Low Quality of Care for Acute Myocardial Infarction Observed in Young Adults

Louise Pilote MD

Factors such as health care systems and patient-level factors, including biological sex and social determinants of health, may play a role in the quality of care of young adults with acute myocardial infarction (AMI).

Led by Louise Pilote MD, Centre for Outcomes Research and Evaluation, McGill University Health Centre Research Institute, a team of investigators examined the differences in quality of in-hospital and postacute care in young adults with acute myocardial infarction between the US and Canada, as well as the effect of female sex and adverse SDOH on quality of care.

Consequently, the group observed low in-hospital and post-AMI care showed predominantly in young adults treated in the US, in comparison to Canada, regardless of the individual’s sex.

What were the methods?

Data in the study were collected from 2 large, multicenter cohorts, including the “Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients” and the “Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond-Premature Acute Coronary Syndrome.”

It consisted of adults aged ≤55 years old (n = 4048) receiving in-hospital and outpatient care for AMI at 127 centers in the United States and Canada. Data were collected from August 2008 - April 2013.

At baseline, patients characteristics consisted of data on age, country, self-reported race, and type of health care system. From medical records, investigators abstracted self-reported patient sex. Then, social determinants of health (SDOH) were reported, with determinants including identity, roles, relations, and institutionalized gender.

Investigators considered the main outcome an opportunity-based quality-of-care score (QCS). A score was determined by the total number of quality indicators of care received divided by the total number of quality indicators for which the patient was eligible.

The lowest tertile of QCS was considered the lowest quality of care. Analysis of data occurred between July 2019 - March 2021.

Findings

In the overall analysis, a total of 4048 individuals were enrolled, while 3004 individuals (74.2%) were from the United States. Notably, the median age was 49 years, with 57.9% women (n = 2345) and 22.4% (n = 906) individuals were Black.

Particularly, in both countries, women had a greater burden of cardiac risk factor profile, as well as a greater burden of detrimental SDOH, such as low socioeconomic status (42.9% versus 24.0%) and unemployment (42.4% versus 24.3%).

In the patients who had in-hospital ACS available (n = 3416), the data show 1061 (31.1%) received a low QCS. The group was composed of more women than men (725 of 2007, 36.1% versus 336 of 1409, 23.8%; P < .001) and more patients treated in the US versus Canada (962 of 2646, 36.4% versus 99 of 770, 12.9%; P < .001).

Furthermore, the low quality of the post-AMI care group (748 of 2938; 25.5%) was similarly observed for both sexes. However, participants showed worse outcomes in the US compared to Canada (678 of 2346, 28.9% versus 70 of 592, 11.8%).

During adjusted analyses, investigators observed female sex was not associated with low QCS for in-hospital (OR, 1.05; 95% CI, 0.87 - 1.28) and post-AMI care (OR, 1.07; 95% CI, 0.88 - 1.30).

Then, regardless of sex, treatment in the US was associated with low in-hospital (OR, 2.93; 95% CI, 2.16 - 3.99) and post-AMI (OR, 2.67; 95% CI, 1.97 - 3.63). Low quality of in-hospital care had associations with higher 1-year cardiac readmissions rate (234 of 962, 24.3%).

Lastly, investigators noted only employment as a measure of SDOH was associated with higher quality of in-hospital care (OR, 0.72; 95% CI, 0.59 - 0.88).

What were the takeaways? 

“Finally, the fact that the post-AMI QCS was poor in both Canada and the US suggests that increased efforts should be geared toward promoting cardiovascular secondary prevention in young adults with AMI,” investigators wrote. “The importance of gendered SDOH has been at the forefront of the COVID-19 pandemic, and attention to these factors should span all aspects of health care.”

The study, “Variations in Quality of Care by Sex and Social Determinants of Health Among Younger Adults With Acute Myocardial Infarction in the US and Canada,” was published online in JAMA Network Open.