 99.7%, when patient which can't receive it due to several causes, were excluded.
Domain 5: Secondary prevention discharge treatment. Pharmacologic secondary prevention is widely administered. However, there is gap in the integration to secondary prevention programs. In our district, formally cardiac rehab (in a proper gym) is on offered in the gym of this hospital. This is why, strict inclusion criteria, need in order to offer this, to those who can bene t the most. However, suggestions and encouragement to initiate doctor recommended physical activity is carefully given to every patient and their relatives, before they are fully discharge.
Domain 6: Patient experience collected in a systematic way.. Despite being a QI, patients and relatives experience is not routinely gathered. However, the Cardiology service often receives tokens of appreciation from most patients and relatives, some of them in social media, radio, and TV reportages. Yet, from January 2021 on, this parameter will be recorded in the digital system. In Public Relations Bureau, there are only 5 complaints, all of them related to our crowded wait list for several exams that take place out of this center. Domain 7: Outcome measures. After an update of protocols in summer of 2016, a proper outpatient follow up outline was created to assist patients with AMI post hospital discharge. However, the coordination necessary to include data of this consultation and those responsible for entry them in the software, has not been implemented yet, for this reason statistics regarding 30 day after discharge are lacking. Efforts to update this issue are currently running, and perhaps, in a near future, this indicator could be formally presented. In-hospital mortality is quite high: 7.6%, which is a re ex of several gaps previously described.
Domain 8: Composite quality indicator. There is still an opportunity to increase the quality of treatment of those patients complicated with heart failure. Although a near-90%, is a good number, taking into account, that these patients didn't receive proper thrombolytic in time, will not have the chance of a coronary intervention in a near future, and their chances to have a proper cardiac rehab are very low, at least they should leave the facility, with an optimized medical management. So, improvement is mandatory in order to extent the 1-year surviving rate of these patients.

Discussion
This study provides a continuous evaluation of the 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 performed with registries from LMIS, giving priority, for those reports coming from a network where most patients are treated with thrombolytic instead of primary percutaneous coronary intervention (PPCI), as possible.
In Cuba, Delgado-Acosta et al 7 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. 85.7% of patients which received thrombolytic had a system delay time shorter than 60 min 13 .
Since the introduction of Estreptoquinase, no major change has been introduced to reperfusion STEMI in last 20 years, since coronary intervention is only available in 5 hospitals) in Cuba [14][15][16] . Beyond economic burden, there are external political situations that may impact on it. However, with same resources, several improvements stand out, when comparing with older reports from same centers.
Rest of pharmacological treatment is highly ful lled at top level centers in high income settings, except perhaps, for betablockers. However, results in Cuban studies, are for overall population.
In Trinidad and Tobago, in a similar setting 17 19 .
The ACCESS registry showed that treatment in Latin America is quite suboptimal, although high rate of reperfusion by any means were reported. Even though barriers to adopt guideline-recommended treatment are common, quality improvement initiatives may work everywhere, despite the place where they were designed 20 .
Finally, in Africa, results are even more heterogeneous. However, three patterns may be described. First, in northern African countries, attention seems to be dependent on patient's time for rst medical contact, as technologies and human resources appear to be available [21][22][23] . Second, in sub-Saharan countries attention appears 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 population [24][25][26] . And nally, in southern more-wealthy countries, attention seems to be as good as they can afford 27 .

Translating into practice
The absence of o cial document or consensus about describing quality of attention of AMI in Cuba, make reports heterogeneous, and hard to compare with 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.
In Cuba, 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 speci c guidelines 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.
First, this is an opportunity to continue improving local protocols, and second this will contribute to do proper comparisons with higher standards. Physicians from LMICs shouldn't consider quality metrics from high income countries as unachievable. If do so, continuous battle to improve 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 speci c analysis has been made. However, this methodology may be considered as start point for futures evaluation of quality metrics, or descriptions of them.

Conclusion
Determination of the quality metrics brought some improvement for the perception of the actual quality of care. Di culties to achieve high quality attention for these patients were common to those found in LMICs. Despite absence of coronary intervention, there is a chance to modify some performance measures, which are not directly related with this doubtful situation.