International comparison of mortality following AMI using hospital administrative data – the example of Germany and the USA

急性心肌梗死患者的生存至关重要地取决于在配备适当人员和设备的卫生保健机构进行及时和符合指南的护理。这就是为什么在国际比较中使用急性心肌梗死后死亡率作为质量指标，表明护理过程的有效性。根据经合组织卫生保健指标项目，与美国、法国、意大利或斯堪的纳维亚国家相比，德国的年龄和性别标准化急性心肌梗死后30天死亡率更高。这些差异可能表明了德国医疗体系的缺陷。例如，有一些证据表明，在德国，将有急性心肌梗死症状的患者分配到适当的卫生保健机构的管理并不理想。相比之下，德国医疗保健系统的特点是急症护理医院的密度相对较高，以及大量的左心导管设施。经合组织关于医院死亡率的质量指标是通过使用医院护理过程中产生的行政数据来计算的。然而，卫生保健制度、报销规则和其他与质量无关的因素的差异可能会损害这些指标的可比性。在国际比较中几乎没有考虑到一个可能与质量无关的因素。如果在不同国家以同样的方式将感兴趣的治疗病例作为住院患者记录在行政医院数据中，这是值得怀疑的。例如，在德国医院数据中被计算为住院患者的治疗时间较短的治疗事件（例如，由于到达后数小时内死亡），在其他卫生保健系统中可能被计算为急诊病例。因此，这些患者将在行政住院医院数据中缺失。这个问题可能特别影响急性心肌梗死的死亡率测量，因为这些患者在抵达医院后的头24小时内死亡的风险最高。该项目的目的是研究急性心肌梗死后医院死亡率的国际差异是否受到各自医疗保健系统中不同报销模式导致的捕获治疗病例差异的影响。由于数据可用性的原因，研究问题将以德国和美国为例进行分析。通过这种方式，该项目将首次考虑可能影响急性心肌梗死后死亡率国际可比性的重要因素。

Survival of patients who experience an acute myocardial infarction crucially depends on timely and guideline-compliant care at a health care facility with appropriate staffing and equipment. This is why mortality following acute myocardial infarction is used as a quality indicator in international comparisons, indicating the effectiveness of processes of care.According to the OECD Health Care Indicators Project the age-and-sex standardized 30-day mortality following acute myocardial infarction is higher in Germany when compared to the US, France, Italy or Scandinavian countries. These differences might indicate shortcomings in the German health care system. For instance, there is some evidence that the allocation of patients with symptoms of acute myocardial infarction to appropriate health care facilities is not optimally managed in Germany. In contrast, the German health care system is characterized by a comparatively high density of acute care hospitals, as well as a high number of left heart catheter facilities.The OECD quality indicators on hospital mortality are calculated by using administrative data which are generated during the processes of hospitals care. However, differences in health care systems, reimbursement rules and other non-quality-related factors might impair the comparability of such indicators. One possible non-quality-related factor has hardly been considered in international comparisons, yet. It is questionable, if treatment cases of interest are captured as inpatients in administrative hospital data in the same way in different countries. For instance, treatment episodes with a short duration of care (e.g. because of death within hours after arrival), which are counted as inpatients in German hospital data, might in other health care systems be counted as emergency ward cases. As a result, these patients would be missing in the administrative inpatient hospital data. This issue might, in particular, affect mortality measures for acute myocardial infarction because in those patients the risk of death is highest within the first 24 hours after arrival in hospital.The aim of this project is to study if international differences of hospital mortality following acute myocardial infarction are influenced by differences in capturing treatment cases due to varying modes of reimbursement in the respective health care systems. For the reason of data availability the research question will be analyzed for the case of Germany and the US. By this means the project will consider important factors which might impair the international comparability of mortality following acute myocardial infarction for the first time.