ECHO INDICATORS- Getting sound indicators across languages


Select an indicator









Cardiovascular (CV)

INDICATOR: In Hospital Case-Fatalities Rate after Acute Myocardial Infarction (AMI)


Reductions in AMI case fatality rates have been associated with better care processes. In-hospital case-fatality rates are thus often used as an inpatient quality indicator.

Under the ECHO framework, AMI case-fatality rates beyond a defined threshold are taken as indicators of differences in hospital quality, once differences between patients have been ruled out.

Nonetheless, other factors should also be considered when interpreting variation in case fatalities, including differences in the time between pain onset and admission to an emergency ward, difference in discharge policies, and uneven distribution of services for continued care.


Case fatality rate per 1,000 AMI admissions aged 18 and older.

Numerator: Deaths among cases that meet the inclusion and exclusion rules for the denominator.

Denominator: Patients aged 18 years and older with a principal diagnosis code for AMI. Obstetric discharges are excluded.


• This indicator should be used to adjust for differences between patients. To this end, ECHO models AMI in-hospital case-fatality rates using the following covariates: age, sex, Elixhauser comorbidities, and AMI type (STEMI vs. non-STEMI). However, risk adjustment may be suboptimal in identifying differences in severity, which are not routinely recorded, thus penalizing hospitals that treat more complex cases. Volume stratification is recommended in order to reduce this risk.

• Risk adjustment also depends on the quality of coding, especially when it comes to comorbidities. A systematic increase in obesity and hypertension coding is observed in Denmark and England. Although comorbidities usually explain an exiguous 10% of variation, some overadjustment may be observed when using obesity and hypertension as covariates in time-series analyses. Slovene registries are reliable enough after 2005.

• Excluding transfers out has been proposed as a means of increasing specificity of attribution; hospitals could be interested in early discharge, or in transferring out more severe patients, thus getting better results. However, transferring AMI patients out may also be a feature of the organization of a given health system. ECHO recommends not using transfers out in international comparisons, and limiting its use to in-country studies.









'Annex mdc14.pdf'




This project is funded by the Framework 7
Programme of the European Union

ECHO Project   -   Disclaimer   |   Project enquiries