Disparities Abound in Chinese Heart Attack Care

Continued quality improvement in acute MI may be possible in the U.S. given lessons learned from another country with major geographic and other disparities in acute MI care and mortality: China.

Rural hospitals and those with fewer resources showed opportunities for improved care in China, according to findings from two registries now published online in JAMA Network Open.

“Many researchers believe that we have solved the STEMI [ST-segment elevation MI] problem, but the improvement in mortality has plateaued and we have made very little progress in reperfusion times for patients transferred from a non-PCI [percutaneous coronary intervention] center or outcomes for those with out-of-hospital cardiac arrest or cardiogenic shock,” wrote Timothy Henry, MD, of The Christ Hospital, Cincinnati, and James Jollis, MD, of Duke University School of Medicine in Durham, North Carolina, in an accompanying commentary.

The two studies suggest the U.S. still has a lead over China in acute MI care — but will it be able to keep it? The U.S. has been hurt by a fracturing of the national acute MI registry into multiple competing registries, which poses challenges to regional collaboration and quality improvement, Henry and Jollis suggested.

Meanwhile, they wrote, “China has rapidly embraced the best quality improvement models of the U.S.” and is even poised to surpass the collaborative systems of care in the States.

Geographic Variation

China saw persistent regional variations in the use of reperfusion and guideline-recommended medical therapy, one group reported from registry data.

Despite the launch of national health care reform in 2009, hospitals in the country’s center were 17% less likely to provide MI treatments to eligible patients than centers in western areas in 2011-2015 (adjusted OR 0.83, 95% CI 0.76-0.91), according to Yingling Zhou, MD, PhD, of Guangdong Provincial People’s Hospital.

“In the present study, we observed significant differences in the use of guideline-recommended treatments across China, with hospitals in the Western region having the best performance, particularly for clopidogrel [Plavix], ACEIs/ARBs [angiotensin-converting enzyme inhibitors/angiotensin receptor blockers], and statins,” the research group said.

Zhou’s team noted that the western region is the least economically developed region in China and has been subject to special government investment in public health starting in the year 2000.

Eastern China also improved processes of MI care from 2001-2006 to 2011-2015.

Across the board, use of guideline-recommended treatments increased from 2001-2006 to 2011-2015, and there was some improvement in care variation, study authors said.

“However, care delivery remains suboptimal and disparities remained across China when compared with that in the United States and United Kingdom where reperfusion therapy, β-blockers, and ACEIs/ARBs are used at much higher rates. Additional measures should be taken to further narrow regional care disparity across the country,” Zhou and colleagues urged.

Their cross-sectional study was based on the Patient-Centered Evaluative Assessment of Cardiac Events–Retrospective AMI project. A random sampling yielded 27,046 patients hospitalized for acute MI at 153 hospitals across China.

The country was divided into three geographic regions: eastern, central, and western. There were marked regional variations

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New Bill Aims to End Racial Disparities in Amputations

On Friday, Congressman Donald M. Payne Jr., a Democrat from New Jersey, introduced a sweeping bill to reduce unnecessary amputations and address racial disparities that were the subject of a ProPublica story investigating why Black Americans were three times more likely to undergo diabetic amputations than others. The Amputation Reduction and Compassion Act of 2020 was introduced five months after the ProPublica investigation showed how government and hospital policies obstruct equitable care for at-risk patients.

The bill proposes major reforms that seek to address policy gaps explored in the article. Today, about half of patients with peripheral artery disease — a condition in which clogged arteries limit the flow of blood — are asymptomatic, and primary care physicians are not always reimbursed for screening. But catching and treating the disease, which is often caused by diabetes, is critical to preventing unnecessary amputations. The bill seeks to ensure that all at-risk patients can obtain a screening at no cost. It requires that Medicare and Medicaid cover the tests, as well as private insurers.

The ProPublica article also focused on how patients often undergo diabetic amputations without arterial testing beforehand. That testing, either with duplex scans or angiography, can show where blood flow is blocked and can indicate whether an intervention can restore blood flow before surgeons resort to amputation. But nationwide, more than 30% of patients don’t get arterial testing before amputation. One doctor likened this to removing a woman’s breast after she felt a lump, without first ordering a mammogram. The bill proposes that Medicare only pay for an amputation caused by vascular disease or diabetes if the patient has received arterial testing within three months of the surgery.

“The greatest problem with peripheral artery disease is that it can go undetected for years and lead to limb amputations that could be avoided with early detection,” said Congressman Payne, who launched the bi-partisan Congressional Peripheral Artery Disease Caucus with Congressman Gus Bilirakis, a Republican from Florida, in 2019. Payne said the bill provides resources to screen-at risk patients and educate doctors, which in turn will reduce racial disparities in amputations. Five co-sponsors, all Democrats, have signed onto the bill, including Congressman Bobby Rush, from Illinois, Congressman Ruben Gallego, from Arizona, Congressman Bennie Thompson, from Mississippi, Congresswoman Eddie Bernice Johnson, from Texas, and Congresswoman Lisa Blunt Rochester, from Delaware.

Rush and Gallego joined the effort after reading the ProPublica article on the work of Dr. Fakorede, a cardiologist who is reducing amputation rates in Mississippi and advocating nationally for safeguards for patients. “I was shocked and disturbed by the investigative article published earlier this year in ProPublica,” Rush said by email. “The article succinctly highlighted the financial incentives to amputate diabetic patients’ limbs rather than invest earlier in preventive screenings, particularly for poor Black and Brown patients who are disproportionately and discriminatorily overlooked until it is too late.”

After reading the ProPublica article, Gallego was also galvanized to craft legislation to reduce unnecessary amputations. His office reached out to medical experts,

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