A comparison of in-hospital acute myocardial infarction management between Portugal and the United States: 2000-2010.

OBJECTIVE: To compare healthcare in acute myocardial infarction (AMI) treatment between contrasting health systems using comparable representative data from Europe and USA. DESIGN: Repeated cross-sectional retrospective cohort study. SETTING: Acute care hospitals in Portugal and USA during 2000-2010. PARTICIPANTS: Adults discharged with AMI. INTERVENTIONS: Coronary revascularizations procedures (percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery). MAIN OUTCOME MEASURES: In-hospital mortality and length of stay. RESULTS: We identified 1 566 601 AMI hospitalizations. Relative to the USA, more hospitalizations in Portugal presented with elevated ST-segment, and fewer had documented comorbidities. Age-sex-adjusted AMI hospitalization rates decreased in USA but increased in Portugal. Crude procedure rates were generally lower in Portugal (PCI: 44% vs. 47%; CABG: 2% vs. 9%, 2010) but only CABG rates differed significantly after standardization. PCI use increased annually in both countries but CABG decreased only in the USA (USA: 0.95 [0.94, 0.95], Portugal: 1.04 [1.02, 1.07], odds ratios). Both countries observed annual decreases in risk-adjusted mortality (USA: 0.97 [0.965, 0.969]; Portugal: 0.99 [0.979, 0.991], hazard ratios). While between-hospital variability in procedure use was larger in USA, the risk of dying in a high relative to a low mortality hospital (hospitals in percentiles 95 and 5) was 2.65 in Portugal when in USA was only 1.03. CONCLUSIONS: Although in-hospital mortality due to an AMI improved in both countries, patient management in USA seems more effective and alarming disparities in quality of care across hospitals are more likely to exist in Portugal.

Understanding the large heterogeneity in hospital readmissions and mortality for acute myocardial infarction.

This study aims to investigate the variation in two acute myocardial infarction (AMI) outcomes across public hospitals in Portugal. In-hospital mortality and 30-day unplanned readmissions were studied using two distinct AMI cohorts of adults discharged from all acute care public hospital centers in Portugal from 2012-2015. Hierarchical generalized linear models were used to assess the association between patient and hospital characteristics and hospital variability in the two outcomes. Our findings indicate that hospitals are not performing homogeneously-the risk of adverse events tends to be consistently larger in some hospitals and consistently lower in other hospitals. While patient characteristics accounted for a larger share of the explained between-hospital variance, hospital characteristics explain an additional 8% and 10% of hospital heterogeneity in the mortality and the readmission cohorts respectively. Admissions to hospitals with low AMI caseloads or located in Alentejo/Algarve and Lisbon had a higher risk of mortality. Discharges from larger-sized hospitals were associated with increased risk of readmissions. Future health policies should incorporate these findings in order to incentivize more consistent health care outcomes across hospitals. Further investigation addressing geographical disparities, hospital caseload and practices is needed to direct actions of improvement to specific hospitals.

Estimation of populational 24-h urinary sodium and potassium excretion from spot urine samples: evaluation of four formulas in a large national representative population.

OBJECTIVE: The aim of this study was to assess the validity of the estimation of 24-h urinary sodium (UNa) and urinary potassium (UK) excretion obtained through four formulae based on occasional urine samples. DESIGN AND METHODS: We analysed 2399 individuals (51% females) aged 18 to 96 years representatives of Portuguese population. Tanaka, Kawasaki, INTERSALT and NHANES formulae were used to predict 24-h UNa and UK excretions from spot morning urinary samples (OUrS). We compared it with validated real 24-h urine samples (VUrS) (24-h UNa: 4052 ±â€Š1432 mg/day, 24-h UK = 2928 ±â€Š1004 mg/day). We compared observed vs. estimated measurements by examining bias (observed minus predicted UNa and UK), the correlation and intraclass correlation (ICC) coefficients between measurements, and Bland-Altman plots. We analysed the differences between observed and estimated Na and K excretion across subgroups defined by quintiles of observed Na and K excretion and subgroups defined hypertension status and control. The area under the ROC curve was used to assess the discriminatory capacity of formulas between high-intake salt individuals from low-intake individuals, taking the arbitrary values 3000 and 3900 mg/day for, respectively, Na and K intake. RESULTS: Formulas produced significant mean bias for UNa: Kawasaki-1277, INTERSALT-569, NHANES-116 and for UK Tanaka-754, Kawasaki-95 mg/day. Correlation coefficients were less than 0.360 and ICC coefficients were all less than 0.458 for both UNa and UK estimations. Bias varied across quintiles with overestimation of UNa at lower quintiles (by 29-105%) and underestimation at higher quintile (by 7-37%) regardless of formula. The Bland-Altman plots indicated a high dispersion of the estimates biases regardless of the formulae and normotension/hypertension condition particularly at higher levels. All formulas exhibited an area under the receiver operating characteristic curve below 0.67 both in normotensive individuals and hypertensive individuals. CONCLUSION: We found a poor agreement between estimated and observed measurements of UNa and UK in our large population. All these formulas incur in over- or underestimations of UNa and UK excretion that may be unreliable for clinical evaluation of individual's and mean population daily UNa and UK excretion.

The Atlantic divide in coronary heart disease: Epidemiology and patient care in the US and Portugal.

INTRODUCTION AND OBJECTIVES: We aimed to compare access to new health technologies to treat coronary heart disease (CHD) in the health systems of Portugal and the US, characterizing the needs of the populations and the resources available. METHODS: We reviewed data for 2000 and 2010 on epidemiologic profiles of CHD and on health care available to patients. Thirty health technologies (16 medical devices and 14 drugs) introduced during the period 1980-2015 were identified by interventional cardiologists. Approval and marketing dates were compared between countries. RESULTS: Relative to the US, Portugal has lower risk profiles and less than half the hospitalizations per capita, but fewer centers per capita provide catheterization and cardiothoracic surgery services. More than 70% of drugs were available sooner in the US, whereas 12 out of 16 medical devices were approved earlier in Portugal. Nevertheless, at least five of these devices were adopted first or diffused faster in the US. Mortality due to CHD and myocardial infarction (MI) was lower in Portugal (CHD: 72.8 vs. 168 and MI: 48.7 vs. 54.1 in Portugal and the US, respectively; age- and gender-adjusted deaths per 100000 population, 2010); but only CHD deaths exhibited a statistically significant difference between the countries. CONCLUSIONS: Differences in regulatory mechanisms and price regulations have a significant impact on the types of health technologies available in the two countries. However, other factors may influence their adoption and diffusion, and this appears to have a greater impact on mortality, due to acute conditions.

An intrauterine pressure generator for educational simulation of labour and delivery.

Simulation provides a risk free and controllable environment for training of healthcare providers. The limited realism of available simulators and training programs impedes immersive training in obstetric emergencies. In developed countries, intrapartum monitoring in high-risk cases involves continuous evaluation of foetal heart rate and uterine contractions signals. We present an essential component of a high-fidelity simulator for normal and critical situations in labour and delivery, namely an intrauterine pressure generator. The signal model behind the generator consists of a truncated Gaussian curve with the programmable features: amplitude, frequency, duration, and resting tone. Through analysis of 44h of physiological data, we demonstrate that the natural variability of these features and of the baseline pressure can be approximated by deterministic trends and stationary stochastic processes. Signal parameters can be controlled by simulation instructors, scripts, or other models to reflect different patients, pathologies, and evolving clinical situations. Twelve 40-min tracings reflecting three different patients in labour were presented to three clinical experts, who attributed similar realism scores to simulated and to real tracings.