Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Twenty-Year Trends in Outcomes for Older Adults With Acute Myocardial Infarction in the United States

Twenty-Year Trends in Outcomes for Older Adults With Acute Myocardial Infarction in the United... Key Points Question What are the patterns of IMPORTANCE Medicare and other organizations have focused on improving quality of care for hospitalizations, treatments, and patients with acute myocardial infarction (AMI) over the last 2 decades. However, there is no outcomes for older patients with acute comprehensive perspective on the evolution of outcomes for AMI during that period, and it is myocardial infarction (AMI) over a unknown whether temporal changes varied by patient subgroup, hospital, or county. recent 20-year period in the United States? OBJECTIVE To provide a comprehensive evaluation of national trends in inpatient outcomes and Findings In this cohort study of data costs of AMI during this period. from more than 4.3 million Medicare fee-for-service beneficiaries aged 65 DESIGN, SETTING, AND PARTICIPANTS This cohort study included analysis of data from a sample years and older discharged with AMI, of 4 367 485 Medicare fee-for-service beneficiaries aged 65 years or older from January 1, 1995, declines were found in AMI through December 31, 2014, across 5680 hospitals in the United States. Analyses were conducted hospitalizations (914 to 566 per from January 15 to June 5, 2018. 100 000 beneficiary-years), 30-day mortality (20.0% to 12.4%), and 30-day MAIN OUTCOMES AND MEASURES Thirty-day all-cause mortality at the patient, hospital, and all-cause readmissions (21.0% to 15.3%). county levels. Additional outcomes included 30-day all-cause readmissions; 1-year recurrent AMI; There were increases in the 2014 in-hospital mortality; length of hospital stay; 2014 Consumer Price Index–adjusted median Medicare Consumer Price Index–adjusted median inpatient payment per AMI discharge; and rates of catheterization, percutaneous coronary Medicare inpatient payment per AMI intervention, and coronary artery bypass graft surgery. discharge ($9282 to $11 031) and 30-day inpatient catheterization (44.2% RESULTS The cohort included 4 367 485 Medicare fee-for-service patients aged 65 years or older to 59.9%). hospitalized for AMI during the study period. Between 1995 and 2014, the mean (SD) age of patients increased from 76.9 (7.2) to 78.2 (8.7) years, the percentage of female patients declined from 49.5% Meaning The last 2 decades were to 46.1%, the percentage of white patients declined from 91.0% to 86.2%, and the percentage of marked by large changes in the number black patients increased from 5.9% to 8.0%. There were declines in AMI hospitalizations (914 to 566 of people hospitalized with AMI—and per 100 000 beneficiary-years); 30-day mortality (20.0% to 12.4%; difference, 7.6 percentage marked improvements in the short- and points; 95% CI, 7.3-7.8 percentage points); 30-day all-cause readmissions (21.0% to 15.3%; long-term outcomes along with difference, 5.7 percentage points; 95% CI, 5.4-6.0 percentage points); and 1-year recurrent AMI (7.1% increases in cost per hospitalization and to 5.1%; difference, 2.0 percentage points; 95% CI, 1.8-2.2 percentage points). There were increases number of procedures. in the 2014 Consumer Price Index–adjusted median (interquartile range) Medicare inpatient payment per AMI discharge ($9282 [$6969-$12 173] to $11 031 [$8099-$16 861]); 30-day inpatient Supplemental content catheterization (44.2% to 59.9%; difference, 15.7 percentage points; 95% CI, 15.4-16.0 percentage points); and inpatient percutaneous coronary intervention (18.8% to 43.3%; difference, 24.5 Author affiliations and article information are listed at the end of this article. percentage points; 95% CI, 24.2-24.7 percentage points). Coronary artery bypass graft surgery rates decreased from 14.4% to 10.2% (difference, 4.2 percentage points; 95% CI, 3.9-4.3 percentage points). There was heterogeneity by hospital and county in the mortality changes over time. (continued) Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 1/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults Abstract (continued) CONCLUSIONS AND RELEVANCE This study shows marked improvements in short-term mortality and readmissions, with an increase in in-hospital procedures and payments, for the increasingly smaller number of Medicare beneficiaries with AMI. JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 Introduction Acute myocardial infarction (AMI) is undergoing a transition. For the last 2 decades, Medicare has focused on improving quality of care for patients with AMI, starting with the Cooperative 1 2-11 Cardiovascular Project. Studies have reported improvements in quality and reductions in AMI hospitalizations and risk of short-term mortality during various periods within this time span. However, there is no comprehensive perspective on the evolution of outcomes for AMI across the last 2 decades, including cost, length of stay, treatments, and rehospitalizations. It is also unknown whether changes over time varied by patient subgroup, hospital, or county. Accordingly, we sought to provide a comprehensive view of treatments and outcomes for patients with AMI over a recent 20-year period in the United States. We used Medicare fee-for- service data to characterize changes in 30-day mortality at the patient, hospital, and county levels and examined trends in the rates of 30-day all-cause readmissions and 1-year recurrent AMI. Finally, we assessed the changes in 3 common in-hospital AMI-specific surgical procedures (catheterization, percutaneous coronary intervention [PCI], and coronary artery bypass graft [CABG]) within 30 days from the date of an AMI index admission. Methods Study Population This was a cohort study. The Yale University institutional review board reviewed the study protocol and granted a waiver of informed consent for the use of this deidentified database. We used Medicare enrollment data from the Centers for Medicare & Medicaid Services (CMS) to identify individuals in the Medicare population aged 65 years or older enrolled in the fee-for-service program for at least 1 month between January 1995 and December 2014. We then linked the fee-for-service population data to the Medicare inpatient claims data to identify patients discharged from an acute- care nonfederal hospital from January 1, 1995, through December 31, 2014, with a principal discharge diagnosis of AMI as determined using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes 410.xx (with the exception of 410.x2). The linked data include patient demographic characteristics, principal and secondary diagnosis codes, and procedure codes. If a patient had more than 1 AMI hospitalization during the entire study period, we selected the first AMI hospitalization, the index admission, and excluded subsequent hospitalizations (n = 548 546). To ensure that patients did not have an AMI in 1995, we also excluded patients who were hospitalized with an AMI in 1994. The study followed the guidelines for cohort studies described in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for observational studies. Patient, Hospital, and County Characteristics Patient demographic information included age, sex, race (white, black, or other), and dual eligibility status for Medicaid and Medicare. We identified clinical comorbidities that represent additional coexisting illnesses with the method used by CMS to profile hospital 30-day mortality measures for 13,14 AMI. We determined comorbidities for the index hospitalization from secondary diagnosis codes as well as the principal and secondary diagnosis codes from all hospitalizations for up to 12 months before the index hospitalization. Because the maximum number of diagnosis codes in Medicare data JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 2/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults increased from 10 to 25 in 2011, we restricted the 2011 to 2014 data to the first 10 diagnosis codes to align with the 1995 to 2010 data. Hospital characteristics included hospital structure, patient population, and in-hospital care information. Information about hospital structure was obtained from the 2013 American Hospital Association Surveys, including ownership status, geographic location (urban vs rural), teaching status, Medicare and Medicaid volume, nurse-to-patient ratio, safety-net hospital status (yes vs no), and hospital capacity to provide CABG surgery. Information about in-hospital care included rates of AMI transfer in and transfer out, rates of in-hospital PCI and CABG procedures, and discharge disposition (rates of discharge to home for self-care, to home with home health care, and to skilled nursing home facilities). Information about the patient population and in-hospital care was drawn from CMS inpatient all-cause claims data. County characteristics included Consumer Price Index–adjusted median income, proportion of people aged 65 years or older, people below the national poverty level (eTable in the Supplement), and a binary variable to indicate whether a county belongs to a health priority area as defined in one of our previous studies. The priority area has had a persistently high all-cause mortality over time. Outcomes Our primary outcome was 30-day all-cause mortality, defined as death within 30 days from the date of admission for an index AMI hospitalization, regardless of cause. We evaluated mortality at the individual patient level, the hospital level, and the county level. Additional outcomes included (1) 30-day all-cause readmissions, defined as an unplanned rehospitalization within 30 days from the index AMI discharge among individuals who survived to discharge; (2) 1-year recurrent AMI, defined as a recurrent AMI hospitalization within 1 year from the index AMI discharge; (3) in-hospital mortality, defined as all-cause death during the index AMI hospitalization; and (4) length of hospital stay. Additionally, we examined the change in AMI hospitalizations per 100 000 beneficiary-years by using the total number of AMI hospitalizations for each year divided by the corresponding number of beneficiary-years of fee-for-service enrollments, based on the total months that people were in fee-for-service. We also assessed the Consumer Price Index–adjusted Medicare payment for an index AMI hospitalization, referring to the year 2014. For each year, we also measured the rates of individuals who received catheterization, PCI, and CABG, defined as a patient who underwent a targeted procedure in an acute-care hospital within 30 days of an index AMI admission among admitted patients with AMI in each year. Statistical Analysis We conducted analyses at the patient, hospital, and county levels. At the patient level, we assessed changes in patient characteristics over the study period via a logistic regression to model each individual characteristic as a function of a year parameterized as a count, ranging from 0 to 19, corresponding to years 1995 to 2014. To assess the changes in individual patients’ risk of 30-day deaths over time, we used the 2014 data (the end of the study period data) to fit a mixed model with hospital random effects and a logit link function to model mortality as a function of patient age, sex, and comorbidities. Using the estimated parameters, we calculated an expected probability of 30-day death for each patient hospitalized in 1995 to 2013. We then calculated a standardized mortality ratio as the observed 30-day deaths divided by the expected deaths for each year of 1995 to 2013. For a given year, a ratio greater than 1.0 indicates that the risk of death for such a patient is expected to be lower if that patient were hospitalized in 2014. We conducted a nonparametric bootstrapping with replacement to construct a 95% confidence interval for this standardized mortality ratio. To assess potential inequalities in the changes in patients’ risk of death, we compared the standardized mortality ratios across age, sex, race, and dual-eligible subgroups. At the hospital level, we assessed hospital performance by calculating a 30-day risk- standardized mortality rate for each hospital and each year based on the CMS method for profiling 13,14,17,18 hospitals. To assess hospital characteristics associated with mortality declines, we fitted a mixed model with the state as random effects and an identity link function to model the absolute JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 3/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults difference in risk-standardized mortality between 1995 and 2014 as a function of hospital characteristics, adjusting for hospitals’ baseline risk-standardized mortality rate. At the county level, to ensure that each county had an adequate number of patients with AMI, we divided the 20-year period into 5 intervals, each combining 4 sequential years of data (1995-1998, 1999-2002, 2003-2006, 2007-2010, and 2011-2014). We calculated the risk-standardized 30-day mortality rate for each county and each subperiod by extending the CMS method to the county level, adjusted for patient characteristics (age, sex, race [white, black, Hispanic, all others], dual eligibility, and comorbidities). We then mapped counties using a gradient from red, yellow, and green (increase in red, on average in yellow, and decrease in green). To assess county characteristics associated with the decline in mortality, we fitted a mixed model with state as random effects and an identity link function to model the absolute difference in risk-standardized mortality between 1995 to 1998 and 2011 to 2014 as a function of county characteristics. To facilitate data presentation, we report patient characteristics and outcomes by the five 4-year intervals defined in the county-level analysis. Analyses were conducted between January 15 and June 5, 2018, using SAS statistical software, version 9.4, 64-bit Windows version (SAS Institute, Inc). As of 2019, the data were 5 years old. All statistical tests were 2-tailed, at a significance level of .05. Results Study Population and Patient Characteristics There were 4 367 485 unique Medicare fee-for-service patients aged 65 years or older hospitalized for AMI across 5680 unique hospitals during the 20-year period. Between 1995 and 2014, the mean (SD) age of patients with AMI increased from 76.9 (7.2) to 78.2 (8.7) years, an absolute difference of 2.7 years; the proportion of female patients declined from 49.5% to 46.1%; the percentage of white patients declined from 91.0% to 86.2%; and the percentage of black patients increased from 5.9% to 8.0% (all P values for trends <.001). The rate of hospitalization for an initial AMI declined over the period from 914 to 566 per 100 000 beneficiary-years, a relative 38.1% reduction (eFigure 1 in the Supplement). Most comorbidities increased during the study period, but the proportions of patients with cerebrovascular disease, stroke, anterior AMI location, inferior lateral AMI, unstable angina, and valvular heart disease declined (eFigure 2 in the Supplement; Table). Changes in Risk of Mortality at the Patient Level Patient risk of 30-day mortality declined significantly over the 20-year period. The observed 30-day mortality declined from 20.0% in 1995 to 12.4% in 2014 (difference, 7.6 percentage points; 95% CI, 7.3-7.8 percentage points). This reduction in observed mortality was found across age, sex, race, and dual-eligibility subgroups (eFigure 3 in the Supplement); the gap in mortality decreased between the dual-eligible and non–dual-eligible subgroups (24.1% vs 19.4%; difference, 4.7 percentage points; 95% CI, 4.3-5.2 percentage points in 1995 and 14.0% vs 12.1%; difference, 1.9 percentage points; 95% CI, 1.4-2.3 percentage points in 2014) and between the female and male subgroups (21.8% vs 18.2%; difference, 3.6 percentage points; 95% CI, 3.4-4.0 percentage points in 1995 and 13.4% vs 11.6%; difference, 1.8 percentage points; 95% CI, 1.4-2.1 percentage points in 2014) (P < .001 for interactions). There were no differences in mortality by the race subgroups. Between 1995 and 2014, mortality declined from 13.4% to 7.5% (difference, 5.9 percentage points; 95% CI, 5.6-6.2 percentage points) for patients aged 65 to 74 years, 21.7% to 11.7% (difference, 10.0 percentage points; 95% CI, 9.6-10.4 percentage points) for patients aged 75 to 84 years, and 32.2% to 22.0% (difference, 10.2 percentage points; 95% CI, 9.7-10.9 percentage points) for patients aged 85 years or older. An interaction effect (P < .001) between year and age was observed. For a patient hospitalized in 1995, with demographic characteristics and comorbidities unchanged, the adjusted risk of 30-day mortality would be 34% (95% CI, 31.0%-37.2%) lower if the hospitalization occurred in 2014 (Figure 1). This reduction in the adjusted risk of mortality between 1995 and 2014 was lower in JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 4/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults patients aged 85 years or older (24%; 95% CI, 20.1%-28.0%), men (25.8%; 95% CI, 21.4%-28.6%), nonwhite and nonblack patients (27.3%; 95% CI, 23.4%-30.5%), and non–dual-eligible patients (32.4%; 95% CI, 29.3%-35.6%) than the national average (eFigure 4 in the Supplement). Changes in Risk of Mortality at the Hospital Level Between 1995 and 2014, the number of unique hospitals that treated at least 1 patient with AMI each year declined from 4989 to 3056; the median (interquartile range) hospital AMI volume remained unchanged from 31 (11-71) to 31 (8-79). The mean (SD) risk-standardized mortality rate, at the individual hospital level, declined from 20.0% (1.7%) in 1995 to 12.5% (1.1%) in 2014 (difference, 7.5 Table. Patient Characteristics 1995-1998 1999-2002 2003-2006 2007-2010 2011-2014 Aggregated Characteristic (n = 1 012 897) (n = 999 009) (n = 919 981) (n = 742 812) (n = 692 786) (N = 4 367 485) Demographic characteristics and comorbidities, No. (%) Age, mean (SD), y 77.3 (7.3) 78.4 (7.8) 78.6 (8.1) 78.6 (8.5) 78.1 (8.6) 78.2 (8.0) Female 505 015 (49.9) 505 786 (50.6) 461 401 (50.2) 366 863 (49.4) 326 029 (47.1) 2 165 094 (49.6) White 914 985 (90.3) 889 941 (89.1) 809 239 (88.0) 650 931 (87.6) 599 774 (86.6) 3 864 870 (88.5) Black 61 039 (6.0) 68 416 (6.8) 67 842 (7.4) 56 564 (7.6) 55 536 (8.0) 309 397 (7.1) Other race 31 440 (3.1) 40 652 (4.1) 42 900 (4.7) 35 317 (4.8) 37 476 (5.4) 193 218 (4.4) Heart failure 134 488 (13.3) 144 952 (14.5) 136 957 (14.9) 106 029 (14.3) 92 039 (13.3) 614 465 (14.1) Myocardial infarction 46 391 (4.6) 49 164 (4.9) 45 062 (4.9) 36 292 (4.9) 33 072 (4.8) 209 981 (4.8) Unstable angina 56 939 (5.6) 49 009 (4.9) 33 820 (3.7) 21 471 (2.9) 17 680 (2.6) 178 919 (4.1) Chronic atherosclerosis 680 245 (67.2) 655 429 (65.6) 630 149 (68.5) 519 313 (69.9) 496 177 (71.6) 2 981 313 (68.3) Cardiorespiratory disease 21 737 (2.1) 25 313 (2.5) 27 667 (3.0) 34 521 (4.6) 36 762 (5.3) 146 000 (3.3) Hypertension 485 258 (47.9) 537 800 (53.8) 532 660 (57.9) 477 564 (64.3) 468 670 (67.7) 2 501 952 (57.3) Stroke 20 517 (2.0) 20 595 (2.1) 17 841 (1.9) 13 913 (1.9) 12 405 (1.8) 85 271 (2.0) Cerebrovascular disease 40 588 (4.0) 52 259 (5.2) 42 135 (4.6) 30 768 (4.1) 27 183 (3.9) 192 933 (4.4) Renal failure 31 353 (3.1) 45 552 (4.6) 64 392 (7.0) 87 220 (11.7) 92 187 (13.3) 320 704 (7.3) Chronic obstructive pulmonary 204 168 (20.2) 227 051 (22.7) 223 856 (24.3) 158 333 (21.3) 138 327 (20.0) 951 735 (21.8) disease Pneumonia 91 977 (9.1) 126 982 (12.7) 131 896 (14.3) 114 628 (15.4) 101 380 (14.6) 566 863 (13.0) Protein calorie malnutrition 9810 (1.0) 24 282 (2.4) 27 512 (3.0) 33 123 (4.5) 36 604 (5.3) 131 331 (3.0) Dementia 50 051 (4.9) 92 066 (9.2) 95 134 (10.3) 81 219 (10.9) 47 194 (6.8) 365 664 (8.4) Functional disability 18 090 (1.8) 25 823 (2.6) 21 925 (2.4) 18 419 (2.5) 17 522 (2.5) 101 779 (2.3) Peripheral vascular disease 52 800 (5.2) 61 473 (6.2) 60 671 (6.6) 49 220 (6.6) 41 585 (6.0) 265 749 (6.1) Metastatic cancer 23 717 (2.3) 62 611 (6.3) 60 943 (6.6) 50 061 (6.7) 44 158 (6.4) 241 490 (5.5) Trauma in past year 41 581 (4.1) 51 883 (5.2) 56 273 (6.1) 45 483 (6.1) 37 689 (5.4) 232 909 (5.3) Major psychiatric disorder 12 524 (1.2) 18 274 (1.8) 16 481 (1.8) 14 918 (2.0) 15 113 (2.2) 77 310 (1.8) Liver disease 4222 (0.4) 5673 (0.6) 6337 (0.7) 5102 (0.7) 5751 (0.8) 27 085 (0.6) Depression 22 740 (2.2) 44 332 (4.4) 48 799 (5.3) 40 341 (5.4) 41 069 (5.9) 197 281 (4.5) Diabetes 334 688 (33.0) 293 433 (29.4) 277 281 (30.1) 225 956 (30.4) 229 613 (33.1) 1 360 971 (31.2) Outcomes, % (95% CI) 30-d mortality 19.1 (19.1-19.2) 19.2 (19.2-19.3) 17.1 (17.1-17.2) 15.2 (15.1-15.3) 13.4 (13.3-13.5) 17.2 (17.1-17.2) In-hospital mortality 14.3 (14.2-14.4) 14.1 (14.0-14.1) 11.5 (11.5-11.6) 9.2 (9.15-9.28) 7.7 (7.63-7.76) 11.7 (11.7-11.8) 30-d readmission 21.3 (21.2-21.4) 21.8 (21.7-21.9) 21.4 (21.3-21.5) 20.2 (20.1-20.3) 17.4 (17.3-17.5) 20.4 (20.3-20.4) Discharge to home 44.5 (44.4-44.6) 46.1 (46.0-46.2) 45.1 (45.0-45.2) 46.9 (46.8-47.0) 50.2 (50.1-50.3) 46.3 (46.3-46.3) Discharge to home with home 9.1 (9.06-9.17) 9.6 (9.51-9.62) 12.1 (12.1-12.2) 13.2 (13.2-13.3) 13.2 (13.1-13.3) 11.2 (11.2-11.2) health service Discharge to skilled nursing home 10.5 (10.4-10.5) 14.0 (13.9-14.1) 15.9 (15.8-16.0) 16.6 (16.6-16.7) 15.4 (15.3-15.5) 11.8 (11.8-11.9) Discharge to hospice 0 (0.01-0.01) 0.3 (0.30-0.32) 1.7 (1.64-1.69) 2.7 (2.71-2.78) 3.0 (2.96-3.04) 1.4 (1.35-1.38) Transferred to another 19.0 (18.9-19.1) 11.7 (11.6-11.7) 8.8 (8.70-8.82) 6.6 (6.57-6.68) 5.6 (5.59-5.70) 10.9 (10.9-11.0) acute-care hospital Length of stay, mean (SD), d 6.5 (6.0) 6.5 (6.7) 6.2 (6.5) 5.7 (5.9) 5.1 (5.2) 6.1 (6.2) JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 5/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults percentage points; 95% CI, 7.4-7.6 percentage points) (Figure 2). The distributions of risk- standardized mortality are shown in eFigure 5 in the Supplement. Overall, the annual national decline was 2.2%. There were 2635 hospitals represented in both 1995 and 2014. Among these, the absolute change in mortality between 1995 and 2014 ranged from a decrease of 15.4 percentage points to an increase of 2.5 percentage points, with 4 hospitals having increased mortality (increases ranging from 0.7-2.5 percentage points). A reduction in between-hospital heterogeneity in mortality was also observed: the hospital-specific mortality ranged from 11.3% to 28.0% (difference, 16.7 percentage points) in 1995 and ranged from 8.3% to 19.4% (difference, 11.1 percentage points) in 2014. Hospital characteristics were not associated with the decline in risk-standardized 30-day mortality (eFigure 6 in the Supplement). Figure 1. Change in Adjusted Risk of 30-Day Acute Myocardial Infarction Mortality at the Patient Level Between 1995 and 2014 1.5 95% Confidence limits 1.4 Change in patient risk of death 1.3 1.2 1.1 1.0 0.9 0.8 0.7 Points indicate year-specific risk-standardized 30-day 0.6 mortality ratios. The line was smoothed using the 0.5 locally estimated scatterplot smoothing (LOESS) 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 method (local regression). Year Figure 2. Change in Hospital-Specific Risk-Standardized 30-Day Acute Myocardial Infarction Mortality Rates Between 1995 and 2014 The size of each bar reflects the number of hospitals that filled in a particular interval of risk-standardized mortality rate as well as the distributions (ranges) of rates in 1995 and 2014. The curves represent distribution of the data. Mean (SD) risk-standardized 30-day mortality rates were 20.0% (2.0%) and 12.5% 0 (1.2%) for 1995 and 2014, respectively (n = 2635 6 8 10 12 14 16 18 20 22 24 26 28 30 hospitals). Restricted to hospitals that had at least 1 Risk-Standardized 30-d Mortality Rate, % case in both 1995 and 2014. JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 6/12 Hospitals, No. Risk-Standardized 30-d Mortality Ratio JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults Changes in Risk of Mortality at the County Level From 1995 to 1998 and 2011 to 2014, the county-specific mean (SD) 30-day risk-standardized mortality rate, adjusted for patient characteristics (age, sex, race [white, black, Hispanic, and all others], dual-eligible status, and comorbidities), declined from 19.2% (1.3%) to 13.4% (0.6%). Across counties, the absolute decline in percentage points ranged from 0.1 to 13.1, with 2 counties having increases (0.2 and 0.5 percentage points) (Figure 3). A reduction in between-county heterogeneity in mortality was also observed: the county-specific mortality ranged from 15.4% to 23.1% in 1995 to 1998 and from 12.2% to 13.9% in 2011 to 2014 (eFigure 7 in the Supplement). Overall, counties with a high rate of individuals enrolled in a Medicare Advantage plan, a high proportion of rural areas, and a high rate of residents who lived in the county for at least 1 year were more likely to have declines in mortality, but counties with high proportions of Medicare beneficiaries not enrolled in the Medicare Part B plan, unemployed residents, and a high risk of potential life lost were less likely to show declines in mortality (eFigure 8 in the Supplement). Counties in the health priority areas were less likely to have a decline in mortality (point estimate = −0.41; 95% CI, −0.60 to −0.23 points). Changes in Readmissions, In-Hospital Mortality, Length of Stay, and Medicare Payment Between 1995 and 2014 (2013 for 1-year recurrent AMI), the rates of 30-day all-cause readmissions, 1-year recurrent AMI, and in-hospital mortality declined from 21.0% to 15.3% (difference, 5.7 percentage points; 95% CI, 5.4-6.0 percentage points), 7.1% to 5.1% (difference, 2.0 percentage Figure 3. Difference in County-Specific 30-Day Risk-Standardized Acute Myocardial Infarction Mortality Rates Between 1995 to 1998 and 2011 to 2014 –13.1 to –7.7 –7.6 to –6.6 –6.5 to –5.9 –5.8 to –5.3 –5.2 to –4.4 –4.3 to 0.5 The difference was calculated as the percentage point between the 2011 to 2014 2011 to 2014 and 1995 to 1998 are shaded green, while those with the smallest decline combined rate minus the 1995 to 1998 combined rate. Counties are shaded according to or even increase in mortality between 2011 to 2014 and 1995 to 1998 are shaded red. the difference in percentage points of the risk-standardized acute myocardial infarction Counties are shaded white if there were missing or insufficient data that precluded the mortality rates (percentage). Counties with negative values had mortality rates that were calculation of mortality rates. lower in 2011 to 2014 than in 1995 to 1998. Counties with the largest decline between JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 7/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults points; 95% CI, 1.8-2.2 percentage points), and 15.4% to 7.3% (difference, 8.1 percentage points; 95% CI, 7.9-8.3 percentage points), respectively (Figure 4). The median (interquartile range) length of stay declined from 6.0 (3.0-8.0) days in 1995 to 3.0 (2.0-6.0) days in 2014. Between 1995 and 2014, the 2014 Consumer Price Index–adjusted median (interquartile range) Medicare inpatient payment per AMI discharge increased from $9282 ($6969-$12 173) to $11 031 ($8099-$16 861). Although the association between 30-day risk-standardized mortality and Medicare inpatient payment was negative over the study period (eFigure 9 in the Supplement), the effect size was small and it declined slightly over time. In 1995, a $10 000 increase in the payment was associated with an 0.5–percentage point decrease in 30-day risk-standardized mortality; in 2014, the same dollar amount was associated with a decrease of 0.3 percentage points. Changes in Inpatient Procedures Between 1995 and 2014, the rate of 30-day inpatient catheterization increased from 44.2% to 59.9% (difference, 15.7 percentage points; 95% CI, 15.4-16.0 percentage points), the rate of inpatient PCI increased from 18.8% to 43.3% (difference, 24.5 percentage points; 95% CI, 24.2-24.7 percentage points), and the rate of CABG decreased from 14.4% to 10.2% (difference, 4.2 percentage points; 95% CI, 3.9-4.3 percentage points) (eFigure 10 in the Supplement). All 3 procedure rates were correlated at the hospital level. The weighted Pearson correlation coefficients were 0.68 (PCI and CABG), 0.91 (PCI and catheterization), and 0.75 (CABG and catheterization). An increase of 1% in the PCI rate was associated with a decrease in mortality of 0.72 percentage points (95% CI, −0.80 to −0.64 percentage points), but the decrease in CABG rate was not associated with changes in mortality rate. Although we measured these procedures within a 30-day period from the index AMI hospitalization, the majority (96.0% of catheterizations, 96.3% of PCI, and 83.0% of CABG) were performed at the index hospitalization. Discussion From 1995 through 2014, the Medicare fee-for-service population experienced a remarkable and progressive improvement in the hospitalization rates for AMI and the 30-day mortality rate after AMI. In addition, the 2.7-year increase in the average age of patients suggests progress in delaying the onset of AMI. Mortality after AMI is at a historic low of 12%, a reduction of 34% since 1995, accounting for changes in patient characteristics. The improvements were consistent across demographic groups defined by age, sex, race, and eligibility for Medicaid. Almost all hospitals improved over this period, although there was some heterogeneity in the improvement over time, Figure 4. Changes in 30-Day All-Cause Readmissions, 1-Year Recurrent Acute Myocardial Infarction (AMI), In-Hospital Mortality, and Length of Stay All-cause 30-day readmission rate, % 1-y recurrent AMI, % Mean length of hospital stay, d In-hospital mortality, % Symbols denote observed values and lines represent changes over time. Lines were smoothed using the locally estimated scatterplot smoothing (LOESS) method (local regression). Triangles indicate 30-day all-cause readmissions; circles, 1-year recurrent AMI; diamonds, in-hospital mortality; and squares, length 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 of stay. Year JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 8/12 Outcomes JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults and almost every county experienced improvement, although the size of the change varied. The in-hospital mortality, length of stay, 30-day all-cause rehospitalization, and 1-year recurrent AMI rates also declined, while payments and rates of revascularization increased. The decline in in-hospital mortality was unlikely to have been affected by the decline in length of stay, given the decline in 30-day mortality. 2-4,7,8,10,11,19 This work extends the prior literature in several ways. Previous studies have reported some of these improvements, but not as comprehensively, or over a 20-year period or across the entire United States. As such, this work reveals novel insights about what has been achieved in reducing and mitigating AMI among Medicare beneficiaries. Moreover, even as payments per hospitalization have increased, outcomes improved and total cost declined because the number of hospitalizations was greatly reduced. There are several potential explanations for our findings, including changes in the treatment of AMI over this period. By the beginning of the period, it was established that aspirin, β-blockers, and rapid reperfusion therapy could improve outcomes for patients with AMI and that statins and risk factor control could reduce risk. However, it became apparent that the translation of the evidence into practice was incomplete. In the early 1990s, the Health Care Financing Administration (now CMS) launched an improvement initiative focused specifically on AMI. Many patients who were ideal 20-23 for particular clinical strategies were not receiving them. Moreover, PCI was emerging as a superior method of reperfusion but was used infrequently, in part because of its availability. Over the years, the use of evidence-based strategies improved dramatically. The speed of reperfusion therapy 3,24 for ST-segment elevation AMI also improved, as did the use of PCI in general. All of this occurred as a result of concerted efforts by CMS, the American College of Cardiology, the American Heart Association, and other national organizations, along with local hospitals and clinicians, to improve population risk and acute care. Lifestyle changes likely also contributed to the change in the rates of AMI. We identified some county characteristics that were associated with changes over time. Perhaps most disconcerting is that the areas of the country with persistently highest mortality rates, which we previously termed health priority areas, also had slower-than-average decline in AMI mortality. These areas may particularly benefit from future improvement activities. Limitations The study has several limitations. We examined data about individuals in the Medicare fee-for-service population, and the findings may not reflect the changes in the Medicare Advantage population. Moreover, the growing Medicare Advantage population may have implications for trend analyses, but we have risk adjusted the outcomes data. Also, the hospitalization rate has been dropping over time, and there is no indication that the fee-for-service population is getting healthier over time. Because this is a Medicare population, we cannot be sure about how our results may reflect the experience of younger populations. The lack of laboratory data in our study precluded our ability to include troponin levels in the risk adjustments. The lack of clinical information in claims data precluded our ability to assess the changes in process of care over time, such as door-to-balloon time and the use of medications, which could explain the changes in outcomes. Nevertheless, other 9,27 studies have shown remarkable improvement in AMI process measures over this period. Additionally, our assessments of comorbidities are dependent on codes and may not accurately reflect the condition of the patients, but the improvements were also present in unadjusted analyses. There may be some concerns that the higher sensitivity of biomarkers used to diagnose AMI may have contributed to the trend. Changing definitions of AMI do make comparisons difficult and likely led to shifting of patients among the categories of acute coronary syndromes. However, this improvement in mortality occurred in a period of a marked reduction in the number of hospitalizations. Moreover, the changes in mortality were gradual over time and did not show an abrupt change with the introduction of troponins—or level off after a period of adoption. Also, a systematic review of the validity of administrative codes did not find evidence of a secular trend in JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 9/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults code sensitivity, although the evidence is limited. Finally, we also restricted this study to a period in which International Classification of Diseases, Ninth Revision, Clinical Modification codes were used so as not to introduce a new coding system into the assessment of the trends. Also, the effect of the expansion of codes during this period on risk determination is unclear, but this seems unlikely to affect the overall findings of this study. Conclusions This study charts the course of AMI among Medicare fee-for-service beneficiaries over a recent 20-year period. Hospitalization rates for AMI declined 38%, and there were improvements in 30-day mortality, readmissions, length of stay, and 1-year recurrent AMI, with only a modest increase in payments. Revascularization rates increased markedly. Thirty-day adjusted mortality, which declined 34%, touched almost every county and hospital in the country. Nevertheless, there was heterogeneity in the performance over time with some hospital and county characteristics associated with the change. Overall, however, we describe 2 decades of marked improvements in outcomes for AMI among the increasingly smaller number of people in the United States who experience it, representing a transition in the impact of this condition. ARTICLE INFORMATION Accepted for Publication: February 18, 2019. Published: March 15, 2019. doi:10.1001/jamanetworkopen.2019.1938 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Krumholz HM et al. JAMA Network Open. Corresponding Author: Harlan M. Krumholz, MD, SM, Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, One Church St, Ste 200, New Haven, CT 06510 (harlan.krumholz@yale.edu). Author Affiliations: Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut (Krumholz); Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut (Krumholz); Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut (Krumholz, Wang); Department of Health Care Policy, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Normand, Wang); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Wang). Author Contributions: Dr Wang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Krumholz, Wang. Acquisition, analysis, or interpretation of data: Normand, Wang. Drafting of the manuscript: Krumholz. Critical revision of the manuscript for important intellectual content: Normand, Wang. Statistical analysis: Normand, Wang. Supervision: Krumholz. Conflict of Interest Disclosures: Dr Krumholz reported personal fees from UnitedHealth, IBM Watson Health, Element Science, Aetna, Facebook, Arnold & Porter, and the Ben C. Martin Law Firm; grants from the Centers for Medicare & Medicaid Services, Medtronic, Johnson & Johnson, and the Food and Drug Administration; and serving as founder of the personal health information platform Hugo outside the submitted work. Dr Normand reported a patent to 201810345624.5 pending. No other disclosures were reported. REFERENCES 1. Ellerbeck EF, Jencks SF, Radford MJ, et al. Quality of care for Medicare patients with acute myocardial infarction: a four-state pilot study from the Cooperative Cardiovascular Project. JAMA. 1995;273(19):1509-1514. doi:10.1001/ jama.1995.03520430045037 2. Chen HY, Gore JM, Lapane KL, et al. A 35-year perspective (1975 to 2009) into the long-term prognosis and hospital management of patients discharged from the hospital after a first acute myocardial infarction. Am J Cardiol. 2015;116(1):24-29. doi:10.1016/j.amjcard.2015.03.035 JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 10/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults 3. Chen HY, Tisminetzky M, Lapane KL, et al. Decade-long trends in 30-day rehospitalization rates after acute myocardial infarction. J Am Heart Assoc. 2015;4(11):e002291. doi:10.1161/JAHA.115.002291 4. Gerber Y, Weston SA, Jiang R, Roger VL. The changing epidemiology of myocardial infarction in Olmsted County, Minnesota, 1995-2012. Am J Med. 2015;128(2):144-151. doi:10.1016/j.amjmed.2014.09.012 5. Krumholz HM, Normand SL, Wang Y. Trends in hospitalizations and outcomes for acute cardiovascular disease and stroke, 1999-2011. Circulation. 2014;130(12):966-975. doi:10.1161/CIRCULATIONAHA.113.007787 6. Krumholz HM, Wang Y, Chen J, et al. Reduction in acute myocardial infarction mortality in the United States: risk-standardized mortality rates from 1995-2006. JAMA. 2009;302(7):767-773. doi:10.1001/jama.2009.1178 7. McGovern PG, Pankow JS, Shahar E, et al; The Minnesota Heart Survey Investigators. Recent trends in acute coronary heart disease—mortality, morbidity, medical care, and risk factors. N Engl J Med. 1996;334(14):884-890. doi:10.1056/NEJM199604043341403 8. Newman JD, Shimbo D, Baggett C, et al; ARIC Study Investigators. Trends in myocardial infarction rates and case fatality by anatomical location in four United States communities, 1987 to 2008 (from the Atherosclerosis Risk in Communities Study). Am J Cardiol. 2013;112(11):1714-1719. doi:10.1016/j.amjcard.2013.07.037 9. Nuti SV, Wang Y, Masoudi FA, et al. Improvements in the distribution of hospital performance for the care of patients with acute myocardial infarction, heart failure, and pneumonia, 2006-2011. Med Care. 2015;53(6): 485-491. doi:10.1097/MLR.0000000000000358 10. O’Brien EC, Rose KM, Suchindran CM, et al. Temporal trends in medical therapies for ST- and non-ST elevation myocardial infarction (from the Atherosclerosis Risk in Communities [ARIC] Surveillance Study). Am J Cardiol. 2013;111(3):305-311. doi:10.1016/j.amjcard.2012.09.032 11. Rosamond WD, Chambless LE, Heiss G, et al. Twenty-two-year trends in incidence of myocardial infarction, coronary heart disease mortality, and case fatality in 4 US communities, 1987-2008. Circulation. 2012;125(15): 1848-1857. doi:10.1161/CIRCULATIONAHA.111.047480 12. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 2007;4(10):e296. doi:10.1371/journal.pmed.0040296 13. Krumholz HM, Wang Y, Mattera JA, et al. An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with an acute myocardial infarction. Circulation. 2006;113(13):1683-1692. doi:10.1161/CIRCULATIONAHA.105.611186 14. Normand S-LT, Wang Y, Krumholz HM. Assessing surrogacy of data sources for institutional comparisons. Health Serv Outcomes Res Methodol. 2007;7:79-96. doi:10.1007/s10742-006-0018-8 15. Centers for Medicare & Medicaid Services. 5010 implementation—processing additional International Classification of Diseases, 9th Revision—Clinical Modification (ICD-9-CM) diagnosis and procedure codes in pricer, grouper, and the Medicare code editor (MCE). https://www.cms.gov/Regulations-and-Guidance/Guidance/ Transmittals/downloads/ R2028CP.pdf. Published August 13, 2010. Accessed January 30, 2019. 16. Krumholz HM, Normand ST, Wang Y. Geographical health priority areas for older Americans. Health Aff (Millwood). 2018;37(1):104-110. doi:10.1377/hlthaff.2017.0744 17. Bratzler DW, Normand SL, Wang Y, et al. An administrative claims model for profiling hospital 30-day mortality rates for pneumonia patients. PLoS One. 2011;6(4):e17401. doi:10.1371/journal.pone.0017401 18. Krumholz HM, Wang Y, Mattera JA, et al. An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with heart failure. Circulation. 2006;113(13): 1693-1701. doi:10.1161/CIRCULATIONAHA.105.611194 19. Rosamond WD, Chambless LE, Folsom AR, et al. Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994. N Engl J Med. 1998;339(13):861-867. doi:10.1056/ NEJM199809243391301 20. Krumholz HM, Murillo JE, Chen J, et al. Thrombolytic therapy for eligible elderly patients with acute myocardial infarction. JAMA. 1997;277(21):1683-1688. doi:10.1001/jama.1997.03540450039032 21. Krumholz HM, Radford MJ, Ellerbeck EF, et al. Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcomes. Ann Intern Med. 1996;124(3):292-298. doi:10.7326/0003- 4819-124-3-199602010-00002 22. Krumholz HM, Radford MJ, Ellerbeck EF, et al. Aspirin in the treatment of acute myocardial infarction in elderly Medicare beneficiaries: patterns of use and outcomes. Circulation. 1995;92(10):2841-2847. doi:10.1161/01.CIR.92. 10.2841 JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 11/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults 23. Krumholz HM, Radford MJ, Wang Y, Chen J, Heiat A, Marciniak TA. National use and effectiveness of beta- blockers for the treatment of elderly patients after acute myocardial infarction: National Cooperative Cardiovascular Project. JAMA. 1998;280(7):623-629. doi:10.1001/jama.280.7.623 24. Nallamothu BK, Normand SL, Wang Y, et al. Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study. Lancet. 2015;385(9973):1114-1122. doi:10.1016/S0140-6736(14)61932-2 25. Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary heart disease? the Lifestyle Heart Trial. Lancet. 1990;336(8708):129-133. doi:10.1016/0140-6736(90)91656-U 26. Miller EA, Decker SL, Parker JD. Characteristics of Medicare Advantage and fee-for-service beneficiaries upon enrollment in Medicare at age 65. J Ambul Care Manage. 2016;39(3):231-241. doi:10.1097/JAC. 27. Makam RC, Erskine N, McManus DD, et al. Decade-long trends (2001 to 2011) in the use of evidence-based medical therapies at the time of hospital discharge for patients surviving acute myocardial infarction. Am J Cardiol. 2016;118(12):1792-1797. doi:10.1016/j.amjcard.2016.08.065 28. Dalen JE, Alpert JS, Goldberg RJ, Weinstein RS. The epidemic of the 20th century: coronary heart disease. Am J Med. 2014;127(9):807-812. doi:10.1016/j.amjmed.2014.04.015 29. McCormick N, Lacaille D, Bhole V, Avina-Zubieta JA. Validity of myocardial infarction diagnoses in administrative databases: a systematic review. PLoS One. 2014;9(3):e92286. doi:10.1371/journal.pone.0092286 SUPPLEMENT. eTable. County-Specific Characteristics eFigure 1. Change in Number of Initial AMI Hospitalizations per 100,000 Beneficiary-Years, 1995-2014 eFigure 2. Annual Relative Changes in Patient Characteristics eFigure 3. Trend in Observed Mortality by Year and Sub-population eFigure 4. Changes in Patient Risk of 30-Day Mortality Between 2014 and 1995 by Sub-population eFigure 5. Nationwide Change in Hospital-Specific 30-Day Risk-Standardized Mortality Rate by Selected Years eFigure 6. Hospital Characteristics Associated With Change in Difference in Hospital-Specific Risk-Standardized 30-Day Mortality Rates Between 1995 and 2014 eFigure 7. Change in County-Specific Risk-Standardized 30-Day Mortality in 1995-1998 (Top Panel) and in 2011- 2014 (Bottom Panel) eFigure 8. County-Specific Characteristics Associated With Difference in County-Specific Risk-Standardized 30-Day Mortality Between 1995-1998 and 2011-2014 eFigure 9. Association Between Medicare Inpatient Payment and 30-Day Risk-Standardized Mortality at the Hospital Level eFigure 10. Annual Changes in the 30-Day Rates of Three Common AMI-Specific Procedures (Catheterization, CABG, and PCI) JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 12/12 Supplementary Online Content Krumholz HM, Normand S-LT, Wang Y. Twenty-year trends in outcomes for older adults with acute myocardial infarction in the United States. JAMA Netw Open. 2019;2(3):e191938 doi:10.1001/jamanetworkopen.2019.1938 eTable. County-Specific Characteristics eFigure 1. Change in Number of Initial AMI Hospitalizations per 100,000 Beneficiary- Years, 1995-2014 eFigure 2. Annual Relative Changes in Patient Characteristics eFigure 3. Trend in Observed Mortality by Year and Sub-population eFigure 4. Changes in Patient Risk of 30-Day Mortality Between 2014 and 1995 by Sub-population eFigure 5. Nationwide Change in Hospital-Specific 30-Day Risk-Standardized Mortality Rate by Selected Years eFigure 6. Hospital Characteristics Associated With Change in Difference in Hospital- Specific Risk-Standardized 30-Day Mortality Rates Between 1995 and 2014 eFigure 7. Change in County-Specific Risk-Standardized 30-Day Mortality in 1995-1998 (Top Panel) and in 2011-2014 (Bottom Panel) eFigure 8. County-Specific Characteristics Associated With Difference in County- Specific Risk-Standardized 30-Day Mortality Between 1995-1998 and 2011-2014 eFigure 9. Association Between Medicare Inpatient Payment and 30-Day Risk- Standardized Mortality at the Hospital Level eFigure 10. Annual Changes in the 30-Day Rates of Three Common AMI-Specific Procedures (Catheterization, CABG, and PCI) This supplementary material has been provided by the authors to give readers additional information about their work. © 2019 Krumholz HM et al. JAMA Network Open. eTable. County-specific characteristics. Proportion of senior population (age 65) (%) Divorced (%) Residence one year ago (%) - Different house in the U.S. - different county Geography Rural area residents (%) In health priority area (yes/no) Socioeconomic Status Bachelor or higher degree (%) Consumer Price Index-adjusted median income ($10,000) Proportion of population under the poverty level (%) Eligible for both Medicare and Medicaid (dual-eligible) (%) Gini coefficient, continuous (0 to 1) Percent of unemployed in 2010 (%) General Health Age-adjusted prevalence of adult diabetes (%) At least 1 ambulatory visit to a primary care clinician (%) Years of potential life lost Emergency department visit rate (%) Availability of Care Percent of diabetic Medicare beneficiaries receiving HbA1c test (%) Percent of female Medicare beneficiaries having at least 1 mammogram in 2 yrs (age 67-69) (%) Enrolled in Medicare Advantage for all 12 months (%) Not enrolled in supplementary medical insurance (Medicare Part B) (%) Health Behaviors Age-adjusted rate of physical inactivity (%) © 2019 Krumholz HM et al. JAMA Network Open. eFigure 1. Change in number of initial AMI hospitalizations per 100,000 beneficiary-years, 1995-2014. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 2. Annual relative changes in patient characteristics. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 3. Trend in observed mortality by year and sub-population. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 4. Changes in patient risk of 30-day mortality between 2014 and 1995 by sub-population. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 5. Nationwide change in hospital-specific 30-day risk-standardized mortality rate by selected years. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 6. Hospital characteristics associated with change in difference in hospital-specific risk-standardized 30-day mortality rates between 1995 and 2014. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 7. Change in county-specific risk-standardized 30-day mortality in 1995-1998 (top panel) and in 2011-2014 (bottom panel). Note: The mortality rate in the highest regions in 2011-2014 was lower than the mortality rate in the lowest regions in 1995-1998. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 8. County-specific characteristics associated with difference in county- specific risk-standardized 30-day mortality between 1995-1998 and 2011-2014. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 9. Association between Medicare inpatient payment and 30-day risk-standardized mortality at the hospital level. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 10. Annual changes in the 30-day rates of three common AMI-specific procedures (catheterization, CABG, and PCI). © 2019 Krumholz HM et al. JAMA Network Open. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Network Open American Medical Association

Twenty-Year Trends in Outcomes for Older Adults With Acute Myocardial Infarction in the United States

Download PDF
24 pages

Loading next page...
 
/lp/american-medical-association/twenty-year-trends-in-outcomes-for-older-adults-with-acute-myocardial-4xbQBmBm8p

References (55)

Publisher
American Medical Association
Copyright
Copyright 2019 Krumholz HM et al. JAMA Network Open.
eISSN
2574-3805
DOI
10.1001/jamanetworkopen.2019.1938
Publisher site
See Article on Publisher Site

Abstract

Key Points Question What are the patterns of IMPORTANCE Medicare and other organizations have focused on improving quality of care for hospitalizations, treatments, and patients with acute myocardial infarction (AMI) over the last 2 decades. However, there is no outcomes for older patients with acute comprehensive perspective on the evolution of outcomes for AMI during that period, and it is myocardial infarction (AMI) over a unknown whether temporal changes varied by patient subgroup, hospital, or county. recent 20-year period in the United States? OBJECTIVE To provide a comprehensive evaluation of national trends in inpatient outcomes and Findings In this cohort study of data costs of AMI during this period. from more than 4.3 million Medicare fee-for-service beneficiaries aged 65 DESIGN, SETTING, AND PARTICIPANTS This cohort study included analysis of data from a sample years and older discharged with AMI, of 4 367 485 Medicare fee-for-service beneficiaries aged 65 years or older from January 1, 1995, declines were found in AMI through December 31, 2014, across 5680 hospitals in the United States. Analyses were conducted hospitalizations (914 to 566 per from January 15 to June 5, 2018. 100 000 beneficiary-years), 30-day mortality (20.0% to 12.4%), and 30-day MAIN OUTCOMES AND MEASURES Thirty-day all-cause mortality at the patient, hospital, and all-cause readmissions (21.0% to 15.3%). county levels. Additional outcomes included 30-day all-cause readmissions; 1-year recurrent AMI; There were increases in the 2014 in-hospital mortality; length of hospital stay; 2014 Consumer Price Index–adjusted median Medicare Consumer Price Index–adjusted median inpatient payment per AMI discharge; and rates of catheterization, percutaneous coronary Medicare inpatient payment per AMI intervention, and coronary artery bypass graft surgery. discharge ($9282 to $11 031) and 30-day inpatient catheterization (44.2% RESULTS The cohort included 4 367 485 Medicare fee-for-service patients aged 65 years or older to 59.9%). hospitalized for AMI during the study period. Between 1995 and 2014, the mean (SD) age of patients increased from 76.9 (7.2) to 78.2 (8.7) years, the percentage of female patients declined from 49.5% Meaning The last 2 decades were to 46.1%, the percentage of white patients declined from 91.0% to 86.2%, and the percentage of marked by large changes in the number black patients increased from 5.9% to 8.0%. There were declines in AMI hospitalizations (914 to 566 of people hospitalized with AMI—and per 100 000 beneficiary-years); 30-day mortality (20.0% to 12.4%; difference, 7.6 percentage marked improvements in the short- and points; 95% CI, 7.3-7.8 percentage points); 30-day all-cause readmissions (21.0% to 15.3%; long-term outcomes along with difference, 5.7 percentage points; 95% CI, 5.4-6.0 percentage points); and 1-year recurrent AMI (7.1% increases in cost per hospitalization and to 5.1%; difference, 2.0 percentage points; 95% CI, 1.8-2.2 percentage points). There were increases number of procedures. in the 2014 Consumer Price Index–adjusted median (interquartile range) Medicare inpatient payment per AMI discharge ($9282 [$6969-$12 173] to $11 031 [$8099-$16 861]); 30-day inpatient Supplemental content catheterization (44.2% to 59.9%; difference, 15.7 percentage points; 95% CI, 15.4-16.0 percentage points); and inpatient percutaneous coronary intervention (18.8% to 43.3%; difference, 24.5 Author affiliations and article information are listed at the end of this article. percentage points; 95% CI, 24.2-24.7 percentage points). Coronary artery bypass graft surgery rates decreased from 14.4% to 10.2% (difference, 4.2 percentage points; 95% CI, 3.9-4.3 percentage points). There was heterogeneity by hospital and county in the mortality changes over time. (continued) Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 1/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults Abstract (continued) CONCLUSIONS AND RELEVANCE This study shows marked improvements in short-term mortality and readmissions, with an increase in in-hospital procedures and payments, for the increasingly smaller number of Medicare beneficiaries with AMI. JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 Introduction Acute myocardial infarction (AMI) is undergoing a transition. For the last 2 decades, Medicare has focused on improving quality of care for patients with AMI, starting with the Cooperative 1 2-11 Cardiovascular Project. Studies have reported improvements in quality and reductions in AMI hospitalizations and risk of short-term mortality during various periods within this time span. However, there is no comprehensive perspective on the evolution of outcomes for AMI across the last 2 decades, including cost, length of stay, treatments, and rehospitalizations. It is also unknown whether changes over time varied by patient subgroup, hospital, or county. Accordingly, we sought to provide a comprehensive view of treatments and outcomes for patients with AMI over a recent 20-year period in the United States. We used Medicare fee-for- service data to characterize changes in 30-day mortality at the patient, hospital, and county levels and examined trends in the rates of 30-day all-cause readmissions and 1-year recurrent AMI. Finally, we assessed the changes in 3 common in-hospital AMI-specific surgical procedures (catheterization, percutaneous coronary intervention [PCI], and coronary artery bypass graft [CABG]) within 30 days from the date of an AMI index admission. Methods Study Population This was a cohort study. The Yale University institutional review board reviewed the study protocol and granted a waiver of informed consent for the use of this deidentified database. We used Medicare enrollment data from the Centers for Medicare & Medicaid Services (CMS) to identify individuals in the Medicare population aged 65 years or older enrolled in the fee-for-service program for at least 1 month between January 1995 and December 2014. We then linked the fee-for-service population data to the Medicare inpatient claims data to identify patients discharged from an acute- care nonfederal hospital from January 1, 1995, through December 31, 2014, with a principal discharge diagnosis of AMI as determined using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes 410.xx (with the exception of 410.x2). The linked data include patient demographic characteristics, principal and secondary diagnosis codes, and procedure codes. If a patient had more than 1 AMI hospitalization during the entire study period, we selected the first AMI hospitalization, the index admission, and excluded subsequent hospitalizations (n = 548 546). To ensure that patients did not have an AMI in 1995, we also excluded patients who were hospitalized with an AMI in 1994. The study followed the guidelines for cohort studies described in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for observational studies. Patient, Hospital, and County Characteristics Patient demographic information included age, sex, race (white, black, or other), and dual eligibility status for Medicaid and Medicare. We identified clinical comorbidities that represent additional coexisting illnesses with the method used by CMS to profile hospital 30-day mortality measures for 13,14 AMI. We determined comorbidities for the index hospitalization from secondary diagnosis codes as well as the principal and secondary diagnosis codes from all hospitalizations for up to 12 months before the index hospitalization. Because the maximum number of diagnosis codes in Medicare data JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 2/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults increased from 10 to 25 in 2011, we restricted the 2011 to 2014 data to the first 10 diagnosis codes to align with the 1995 to 2010 data. Hospital characteristics included hospital structure, patient population, and in-hospital care information. Information about hospital structure was obtained from the 2013 American Hospital Association Surveys, including ownership status, geographic location (urban vs rural), teaching status, Medicare and Medicaid volume, nurse-to-patient ratio, safety-net hospital status (yes vs no), and hospital capacity to provide CABG surgery. Information about in-hospital care included rates of AMI transfer in and transfer out, rates of in-hospital PCI and CABG procedures, and discharge disposition (rates of discharge to home for self-care, to home with home health care, and to skilled nursing home facilities). Information about the patient population and in-hospital care was drawn from CMS inpatient all-cause claims data. County characteristics included Consumer Price Index–adjusted median income, proportion of people aged 65 years or older, people below the national poverty level (eTable in the Supplement), and a binary variable to indicate whether a county belongs to a health priority area as defined in one of our previous studies. The priority area has had a persistently high all-cause mortality over time. Outcomes Our primary outcome was 30-day all-cause mortality, defined as death within 30 days from the date of admission for an index AMI hospitalization, regardless of cause. We evaluated mortality at the individual patient level, the hospital level, and the county level. Additional outcomes included (1) 30-day all-cause readmissions, defined as an unplanned rehospitalization within 30 days from the index AMI discharge among individuals who survived to discharge; (2) 1-year recurrent AMI, defined as a recurrent AMI hospitalization within 1 year from the index AMI discharge; (3) in-hospital mortality, defined as all-cause death during the index AMI hospitalization; and (4) length of hospital stay. Additionally, we examined the change in AMI hospitalizations per 100 000 beneficiary-years by using the total number of AMI hospitalizations for each year divided by the corresponding number of beneficiary-years of fee-for-service enrollments, based on the total months that people were in fee-for-service. We also assessed the Consumer Price Index–adjusted Medicare payment for an index AMI hospitalization, referring to the year 2014. For each year, we also measured the rates of individuals who received catheterization, PCI, and CABG, defined as a patient who underwent a targeted procedure in an acute-care hospital within 30 days of an index AMI admission among admitted patients with AMI in each year. Statistical Analysis We conducted analyses at the patient, hospital, and county levels. At the patient level, we assessed changes in patient characteristics over the study period via a logistic regression to model each individual characteristic as a function of a year parameterized as a count, ranging from 0 to 19, corresponding to years 1995 to 2014. To assess the changes in individual patients’ risk of 30-day deaths over time, we used the 2014 data (the end of the study period data) to fit a mixed model with hospital random effects and a logit link function to model mortality as a function of patient age, sex, and comorbidities. Using the estimated parameters, we calculated an expected probability of 30-day death for each patient hospitalized in 1995 to 2013. We then calculated a standardized mortality ratio as the observed 30-day deaths divided by the expected deaths for each year of 1995 to 2013. For a given year, a ratio greater than 1.0 indicates that the risk of death for such a patient is expected to be lower if that patient were hospitalized in 2014. We conducted a nonparametric bootstrapping with replacement to construct a 95% confidence interval for this standardized mortality ratio. To assess potential inequalities in the changes in patients’ risk of death, we compared the standardized mortality ratios across age, sex, race, and dual-eligible subgroups. At the hospital level, we assessed hospital performance by calculating a 30-day risk- standardized mortality rate for each hospital and each year based on the CMS method for profiling 13,14,17,18 hospitals. To assess hospital characteristics associated with mortality declines, we fitted a mixed model with the state as random effects and an identity link function to model the absolute JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 3/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults difference in risk-standardized mortality between 1995 and 2014 as a function of hospital characteristics, adjusting for hospitals’ baseline risk-standardized mortality rate. At the county level, to ensure that each county had an adequate number of patients with AMI, we divided the 20-year period into 5 intervals, each combining 4 sequential years of data (1995-1998, 1999-2002, 2003-2006, 2007-2010, and 2011-2014). We calculated the risk-standardized 30-day mortality rate for each county and each subperiod by extending the CMS method to the county level, adjusted for patient characteristics (age, sex, race [white, black, Hispanic, all others], dual eligibility, and comorbidities). We then mapped counties using a gradient from red, yellow, and green (increase in red, on average in yellow, and decrease in green). To assess county characteristics associated with the decline in mortality, we fitted a mixed model with state as random effects and an identity link function to model the absolute difference in risk-standardized mortality between 1995 to 1998 and 2011 to 2014 as a function of county characteristics. To facilitate data presentation, we report patient characteristics and outcomes by the five 4-year intervals defined in the county-level analysis. Analyses were conducted between January 15 and June 5, 2018, using SAS statistical software, version 9.4, 64-bit Windows version (SAS Institute, Inc). As of 2019, the data were 5 years old. All statistical tests were 2-tailed, at a significance level of .05. Results Study Population and Patient Characteristics There were 4 367 485 unique Medicare fee-for-service patients aged 65 years or older hospitalized for AMI across 5680 unique hospitals during the 20-year period. Between 1995 and 2014, the mean (SD) age of patients with AMI increased from 76.9 (7.2) to 78.2 (8.7) years, an absolute difference of 2.7 years; the proportion of female patients declined from 49.5% to 46.1%; the percentage of white patients declined from 91.0% to 86.2%; and the percentage of black patients increased from 5.9% to 8.0% (all P values for trends <.001). The rate of hospitalization for an initial AMI declined over the period from 914 to 566 per 100 000 beneficiary-years, a relative 38.1% reduction (eFigure 1 in the Supplement). Most comorbidities increased during the study period, but the proportions of patients with cerebrovascular disease, stroke, anterior AMI location, inferior lateral AMI, unstable angina, and valvular heart disease declined (eFigure 2 in the Supplement; Table). Changes in Risk of Mortality at the Patient Level Patient risk of 30-day mortality declined significantly over the 20-year period. The observed 30-day mortality declined from 20.0% in 1995 to 12.4% in 2014 (difference, 7.6 percentage points; 95% CI, 7.3-7.8 percentage points). This reduction in observed mortality was found across age, sex, race, and dual-eligibility subgroups (eFigure 3 in the Supplement); the gap in mortality decreased between the dual-eligible and non–dual-eligible subgroups (24.1% vs 19.4%; difference, 4.7 percentage points; 95% CI, 4.3-5.2 percentage points in 1995 and 14.0% vs 12.1%; difference, 1.9 percentage points; 95% CI, 1.4-2.3 percentage points in 2014) and between the female and male subgroups (21.8% vs 18.2%; difference, 3.6 percentage points; 95% CI, 3.4-4.0 percentage points in 1995 and 13.4% vs 11.6%; difference, 1.8 percentage points; 95% CI, 1.4-2.1 percentage points in 2014) (P < .001 for interactions). There were no differences in mortality by the race subgroups. Between 1995 and 2014, mortality declined from 13.4% to 7.5% (difference, 5.9 percentage points; 95% CI, 5.6-6.2 percentage points) for patients aged 65 to 74 years, 21.7% to 11.7% (difference, 10.0 percentage points; 95% CI, 9.6-10.4 percentage points) for patients aged 75 to 84 years, and 32.2% to 22.0% (difference, 10.2 percentage points; 95% CI, 9.7-10.9 percentage points) for patients aged 85 years or older. An interaction effect (P < .001) between year and age was observed. For a patient hospitalized in 1995, with demographic characteristics and comorbidities unchanged, the adjusted risk of 30-day mortality would be 34% (95% CI, 31.0%-37.2%) lower if the hospitalization occurred in 2014 (Figure 1). This reduction in the adjusted risk of mortality between 1995 and 2014 was lower in JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 4/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults patients aged 85 years or older (24%; 95% CI, 20.1%-28.0%), men (25.8%; 95% CI, 21.4%-28.6%), nonwhite and nonblack patients (27.3%; 95% CI, 23.4%-30.5%), and non–dual-eligible patients (32.4%; 95% CI, 29.3%-35.6%) than the national average (eFigure 4 in the Supplement). Changes in Risk of Mortality at the Hospital Level Between 1995 and 2014, the number of unique hospitals that treated at least 1 patient with AMI each year declined from 4989 to 3056; the median (interquartile range) hospital AMI volume remained unchanged from 31 (11-71) to 31 (8-79). The mean (SD) risk-standardized mortality rate, at the individual hospital level, declined from 20.0% (1.7%) in 1995 to 12.5% (1.1%) in 2014 (difference, 7.5 Table. Patient Characteristics 1995-1998 1999-2002 2003-2006 2007-2010 2011-2014 Aggregated Characteristic (n = 1 012 897) (n = 999 009) (n = 919 981) (n = 742 812) (n = 692 786) (N = 4 367 485) Demographic characteristics and comorbidities, No. (%) Age, mean (SD), y 77.3 (7.3) 78.4 (7.8) 78.6 (8.1) 78.6 (8.5) 78.1 (8.6) 78.2 (8.0) Female 505 015 (49.9) 505 786 (50.6) 461 401 (50.2) 366 863 (49.4) 326 029 (47.1) 2 165 094 (49.6) White 914 985 (90.3) 889 941 (89.1) 809 239 (88.0) 650 931 (87.6) 599 774 (86.6) 3 864 870 (88.5) Black 61 039 (6.0) 68 416 (6.8) 67 842 (7.4) 56 564 (7.6) 55 536 (8.0) 309 397 (7.1) Other race 31 440 (3.1) 40 652 (4.1) 42 900 (4.7) 35 317 (4.8) 37 476 (5.4) 193 218 (4.4) Heart failure 134 488 (13.3) 144 952 (14.5) 136 957 (14.9) 106 029 (14.3) 92 039 (13.3) 614 465 (14.1) Myocardial infarction 46 391 (4.6) 49 164 (4.9) 45 062 (4.9) 36 292 (4.9) 33 072 (4.8) 209 981 (4.8) Unstable angina 56 939 (5.6) 49 009 (4.9) 33 820 (3.7) 21 471 (2.9) 17 680 (2.6) 178 919 (4.1) Chronic atherosclerosis 680 245 (67.2) 655 429 (65.6) 630 149 (68.5) 519 313 (69.9) 496 177 (71.6) 2 981 313 (68.3) Cardiorespiratory disease 21 737 (2.1) 25 313 (2.5) 27 667 (3.0) 34 521 (4.6) 36 762 (5.3) 146 000 (3.3) Hypertension 485 258 (47.9) 537 800 (53.8) 532 660 (57.9) 477 564 (64.3) 468 670 (67.7) 2 501 952 (57.3) Stroke 20 517 (2.0) 20 595 (2.1) 17 841 (1.9) 13 913 (1.9) 12 405 (1.8) 85 271 (2.0) Cerebrovascular disease 40 588 (4.0) 52 259 (5.2) 42 135 (4.6) 30 768 (4.1) 27 183 (3.9) 192 933 (4.4) Renal failure 31 353 (3.1) 45 552 (4.6) 64 392 (7.0) 87 220 (11.7) 92 187 (13.3) 320 704 (7.3) Chronic obstructive pulmonary 204 168 (20.2) 227 051 (22.7) 223 856 (24.3) 158 333 (21.3) 138 327 (20.0) 951 735 (21.8) disease Pneumonia 91 977 (9.1) 126 982 (12.7) 131 896 (14.3) 114 628 (15.4) 101 380 (14.6) 566 863 (13.0) Protein calorie malnutrition 9810 (1.0) 24 282 (2.4) 27 512 (3.0) 33 123 (4.5) 36 604 (5.3) 131 331 (3.0) Dementia 50 051 (4.9) 92 066 (9.2) 95 134 (10.3) 81 219 (10.9) 47 194 (6.8) 365 664 (8.4) Functional disability 18 090 (1.8) 25 823 (2.6) 21 925 (2.4) 18 419 (2.5) 17 522 (2.5) 101 779 (2.3) Peripheral vascular disease 52 800 (5.2) 61 473 (6.2) 60 671 (6.6) 49 220 (6.6) 41 585 (6.0) 265 749 (6.1) Metastatic cancer 23 717 (2.3) 62 611 (6.3) 60 943 (6.6) 50 061 (6.7) 44 158 (6.4) 241 490 (5.5) Trauma in past year 41 581 (4.1) 51 883 (5.2) 56 273 (6.1) 45 483 (6.1) 37 689 (5.4) 232 909 (5.3) Major psychiatric disorder 12 524 (1.2) 18 274 (1.8) 16 481 (1.8) 14 918 (2.0) 15 113 (2.2) 77 310 (1.8) Liver disease 4222 (0.4) 5673 (0.6) 6337 (0.7) 5102 (0.7) 5751 (0.8) 27 085 (0.6) Depression 22 740 (2.2) 44 332 (4.4) 48 799 (5.3) 40 341 (5.4) 41 069 (5.9) 197 281 (4.5) Diabetes 334 688 (33.0) 293 433 (29.4) 277 281 (30.1) 225 956 (30.4) 229 613 (33.1) 1 360 971 (31.2) Outcomes, % (95% CI) 30-d mortality 19.1 (19.1-19.2) 19.2 (19.2-19.3) 17.1 (17.1-17.2) 15.2 (15.1-15.3) 13.4 (13.3-13.5) 17.2 (17.1-17.2) In-hospital mortality 14.3 (14.2-14.4) 14.1 (14.0-14.1) 11.5 (11.5-11.6) 9.2 (9.15-9.28) 7.7 (7.63-7.76) 11.7 (11.7-11.8) 30-d readmission 21.3 (21.2-21.4) 21.8 (21.7-21.9) 21.4 (21.3-21.5) 20.2 (20.1-20.3) 17.4 (17.3-17.5) 20.4 (20.3-20.4) Discharge to home 44.5 (44.4-44.6) 46.1 (46.0-46.2) 45.1 (45.0-45.2) 46.9 (46.8-47.0) 50.2 (50.1-50.3) 46.3 (46.3-46.3) Discharge to home with home 9.1 (9.06-9.17) 9.6 (9.51-9.62) 12.1 (12.1-12.2) 13.2 (13.2-13.3) 13.2 (13.1-13.3) 11.2 (11.2-11.2) health service Discharge to skilled nursing home 10.5 (10.4-10.5) 14.0 (13.9-14.1) 15.9 (15.8-16.0) 16.6 (16.6-16.7) 15.4 (15.3-15.5) 11.8 (11.8-11.9) Discharge to hospice 0 (0.01-0.01) 0.3 (0.30-0.32) 1.7 (1.64-1.69) 2.7 (2.71-2.78) 3.0 (2.96-3.04) 1.4 (1.35-1.38) Transferred to another 19.0 (18.9-19.1) 11.7 (11.6-11.7) 8.8 (8.70-8.82) 6.6 (6.57-6.68) 5.6 (5.59-5.70) 10.9 (10.9-11.0) acute-care hospital Length of stay, mean (SD), d 6.5 (6.0) 6.5 (6.7) 6.2 (6.5) 5.7 (5.9) 5.1 (5.2) 6.1 (6.2) JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 5/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults percentage points; 95% CI, 7.4-7.6 percentage points) (Figure 2). The distributions of risk- standardized mortality are shown in eFigure 5 in the Supplement. Overall, the annual national decline was 2.2%. There were 2635 hospitals represented in both 1995 and 2014. Among these, the absolute change in mortality between 1995 and 2014 ranged from a decrease of 15.4 percentage points to an increase of 2.5 percentage points, with 4 hospitals having increased mortality (increases ranging from 0.7-2.5 percentage points). A reduction in between-hospital heterogeneity in mortality was also observed: the hospital-specific mortality ranged from 11.3% to 28.0% (difference, 16.7 percentage points) in 1995 and ranged from 8.3% to 19.4% (difference, 11.1 percentage points) in 2014. Hospital characteristics were not associated with the decline in risk-standardized 30-day mortality (eFigure 6 in the Supplement). Figure 1. Change in Adjusted Risk of 30-Day Acute Myocardial Infarction Mortality at the Patient Level Between 1995 and 2014 1.5 95% Confidence limits 1.4 Change in patient risk of death 1.3 1.2 1.1 1.0 0.9 0.8 0.7 Points indicate year-specific risk-standardized 30-day 0.6 mortality ratios. The line was smoothed using the 0.5 locally estimated scatterplot smoothing (LOESS) 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 method (local regression). Year Figure 2. Change in Hospital-Specific Risk-Standardized 30-Day Acute Myocardial Infarction Mortality Rates Between 1995 and 2014 The size of each bar reflects the number of hospitals that filled in a particular interval of risk-standardized mortality rate as well as the distributions (ranges) of rates in 1995 and 2014. The curves represent distribution of the data. Mean (SD) risk-standardized 30-day mortality rates were 20.0% (2.0%) and 12.5% 0 (1.2%) for 1995 and 2014, respectively (n = 2635 6 8 10 12 14 16 18 20 22 24 26 28 30 hospitals). Restricted to hospitals that had at least 1 Risk-Standardized 30-d Mortality Rate, % case in both 1995 and 2014. JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 6/12 Hospitals, No. Risk-Standardized 30-d Mortality Ratio JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults Changes in Risk of Mortality at the County Level From 1995 to 1998 and 2011 to 2014, the county-specific mean (SD) 30-day risk-standardized mortality rate, adjusted for patient characteristics (age, sex, race [white, black, Hispanic, and all others], dual-eligible status, and comorbidities), declined from 19.2% (1.3%) to 13.4% (0.6%). Across counties, the absolute decline in percentage points ranged from 0.1 to 13.1, with 2 counties having increases (0.2 and 0.5 percentage points) (Figure 3). A reduction in between-county heterogeneity in mortality was also observed: the county-specific mortality ranged from 15.4% to 23.1% in 1995 to 1998 and from 12.2% to 13.9% in 2011 to 2014 (eFigure 7 in the Supplement). Overall, counties with a high rate of individuals enrolled in a Medicare Advantage plan, a high proportion of rural areas, and a high rate of residents who lived in the county for at least 1 year were more likely to have declines in mortality, but counties with high proportions of Medicare beneficiaries not enrolled in the Medicare Part B plan, unemployed residents, and a high risk of potential life lost were less likely to show declines in mortality (eFigure 8 in the Supplement). Counties in the health priority areas were less likely to have a decline in mortality (point estimate = −0.41; 95% CI, −0.60 to −0.23 points). Changes in Readmissions, In-Hospital Mortality, Length of Stay, and Medicare Payment Between 1995 and 2014 (2013 for 1-year recurrent AMI), the rates of 30-day all-cause readmissions, 1-year recurrent AMI, and in-hospital mortality declined from 21.0% to 15.3% (difference, 5.7 percentage points; 95% CI, 5.4-6.0 percentage points), 7.1% to 5.1% (difference, 2.0 percentage Figure 3. Difference in County-Specific 30-Day Risk-Standardized Acute Myocardial Infarction Mortality Rates Between 1995 to 1998 and 2011 to 2014 –13.1 to –7.7 –7.6 to –6.6 –6.5 to –5.9 –5.8 to –5.3 –5.2 to –4.4 –4.3 to 0.5 The difference was calculated as the percentage point between the 2011 to 2014 2011 to 2014 and 1995 to 1998 are shaded green, while those with the smallest decline combined rate minus the 1995 to 1998 combined rate. Counties are shaded according to or even increase in mortality between 2011 to 2014 and 1995 to 1998 are shaded red. the difference in percentage points of the risk-standardized acute myocardial infarction Counties are shaded white if there were missing or insufficient data that precluded the mortality rates (percentage). Counties with negative values had mortality rates that were calculation of mortality rates. lower in 2011 to 2014 than in 1995 to 1998. Counties with the largest decline between JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 7/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults points; 95% CI, 1.8-2.2 percentage points), and 15.4% to 7.3% (difference, 8.1 percentage points; 95% CI, 7.9-8.3 percentage points), respectively (Figure 4). The median (interquartile range) length of stay declined from 6.0 (3.0-8.0) days in 1995 to 3.0 (2.0-6.0) days in 2014. Between 1995 and 2014, the 2014 Consumer Price Index–adjusted median (interquartile range) Medicare inpatient payment per AMI discharge increased from $9282 ($6969-$12 173) to $11 031 ($8099-$16 861). Although the association between 30-day risk-standardized mortality and Medicare inpatient payment was negative over the study period (eFigure 9 in the Supplement), the effect size was small and it declined slightly over time. In 1995, a $10 000 increase in the payment was associated with an 0.5–percentage point decrease in 30-day risk-standardized mortality; in 2014, the same dollar amount was associated with a decrease of 0.3 percentage points. Changes in Inpatient Procedures Between 1995 and 2014, the rate of 30-day inpatient catheterization increased from 44.2% to 59.9% (difference, 15.7 percentage points; 95% CI, 15.4-16.0 percentage points), the rate of inpatient PCI increased from 18.8% to 43.3% (difference, 24.5 percentage points; 95% CI, 24.2-24.7 percentage points), and the rate of CABG decreased from 14.4% to 10.2% (difference, 4.2 percentage points; 95% CI, 3.9-4.3 percentage points) (eFigure 10 in the Supplement). All 3 procedure rates were correlated at the hospital level. The weighted Pearson correlation coefficients were 0.68 (PCI and CABG), 0.91 (PCI and catheterization), and 0.75 (CABG and catheterization). An increase of 1% in the PCI rate was associated with a decrease in mortality of 0.72 percentage points (95% CI, −0.80 to −0.64 percentage points), but the decrease in CABG rate was not associated with changes in mortality rate. Although we measured these procedures within a 30-day period from the index AMI hospitalization, the majority (96.0% of catheterizations, 96.3% of PCI, and 83.0% of CABG) were performed at the index hospitalization. Discussion From 1995 through 2014, the Medicare fee-for-service population experienced a remarkable and progressive improvement in the hospitalization rates for AMI and the 30-day mortality rate after AMI. In addition, the 2.7-year increase in the average age of patients suggests progress in delaying the onset of AMI. Mortality after AMI is at a historic low of 12%, a reduction of 34% since 1995, accounting for changes in patient characteristics. The improvements were consistent across demographic groups defined by age, sex, race, and eligibility for Medicaid. Almost all hospitals improved over this period, although there was some heterogeneity in the improvement over time, Figure 4. Changes in 30-Day All-Cause Readmissions, 1-Year Recurrent Acute Myocardial Infarction (AMI), In-Hospital Mortality, and Length of Stay All-cause 30-day readmission rate, % 1-y recurrent AMI, % Mean length of hospital stay, d In-hospital mortality, % Symbols denote observed values and lines represent changes over time. Lines were smoothed using the locally estimated scatterplot smoothing (LOESS) method (local regression). Triangles indicate 30-day all-cause readmissions; circles, 1-year recurrent AMI; diamonds, in-hospital mortality; and squares, length 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 of stay. Year JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 8/12 Outcomes JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults and almost every county experienced improvement, although the size of the change varied. The in-hospital mortality, length of stay, 30-day all-cause rehospitalization, and 1-year recurrent AMI rates also declined, while payments and rates of revascularization increased. The decline in in-hospital mortality was unlikely to have been affected by the decline in length of stay, given the decline in 30-day mortality. 2-4,7,8,10,11,19 This work extends the prior literature in several ways. Previous studies have reported some of these improvements, but not as comprehensively, or over a 20-year period or across the entire United States. As such, this work reveals novel insights about what has been achieved in reducing and mitigating AMI among Medicare beneficiaries. Moreover, even as payments per hospitalization have increased, outcomes improved and total cost declined because the number of hospitalizations was greatly reduced. There are several potential explanations for our findings, including changes in the treatment of AMI over this period. By the beginning of the period, it was established that aspirin, β-blockers, and rapid reperfusion therapy could improve outcomes for patients with AMI and that statins and risk factor control could reduce risk. However, it became apparent that the translation of the evidence into practice was incomplete. In the early 1990s, the Health Care Financing Administration (now CMS) launched an improvement initiative focused specifically on AMI. Many patients who were ideal 20-23 for particular clinical strategies were not receiving them. Moreover, PCI was emerging as a superior method of reperfusion but was used infrequently, in part because of its availability. Over the years, the use of evidence-based strategies improved dramatically. The speed of reperfusion therapy 3,24 for ST-segment elevation AMI also improved, as did the use of PCI in general. All of this occurred as a result of concerted efforts by CMS, the American College of Cardiology, the American Heart Association, and other national organizations, along with local hospitals and clinicians, to improve population risk and acute care. Lifestyle changes likely also contributed to the change in the rates of AMI. We identified some county characteristics that were associated with changes over time. Perhaps most disconcerting is that the areas of the country with persistently highest mortality rates, which we previously termed health priority areas, also had slower-than-average decline in AMI mortality. These areas may particularly benefit from future improvement activities. Limitations The study has several limitations. We examined data about individuals in the Medicare fee-for-service population, and the findings may not reflect the changes in the Medicare Advantage population. Moreover, the growing Medicare Advantage population may have implications for trend analyses, but we have risk adjusted the outcomes data. Also, the hospitalization rate has been dropping over time, and there is no indication that the fee-for-service population is getting healthier over time. Because this is a Medicare population, we cannot be sure about how our results may reflect the experience of younger populations. The lack of laboratory data in our study precluded our ability to include troponin levels in the risk adjustments. The lack of clinical information in claims data precluded our ability to assess the changes in process of care over time, such as door-to-balloon time and the use of medications, which could explain the changes in outcomes. Nevertheless, other 9,27 studies have shown remarkable improvement in AMI process measures over this period. Additionally, our assessments of comorbidities are dependent on codes and may not accurately reflect the condition of the patients, but the improvements were also present in unadjusted analyses. There may be some concerns that the higher sensitivity of biomarkers used to diagnose AMI may have contributed to the trend. Changing definitions of AMI do make comparisons difficult and likely led to shifting of patients among the categories of acute coronary syndromes. However, this improvement in mortality occurred in a period of a marked reduction in the number of hospitalizations. Moreover, the changes in mortality were gradual over time and did not show an abrupt change with the introduction of troponins—or level off after a period of adoption. Also, a systematic review of the validity of administrative codes did not find evidence of a secular trend in JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 9/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults code sensitivity, although the evidence is limited. Finally, we also restricted this study to a period in which International Classification of Diseases, Ninth Revision, Clinical Modification codes were used so as not to introduce a new coding system into the assessment of the trends. Also, the effect of the expansion of codes during this period on risk determination is unclear, but this seems unlikely to affect the overall findings of this study. Conclusions This study charts the course of AMI among Medicare fee-for-service beneficiaries over a recent 20-year period. Hospitalization rates for AMI declined 38%, and there were improvements in 30-day mortality, readmissions, length of stay, and 1-year recurrent AMI, with only a modest increase in payments. Revascularization rates increased markedly. Thirty-day adjusted mortality, which declined 34%, touched almost every county and hospital in the country. Nevertheless, there was heterogeneity in the performance over time with some hospital and county characteristics associated with the change. Overall, however, we describe 2 decades of marked improvements in outcomes for AMI among the increasingly smaller number of people in the United States who experience it, representing a transition in the impact of this condition. ARTICLE INFORMATION Accepted for Publication: February 18, 2019. Published: March 15, 2019. doi:10.1001/jamanetworkopen.2019.1938 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Krumholz HM et al. JAMA Network Open. Corresponding Author: Harlan M. Krumholz, MD, SM, Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, One Church St, Ste 200, New Haven, CT 06510 (harlan.krumholz@yale.edu). Author Affiliations: Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut (Krumholz); Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut (Krumholz); Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut (Krumholz, Wang); Department of Health Care Policy, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Normand, Wang); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Wang). Author Contributions: Dr Wang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Krumholz, Wang. Acquisition, analysis, or interpretation of data: Normand, Wang. Drafting of the manuscript: Krumholz. Critical revision of the manuscript for important intellectual content: Normand, Wang. Statistical analysis: Normand, Wang. Supervision: Krumholz. Conflict of Interest Disclosures: Dr Krumholz reported personal fees from UnitedHealth, IBM Watson Health, Element Science, Aetna, Facebook, Arnold & Porter, and the Ben C. Martin Law Firm; grants from the Centers for Medicare & Medicaid Services, Medtronic, Johnson & Johnson, and the Food and Drug Administration; and serving as founder of the personal health information platform Hugo outside the submitted work. Dr Normand reported a patent to 201810345624.5 pending. No other disclosures were reported. REFERENCES 1. Ellerbeck EF, Jencks SF, Radford MJ, et al. Quality of care for Medicare patients with acute myocardial infarction: a four-state pilot study from the Cooperative Cardiovascular Project. JAMA. 1995;273(19):1509-1514. doi:10.1001/ jama.1995.03520430045037 2. Chen HY, Gore JM, Lapane KL, et al. A 35-year perspective (1975 to 2009) into the long-term prognosis and hospital management of patients discharged from the hospital after a first acute myocardial infarction. Am J Cardiol. 2015;116(1):24-29. doi:10.1016/j.amjcard.2015.03.035 JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 10/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults 3. Chen HY, Tisminetzky M, Lapane KL, et al. Decade-long trends in 30-day rehospitalization rates after acute myocardial infarction. J Am Heart Assoc. 2015;4(11):e002291. doi:10.1161/JAHA.115.002291 4. Gerber Y, Weston SA, Jiang R, Roger VL. The changing epidemiology of myocardial infarction in Olmsted County, Minnesota, 1995-2012. Am J Med. 2015;128(2):144-151. doi:10.1016/j.amjmed.2014.09.012 5. Krumholz HM, Normand SL, Wang Y. Trends in hospitalizations and outcomes for acute cardiovascular disease and stroke, 1999-2011. Circulation. 2014;130(12):966-975. doi:10.1161/CIRCULATIONAHA.113.007787 6. Krumholz HM, Wang Y, Chen J, et al. Reduction in acute myocardial infarction mortality in the United States: risk-standardized mortality rates from 1995-2006. JAMA. 2009;302(7):767-773. doi:10.1001/jama.2009.1178 7. McGovern PG, Pankow JS, Shahar E, et al; The Minnesota Heart Survey Investigators. Recent trends in acute coronary heart disease—mortality, morbidity, medical care, and risk factors. N Engl J Med. 1996;334(14):884-890. doi:10.1056/NEJM199604043341403 8. Newman JD, Shimbo D, Baggett C, et al; ARIC Study Investigators. Trends in myocardial infarction rates and case fatality by anatomical location in four United States communities, 1987 to 2008 (from the Atherosclerosis Risk in Communities Study). Am J Cardiol. 2013;112(11):1714-1719. doi:10.1016/j.amjcard.2013.07.037 9. Nuti SV, Wang Y, Masoudi FA, et al. Improvements in the distribution of hospital performance for the care of patients with acute myocardial infarction, heart failure, and pneumonia, 2006-2011. Med Care. 2015;53(6): 485-491. doi:10.1097/MLR.0000000000000358 10. O’Brien EC, Rose KM, Suchindran CM, et al. Temporal trends in medical therapies for ST- and non-ST elevation myocardial infarction (from the Atherosclerosis Risk in Communities [ARIC] Surveillance Study). Am J Cardiol. 2013;111(3):305-311. doi:10.1016/j.amjcard.2012.09.032 11. Rosamond WD, Chambless LE, Heiss G, et al. Twenty-two-year trends in incidence of myocardial infarction, coronary heart disease mortality, and case fatality in 4 US communities, 1987-2008. Circulation. 2012;125(15): 1848-1857. doi:10.1161/CIRCULATIONAHA.111.047480 12. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 2007;4(10):e296. doi:10.1371/journal.pmed.0040296 13. Krumholz HM, Wang Y, Mattera JA, et al. An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with an acute myocardial infarction. Circulation. 2006;113(13):1683-1692. doi:10.1161/CIRCULATIONAHA.105.611186 14. Normand S-LT, Wang Y, Krumholz HM. Assessing surrogacy of data sources for institutional comparisons. Health Serv Outcomes Res Methodol. 2007;7:79-96. doi:10.1007/s10742-006-0018-8 15. Centers for Medicare & Medicaid Services. 5010 implementation—processing additional International Classification of Diseases, 9th Revision—Clinical Modification (ICD-9-CM) diagnosis and procedure codes in pricer, grouper, and the Medicare code editor (MCE). https://www.cms.gov/Regulations-and-Guidance/Guidance/ Transmittals/downloads/ R2028CP.pdf. Published August 13, 2010. Accessed January 30, 2019. 16. Krumholz HM, Normand ST, Wang Y. Geographical health priority areas for older Americans. Health Aff (Millwood). 2018;37(1):104-110. doi:10.1377/hlthaff.2017.0744 17. Bratzler DW, Normand SL, Wang Y, et al. An administrative claims model for profiling hospital 30-day mortality rates for pneumonia patients. PLoS One. 2011;6(4):e17401. doi:10.1371/journal.pone.0017401 18. Krumholz HM, Wang Y, Mattera JA, et al. An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with heart failure. Circulation. 2006;113(13): 1693-1701. doi:10.1161/CIRCULATIONAHA.105.611194 19. Rosamond WD, Chambless LE, Folsom AR, et al. Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994. N Engl J Med. 1998;339(13):861-867. doi:10.1056/ NEJM199809243391301 20. Krumholz HM, Murillo JE, Chen J, et al. Thrombolytic therapy for eligible elderly patients with acute myocardial infarction. JAMA. 1997;277(21):1683-1688. doi:10.1001/jama.1997.03540450039032 21. Krumholz HM, Radford MJ, Ellerbeck EF, et al. Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcomes. Ann Intern Med. 1996;124(3):292-298. doi:10.7326/0003- 4819-124-3-199602010-00002 22. Krumholz HM, Radford MJ, Ellerbeck EF, et al. Aspirin in the treatment of acute myocardial infarction in elderly Medicare beneficiaries: patterns of use and outcomes. Circulation. 1995;92(10):2841-2847. doi:10.1161/01.CIR.92. 10.2841 JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 11/12 JAMA Network Open | Cardiology Twenty-Year Trends in Outcomes of Acute Myocardial Infarction in Older US Adults 23. Krumholz HM, Radford MJ, Wang Y, Chen J, Heiat A, Marciniak TA. National use and effectiveness of beta- blockers for the treatment of elderly patients after acute myocardial infarction: National Cooperative Cardiovascular Project. JAMA. 1998;280(7):623-629. doi:10.1001/jama.280.7.623 24. Nallamothu BK, Normand SL, Wang Y, et al. Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study. Lancet. 2015;385(9973):1114-1122. doi:10.1016/S0140-6736(14)61932-2 25. Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary heart disease? the Lifestyle Heart Trial. Lancet. 1990;336(8708):129-133. doi:10.1016/0140-6736(90)91656-U 26. Miller EA, Decker SL, Parker JD. Characteristics of Medicare Advantage and fee-for-service beneficiaries upon enrollment in Medicare at age 65. J Ambul Care Manage. 2016;39(3):231-241. doi:10.1097/JAC. 27. Makam RC, Erskine N, McManus DD, et al. Decade-long trends (2001 to 2011) in the use of evidence-based medical therapies at the time of hospital discharge for patients surviving acute myocardial infarction. Am J Cardiol. 2016;118(12):1792-1797. doi:10.1016/j.amjcard.2016.08.065 28. Dalen JE, Alpert JS, Goldberg RJ, Weinstein RS. The epidemic of the 20th century: coronary heart disease. Am J Med. 2014;127(9):807-812. doi:10.1016/j.amjmed.2014.04.015 29. McCormick N, Lacaille D, Bhole V, Avina-Zubieta JA. Validity of myocardial infarction diagnoses in administrative databases: a systematic review. PLoS One. 2014;9(3):e92286. doi:10.1371/journal.pone.0092286 SUPPLEMENT. eTable. County-Specific Characteristics eFigure 1. Change in Number of Initial AMI Hospitalizations per 100,000 Beneficiary-Years, 1995-2014 eFigure 2. Annual Relative Changes in Patient Characteristics eFigure 3. Trend in Observed Mortality by Year and Sub-population eFigure 4. Changes in Patient Risk of 30-Day Mortality Between 2014 and 1995 by Sub-population eFigure 5. Nationwide Change in Hospital-Specific 30-Day Risk-Standardized Mortality Rate by Selected Years eFigure 6. Hospital Characteristics Associated With Change in Difference in Hospital-Specific Risk-Standardized 30-Day Mortality Rates Between 1995 and 2014 eFigure 7. Change in County-Specific Risk-Standardized 30-Day Mortality in 1995-1998 (Top Panel) and in 2011- 2014 (Bottom Panel) eFigure 8. County-Specific Characteristics Associated With Difference in County-Specific Risk-Standardized 30-Day Mortality Between 1995-1998 and 2011-2014 eFigure 9. Association Between Medicare Inpatient Payment and 30-Day Risk-Standardized Mortality at the Hospital Level eFigure 10. Annual Changes in the 30-Day Rates of Three Common AMI-Specific Procedures (Catheterization, CABG, and PCI) JAMA Network Open. 2019;2(3):e191938. doi:10.1001/jamanetworkopen.2019.1938 (Reprinted) March 15, 2019 12/12 Supplementary Online Content Krumholz HM, Normand S-LT, Wang Y. Twenty-year trends in outcomes for older adults with acute myocardial infarction in the United States. JAMA Netw Open. 2019;2(3):e191938 doi:10.1001/jamanetworkopen.2019.1938 eTable. County-Specific Characteristics eFigure 1. Change in Number of Initial AMI Hospitalizations per 100,000 Beneficiary- Years, 1995-2014 eFigure 2. Annual Relative Changes in Patient Characteristics eFigure 3. Trend in Observed Mortality by Year and Sub-population eFigure 4. Changes in Patient Risk of 30-Day Mortality Between 2014 and 1995 by Sub-population eFigure 5. Nationwide Change in Hospital-Specific 30-Day Risk-Standardized Mortality Rate by Selected Years eFigure 6. Hospital Characteristics Associated With Change in Difference in Hospital- Specific Risk-Standardized 30-Day Mortality Rates Between 1995 and 2014 eFigure 7. Change in County-Specific Risk-Standardized 30-Day Mortality in 1995-1998 (Top Panel) and in 2011-2014 (Bottom Panel) eFigure 8. County-Specific Characteristics Associated With Difference in County- Specific Risk-Standardized 30-Day Mortality Between 1995-1998 and 2011-2014 eFigure 9. Association Between Medicare Inpatient Payment and 30-Day Risk- Standardized Mortality at the Hospital Level eFigure 10. Annual Changes in the 30-Day Rates of Three Common AMI-Specific Procedures (Catheterization, CABG, and PCI) This supplementary material has been provided by the authors to give readers additional information about their work. © 2019 Krumholz HM et al. JAMA Network Open. eTable. County-specific characteristics. Proportion of senior population (age 65) (%) Divorced (%) Residence one year ago (%) - Different house in the U.S. - different county Geography Rural area residents (%) In health priority area (yes/no) Socioeconomic Status Bachelor or higher degree (%) Consumer Price Index-adjusted median income ($10,000) Proportion of population under the poverty level (%) Eligible for both Medicare and Medicaid (dual-eligible) (%) Gini coefficient, continuous (0 to 1) Percent of unemployed in 2010 (%) General Health Age-adjusted prevalence of adult diabetes (%) At least 1 ambulatory visit to a primary care clinician (%) Years of potential life lost Emergency department visit rate (%) Availability of Care Percent of diabetic Medicare beneficiaries receiving HbA1c test (%) Percent of female Medicare beneficiaries having at least 1 mammogram in 2 yrs (age 67-69) (%) Enrolled in Medicare Advantage for all 12 months (%) Not enrolled in supplementary medical insurance (Medicare Part B) (%) Health Behaviors Age-adjusted rate of physical inactivity (%) © 2019 Krumholz HM et al. JAMA Network Open. eFigure 1. Change in number of initial AMI hospitalizations per 100,000 beneficiary-years, 1995-2014. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 2. Annual relative changes in patient characteristics. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 3. Trend in observed mortality by year and sub-population. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 4. Changes in patient risk of 30-day mortality between 2014 and 1995 by sub-population. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 5. Nationwide change in hospital-specific 30-day risk-standardized mortality rate by selected years. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 6. Hospital characteristics associated with change in difference in hospital-specific risk-standardized 30-day mortality rates between 1995 and 2014. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 7. Change in county-specific risk-standardized 30-day mortality in 1995-1998 (top panel) and in 2011-2014 (bottom panel). Note: The mortality rate in the highest regions in 2011-2014 was lower than the mortality rate in the lowest regions in 1995-1998. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 8. County-specific characteristics associated with difference in county- specific risk-standardized 30-day mortality between 1995-1998 and 2011-2014. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 9. Association between Medicare inpatient payment and 30-day risk-standardized mortality at the hospital level. © 2019 Krumholz HM et al. JAMA Network Open. eFigure 10. Annual changes in the 30-day rates of three common AMI-specific procedures (catheterization, CABG, and PCI). © 2019 Krumholz HM et al. JAMA Network Open.

Journal

JAMA Network Open – American Medical Association

Published: Mar 15, 2019

There are no references for this article.