Background

Myocardial infarction mortality varies substantially within high-income countries. There is limited guidance on what interventions—including primary and secondary prevention, or improvement of care pathways and quality—can reduce myocardial infarction mortality. Our aim was to understand the contributions of incidence (event rate), pre-hospital deaths, and hospital case fatality to the variations in myocardial infarction mortality within England.

Methods

We used linked data from national databases on hospitalisations and deaths with acute myocardial infarction (ICD-10 codes I21 and I22) as a primary hospital diagnosis or underlying cause of death, from Jan 1, 2015, to Dec 31, 2018. We used geographical identifiers to estimate myocardial infarction event rate (number of events per 100 000 population), death rate (number of deaths per 100 000 population), total case fatality (proportion of events that resulted in death), pre-hospital fatality (proportion of events that resulted in pre-hospital death), and hospital case fatality (proportion of admissions due to myocardial infarction that resulted in death within 28 days of admission) for men and women aged 45 years and older across 326 districts in England. Data were analysed in a Bayesian spatial model that accounted for similarities and differences in spatial patterns of fatal and non-fatal myocardial infarction. Age-standardised rates were calculated by weighting age-specific rates by the corresponding national share of the appropriate denominator for each measure.

Findings

From 2015 to 2018, national age-standardised death rates were 63 per 100 000 population in women and 126 per 100 000 in men, and event rates were 233 per 100 000 in women and 512 per 100 000 in men. After age-standardisation, 15·0% of events in women and 16·9% in men resulted in death before hospitalisation, and hospital case fatality was 10·8% in women and 10·6% in men. Across districts, the 99th-to-1st percentile ratio of age-standardised myocardial infarction death rates was 2·63 (95% credible interval 2·45–2·83) in women and 2·56 (2·37–2·76) in men, with death rates highest in parts of northern England. The main contributor to this variation was myocardial infarction event rate, with a 99th-to-1st percentile ratio of 2·55 (2·39–2·72) in women and 2·17 (2·08–2·27) in men across districts. Pre-hospital fatality was greater than hospital case fatality in every district. Pre-hospital fatality had a 99th-to-1st percentile ratio of 1·60 (1·50–1·70) in women and 1·75 (1·66–1·86) in men across districts, and made a greater contribution to variation in total case fatality than did hospital case fatality (99th-to-1st percentile ratio 1·39 [1·29–1·49] and 1·49 [1·39–1·60]). The contribution of case fatality to variation in deaths across districts was largest in women aged 55–64 and 65–74 years and in men aged 55–64, 65–74, and 75–84 years. Pre-hospital fatality was slightly higher in men than in women in most districts and age groups, whereas hospital case fatality was higher in women in virtually all districts at ages up to and including 65–74 years.

Interpretation

Most of the variation in myocardial infarction mortality in England is due to variation in myocardial infarction event rate, with a smaller role for case fatality. Most variation in case fatality occurs before rather than after hospital admission. Reducing subnational variations in myocardial infarction mortality requires interventions that reduce event rate and pre-hospital deaths.

Funding

Wellcome Trust, British Heart Foundation, Medical Research Council (UK Research and Innovation), and National Institute for Health Research (UK).

中文翻译：

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英格兰 326 个地区事件发生率、院前死亡和住院后死亡对心肌梗死死亡率变化的影响：住院和死亡率相关数据的空间分析

背景

高收入国家的心肌梗死死亡率差异很大。关于哪些干预措施（包括一级和二级预防，或改善护理途径和质量）可以降低心肌梗死死亡率的指导有限。我们的目的是了解英格兰境内发病率（事件发生率）、院前死亡和住院病例死亡率对心肌梗死死亡率变化的影响。

方法

我们使用了2015年1月1日至2018年12月31日期间急性心肌梗死（ICD-10代码I21和I22）住院和死亡国家数据库的链接数据作为主要医院诊断或根本死因。我们使用地理用于估算心肌梗死事件发生率（每 10 万人的事件数）、死亡率（每 10 万人的死亡人数）、总病死率（导致死亡的事件比例）、院前死亡（事件比例）的标识符英格兰 326 个地区 45 岁及以上的男性和女性的院内病死率（因心肌梗死导致入院 28 天内死亡的入院比例）。在贝叶斯空间模型中分析数据，该模型解释了致命性和非致命性心肌梗死空间模式的相似性和差异。年龄标准化比率是通过对每项措施的适当分母的相应全国份额对特定年龄比率进行加权来计算的。

发现

2015年至2018年，全国年龄标准化死亡率女性为每10万人63人，男性每10万人126人，事件发生率为每10万人233人，男性每10万人512人。年龄标准化后，女性中 15·0% 的事件导致住院前死亡，男性中 16·9% 的事件导致住院前死亡，女性住院病死率为 10·8%，男性为 10·6%。在各地区，年龄标准化心肌梗死死亡率的第 99 与第 1 个百分位比，女性为 2·63（95% 可信区间 2·45–2·83），女性为 2·56（2·37–2·76）。 ）在男性中，死亡率在英格兰北部部分地区最高。造成这种变化的主要原因是心肌梗塞事件发生率，女性的第 99 与第 1 百分位比为 2·55 (2·39–2·72)，女性为 2·17 (2·08–2·27)。跨地区的男人。每个地区的院前死亡人数均高于医院死亡人数。各地区院前死亡的 99% 与第 1% 的百分位数比率，女性为 1·60 (1·50–1·70)，男性为 1·75 (1·66–1·86)，与医院病死率相比，对总病死率变化的贡献更大（第 99 与第 1 百分位数比 1·39 [1·29–1·49] 和 1·49 [1·39–1·60]）。55-64 岁和 65-74 岁女性以及 55-64 岁、65-74 岁和 75-84 岁男性中病死率对各地区死亡差异的影响最大。在大多数地区和年龄组中，男性的院前死亡率略高于女性，而在几乎所有地区，年龄在 65-74 岁（包括 65-74 岁）的女性医院病死率较高。

解释

英国心肌梗塞死亡率的变化大部分是由于心肌梗塞事件发生率的变化造成的，病死率的影响较小。病死率的大多数变化发生在入院之前而不是入院之后。减少心肌梗死死亡率的地方差异需要采取干预措施来降低事件发生率和院前死亡。

资金

威康信托基金会、英国心脏基金会、医学研究委员会（英国研究与创新）和国家健康研究所（英国）。