ACS patients in New Zealand experience significant delays to access cardiac investigations and revascularisation treatment especially when admitted to non-interventional centres: results of the second comprehensive national audit of ACS patients
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In New Zealand there has been a more than doubling of hospital discharges for a heart attack from 1989 to 2002/2003.1 Hence there is a significant clinical problem which mandates an efficient management strategy. Current management of high-risk ACS patients includes optimal medical treatment and an invasive revascularisation strategy guided by cardiac angiography, as recommended by international2-5 and local6, 7 clinical guidelines. A previous comprehensive nationwide audit of ACS patients undertaken in 2002,8 found inequitable management across New Zealand, as patients admitted to a hospital without cardiac interventional facilities received fewer investigations and less revascularisation treatment than patients admitted to intervention centres.9Smaller local studies in Taranaki/Waikato,10 Invercargill/Dunedin11 and North Shore Hospital/Auckland City Hospital, Auckland12 have all demonstrated a limited access to invasive investigations and revascularisation of ACS patients admitted to non-invasive centres. Patients from Invercargill11 experienced a 2.5-fold lower rate of angiography and revascularisation than those admitted directly to Dunedin hospital. In-hospital mortality differed by 3.3% (10.7% vs 6.4%) and then widened to approximately 10% at both 6 months (19.1% vs 9.6%), 12 months (22.1% vs 12.1%) and up to 5 years.13We aimed to determine the current management of ACS patients presenting to interventional and non-interventional New Zealand hospitals. The primary goal of this study, in particular, was to assess cardiac investigations and treatments received by patients and examine time delays experienced by patients in accessing management.Methods Data collectionThe development of the New Zealand Acute Coronary Syndrome (NZACS) Audit Group and the methodology for the national audit, which was supported by the Cardiac Society of New Zealand, has been published elsewhere.14 The inclusion criterion for the audit was a patient admitted overnight with a suspected or definite acute coronary syndrome. Following admission and investigations, a discharge diagnosis was subsequently determined by the local clinical team who confirmed the diagnosis of an ACS, as a STEMI, NSTEMI or UAP, or determined a non-ACS presentation resultant on investigations undertaken in hospital and the patients clinical course. An extensive four-page case report form was used to obtain patient demographics, initial and discharge diagnosis, medication use in hospital and at discharge, as well as investigations undertaken and invasive treatments received by patients. Ethnicity was self-reported at hospital admission. Data from the NZACS Audit were used to compare patients presentation and management at intervention centres (6 public hospitals and 3 private hospitals), with non-intervention centres (30 public hospital) [Table 1]. One centre (Middlemore Hospital, Auckland), was able to undertake cardiac angiograms and PCIs throughout the working week (08.00 to 16.00, Monday to Friday) but not cout of hoursd, and did not perform CABG operations, and was classified as an intervention centre. One centre (Nelson Hospital) was able to undertake some angiography and a limited number of PCI procedures, but had a limited operation with only one interventional cardiologist performing PCI, and was also unable to perform CABG operations, and hence was classified as a non-interventional centre. Table 1. Admissions and transfers to intervention (n=447) and non-intervention (n=556) centres Facilities No. of own patients Transferred in Total Admissions Transferred Out Angiogram PCI CABG Auckland City Hospital Middlemore, Auckland Mercy, Auckland (Private) Ascot, Auckland (Private) Waikato, Hamilton Wellington Wakefield, Wellington (Private) Christchurch Dunedin Total 122 35 6 2 56 57 0 141 28 447 52 13 50 3 10 128 174 35 6 2 69 107 0 144 38 575 2 1 3 Y Y Y Y Y Y Y Y Y 100% Y Y Y Y Y Y Y Y Y 100% Y N Y Y Y Y Y Y Y 89% Non-Intervention Centres (n=30) Auckland/Northland, North Is Kaitaia Dargaville Rawene Kawakawa Whangarei North Shore Waitakere 9 5 0 3 37 66 24 144 2 1 3 9 5 0 3 39 67 24 147 2 2 1 4 28 15 52 N N N N N N* N 0% N N N N N N* N 0% N N N N N N N 0% Waikato/Central, North Is Thames Tauranga Whakatane Rotorua Tokoroa Te Kuiti Taupo Gisborne Taumarunui New Plymouth 19 44 12 28 2 0 11 16 1 17 150 0 19 44 12 28 2 0 11 16 1 17 150 2 4 4 2 12 N Y N N N N N N N Y 20% N N N N N N N N N N 0% N N N N N N N N N N N 0% Wellington/Southern, North Island/top of South Island Hastings Wanganui Palmerston North Masterton Hutt Nelson Blenheim 76 26 25 10 25 14 12 188 1 2 3 77 26 25 10 25 16 12 191 17 6 13 5 4 4 2 51 Y N Y N N Y N 43% N N N N N Y N 14% N N N N N N N 0% Christchurch/Canterbury, South Island Greymouth Ashburton Timaru 6 3 31 40 0 6 3 31 40 2 1 2 5 N N N 0% N N N 0% N N N 0% Dunedin/Otago, South Island Oamaru Clyde Invercargill 10 3 21 34 0 10 3 21 34 4 1 5 10 N N N 0% N N N 0% N N N 0% Total 556 6 562 130 PCI: Percutaneous coronary intervention; CABG: Coronary artery bypass grafting, Y: yes; N: no; *Acquired angiography and PCI capability during working hours since the Audit in 2007. An additional four public hospitals (Tauranga, New Plymouth, Hastings and Palmerston North) were classified as non-intervention centres as they had the ability to perform some cardiac angiograms, but not PCI or CABG surgery. Cardiac angiography, PCI and CABG surgery was also performed at a private hospital in Christchurch; however this hospital does not plan to admit ACS patients and hence is not further considered with this audit. Investigations and revascularisation of transferred patients was attributed to the referring centre. Data were collected from 0000 hours on Monday 14 May to 2400 hours on Sunday 27 May 2007. StatisticsContinuous data were summarised as median and interquartile range (IQR) and compared using the Wilcoxon rank sums test. Differences in frequencies were tested using standard chi-squared procedures or Fishers exact test as appropriate. All analyses were conducted using SAS (SAS Institute Inc v9.1). All tests were two-tailed and a 5% significance level was maintained throughout. Results Admissions and transfersOver the 14-day period, 1003 suspected or definite ACS patients were admitted to an intervention centre (447) or to a non-intervention centre (556). Eight patients were re-admitted within the 2 weeks (seven once and one twice), all to the same hospital. One hundred and thirty-four patients were transferred to another institution for further management (128 (96%) to an intervention centre). Data from patients transferred were attributed only to the hospital to which they were initially admitted (Table 1). Table 2. Baseline demographic data of patients admitted to an intervention or non-intervention centre (n=1003) Variable Hospital type P Intervention (n=447) Non-intervention (n=556) Age median [years](range) 66 (18-97) 70 (23-95) 0.0097 Sex (male) 265 (59%) 315 (57%) 0.41 Ethnicity Caucasian M\u0101ori Pacifica Asian Indian Not reported Other 340 (76%) 26 (5.8%) 22 (4.9%) 13 (2.9%) 20 (4.5%) 18 (4.0%) 8 (1.8%) 435 (78%) 66 (12%) 11 (2.0%) 7 (1.3%) 7 (1.3%) 29 (5.2%) 1 (0.18%) 0.49 0.0009 0.012 0.072 0.0026 0.45 0.013 Tobacco smoker Current Previous Current and Previous Never Not reported 83 (19%) 157 (35%) 240 (56%) 188 (42%) 19 (4%) 96 (17%) 232 (42%) 328 (62%) 199 (36%) 29 (5%) 0.62 0.037 0.055 0.043 0.55 Hypertension (drug treatment) 231 (52%) 291 (52%) 0.85 Diabetes Type 1 Type 2 Not defined 93 (15%) 3 (3%) 89 (96%) 1 (1%) 89 (16%) 3 (3%) 86 (97%) 0 0.058 0.99 0.99 0.45
Summary
Abstract
Aim
To compare the management of acute coronary syndrome (ACS) patients presenting to interventional versus non-interventional New Zealand hospitals, with emphasis, on access delays for invasive assessment and revascularisation treatments.
Method
Using data collected by the New Zealand Cardiac Society ACS Audit Group over 14 days from each hospital in New Zealand (n=39) that admits ACS patients, patient management at intervention centres (6 public, 3 private) was compared with non-intervention centres (30 public). Investigations and revascularisation procedures performed on transferred patients were attributed to the referring centre.
Results
From 00.00 hours on 14 May 2007 to 24.00 hours on 27 May 2007, 1003 patients were admitted to a New Zealand hospital with a suspected or definite ACS: ST-segment-elevation myocardial infarction [STEMI] (8%), non-STEMI [NSTEMI] (41%), unstable angina pectoris [UAP] 33%, or another cardiac or medical diagnosis (17%). Patients admitted to a non-intervention centre (n=556) were older (median age 70 vs 66 years, p=0.0097), with similar risk factors, and were more likely to be of M ori (12% vs 5.8%, p
Conclusion
Patients admitted to a New Zealand hospital with an acute coronary syndrome experience delays in accessing investigations and subsequent revascularisation. Furthermore, inequity exists with delays being significantly longer for patients admitted to a non-intervention centre. A comprehensive national strategy is needed to improve access to optimal cardiac care.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Elliott J, Richards M. Heart attacks and unstable angina (acute coronary syndromes) have doubled in New Zealand since 1989: how do we best manage the epidemic? NZ Med J 2005;118(1223). http//www.nzma.org.nz/journal/118-1223/1674-- Bassand J, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of cardiology. Eur Heart J 2007;28:1598-1660.-- Van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of cardiology. Eur Heart J 2008;29:2909-2945.-- Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non ST-Elevation Myocardial Infarction Executive Summary. J Am Coll Cardiol 2007;50:652-726.-- Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2008;51:210-247.-- Non ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand. Non ST-elevation myocardial infarction: New Zealand management guidelines. NZ Med J 2005;118:1-19. http://www.nzma.org.nz/journal/118-1223/1680-- ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand. ST-elevation myocardial infarction: New Zealand management guidelines. NZ Med J 2005;118(1223).http://www.nzma.org.nz/journal/118-1223/1679-- Ellis C, Gamble G, French J, et al. Management of patients admitted with an Acute Coronary Syndrome in New Zealand: Results of a comprehensive nationwide audit. NZ Med J 2004;117(1197). http://www.nzma.org.nz/journal/117-1197/953-- Ellis C, Devlin G, Matsis P, et al. Acute Coronary Syndrome patients in New Zealand receive less invasive management when admitted to hospitals without invasive facilities. NZ Med J 2004;117(1197). http://www.nzma.org.nz/journal/117-1197/954-- Conaglen P, Sebastian C, Jayaraman C, et al. Management of unstable angina and non-ST elevation myocardial infarction: do cardiologists do it better? A comparison of secondary and tertiary centre management in New Zealand. NZ Med J 2004;117(1194). http://www.nzma.org.nz/journal/117-1194/890.-- Tang EW, Wong CK, Herbison P. Community hospital versus tertiary hospital comparison in the treatment and outcome of patients with acute coronary syndrome: a New Zealand experience. NZ Med J 2006;119(1238).http://www.nzma.org.nz/journal/119-1238/2078.-- Insull P, Kejriwal R, Patel H, et al. Is it possible to distribute a scarce resource equitably? Access to invasive procedures for patients with acute myocardial infarction. NZ Med J 2007;120(1250). http://www.nzma.org.nz/journal/120-1250/2446.-- Wong C, Tang EW, Herbison P. Survival over 5 years in the initial hospital survivors with acute coronary syndrome: a comparison between a community and a tertiary hospital in New Zealand. NZ Med J 2007;120(1261).http://www.nzma.org.nz/journal/120-1261/2713.-- Ellis C, Gamble G, Hamer A, et al. Patients admitted with an Acute Coronary Syndrome in New Zealand in 2007: Results of a second comprehensive nationwide audit and a comparison with the first audit from 2002. N Z Med J. 2010;123(1319).http://www.nzma.org.nz/journal/123-1319/4235-- Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet 2003;361:13-20.-- Boden EB, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment elevation myocardial infarction. A comprehensive review of contemporary management options. J Am Coll Cardiol 2007;50:917-929.-- Henry TD, Sharkey SW, Burke MN, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation 2007;116:721-728.-- Antman EM. Time is Muscle; Translation into practice. J Am Coll Cardiol 2008;52:1216-1221.-- Gershlick AH, Stephens-Lloyd A, Hughes S, et al. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 2005;353:2758-68.-- Patel T, Bavry AA, Khumbani D, Ellis SG. A meta-analysis of randomized trials of rescue percutaneous coronary intervention after failed fibrinolysis. Am J Cardiol 2006;97:1685-1690.-- White HD. Systems of Care. Need for hub-and-spoke systems for both primary and systematic percutaneous coronary intervention after fibrinolysis. Circulation 2008;118:219-222.-- Cantor WJ, Fitchett D, Borgundvaag B, et al. for the TRANSFER-AMI Trial Investigators. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med 2009;360:2705-2718.-- Verheugt FWA. Routine angioplasty after fibrinolysis-how early should early be? N Eng J Med 2009;360:2779-2781.-- Bavry AA, Kumbhani DJ, Rassi AN, et al. Benefit of early invasive therapy in acute coronary syndromes. A meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006;48:1319-1325.-- Fox KAA, Poole-Wilson P, Clayton TC, et al. 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet 2005;366:914-920.-- Briffa T, Hickling S, Knuiman M, et al. Long term survival after evidence based treatment of acute myocardial infarction and revascularisation: follow-up of population based Perth MONICA cohort, 1984-2005. BMJ 2009;338:b36 doi:10.1136/bmj.b36.-- Neutze J, Haydock D. Prioritisation and cardiac events while waiting for coronary bypass surgery in New Zealand. NZ Med J 2000;113:69-70.-- Ellis CJ, Hamer AW. Cardiovascular health in New Zealand: areas of concern and targets for improvement in 2008 and beyond. NZ Med J 2008;121:5-10. http://www.nzma.org.nz/journal/121-1269/2927-- Bonaca MP, Steg PG, Feldman LJ, et al. Antithrombotics in acute coronary syndromes. J Am Coll cardiol 2009;54:969-984.-- Ellis CJ, Zambanini A, French JK, et al. Inadequate control of lipid levels in patients with a previous myocardial infarction. NZ Med J 1998;111:464-467.-- White H, Ellis C. PHARMAC and the lack of funding for clopidogrel. NZ Med J 2006;119(1228).http://www.nzmj.com/journal/119-1228/1808/content.pdf-- Ellis C, White H. PHARMAC and the statin debacle. NZ Med J 2006;119(1236). http://www.nzma.org.nz/journal/119-1236/2003-- Swinburn B, Milne R, Richards M, et al. Reimbursement of pharmaceuticals in New Zealand: comments on PHARMACs processes. NZ Med J 2000;113:425-427.-- Mehta RH, Montoye CK, Faul JF, et al. Enhancing quality of care for acute myocardial infarction: shifting the focus of improvement from key indicators to process of care and tool use. J Am Coll Cardiol 2004;43:2166-2173.-- Eagle KA, Montoyne CK, Riba AL, et al. Guideline-based standardized care is associated with substantially lower mortality in Medicare patients with acute coronary infarction. The American College of Cardiologys Guidelines applied in practice (GAP) projects in Michigan. J Am Coll Cardiol 2005;46:1242-1248.-- Bridgman P. The challenge of improving cardiac care in secondary centres. NZ Med J 2004;117 (1194).http://www.nzma.org.nz/journal/117-1194/888-- Wong CK. Barriers to a better management for acute coronary syndrome-insights from the Otago-Southland ACS Registry, 2000-2002. NZ Med J 2009;122 (1290). http://www.nzma.org.nz/journal/122-1290/3492-
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ACS patients in New Zealand experience significant delays to access cardiac investigations and revascularisation treatment especially when admitted to non-interventional centres: results of the second comprehensive national audit of ACS patients
View Article PDF
In New Zealand there has been a more than doubling of hospital discharges for a heart attack from 1989 to 2002/2003.1 Hence there is a significant clinical problem which mandates an efficient management strategy. Current management of high-risk ACS patients includes optimal medical treatment and an invasive revascularisation strategy guided by cardiac angiography, as recommended by international2-5 and local6, 7 clinical guidelines. A previous comprehensive nationwide audit of ACS patients undertaken in 2002,8 found inequitable management across New Zealand, as patients admitted to a hospital without cardiac interventional facilities received fewer investigations and less revascularisation treatment than patients admitted to intervention centres.9Smaller local studies in Taranaki/Waikato,10 Invercargill/Dunedin11 and North Shore Hospital/Auckland City Hospital, Auckland12 have all demonstrated a limited access to invasive investigations and revascularisation of ACS patients admitted to non-invasive centres. Patients from Invercargill11 experienced a 2.5-fold lower rate of angiography and revascularisation than those admitted directly to Dunedin hospital. In-hospital mortality differed by 3.3% (10.7% vs 6.4%) and then widened to approximately 10% at both 6 months (19.1% vs 9.6%), 12 months (22.1% vs 12.1%) and up to 5 years.13We aimed to determine the current management of ACS patients presenting to interventional and non-interventional New Zealand hospitals. The primary goal of this study, in particular, was to assess cardiac investigations and treatments received by patients and examine time delays experienced by patients in accessing management.Methods Data collectionThe development of the New Zealand Acute Coronary Syndrome (NZACS) Audit Group and the methodology for the national audit, which was supported by the Cardiac Society of New Zealand, has been published elsewhere.14 The inclusion criterion for the audit was a patient admitted overnight with a suspected or definite acute coronary syndrome. Following admission and investigations, a discharge diagnosis was subsequently determined by the local clinical team who confirmed the diagnosis of an ACS, as a STEMI, NSTEMI or UAP, or determined a non-ACS presentation resultant on investigations undertaken in hospital and the patients clinical course. An extensive four-page case report form was used to obtain patient demographics, initial and discharge diagnosis, medication use in hospital and at discharge, as well as investigations undertaken and invasive treatments received by patients. Ethnicity was self-reported at hospital admission. Data from the NZACS Audit were used to compare patients presentation and management at intervention centres (6 public hospitals and 3 private hospitals), with non-intervention centres (30 public hospital) [Table 1]. One centre (Middlemore Hospital, Auckland), was able to undertake cardiac angiograms and PCIs throughout the working week (08.00 to 16.00, Monday to Friday) but not cout of hoursd, and did not perform CABG operations, and was classified as an intervention centre. One centre (Nelson Hospital) was able to undertake some angiography and a limited number of PCI procedures, but had a limited operation with only one interventional cardiologist performing PCI, and was also unable to perform CABG operations, and hence was classified as a non-interventional centre. Table 1. Admissions and transfers to intervention (n=447) and non-intervention (n=556) centres Facilities No. of own patients Transferred in Total Admissions Transferred Out Angiogram PCI CABG Auckland City Hospital Middlemore, Auckland Mercy, Auckland (Private) Ascot, Auckland (Private) Waikato, Hamilton Wellington Wakefield, Wellington (Private) Christchurch Dunedin Total 122 35 6 2 56 57 0 141 28 447 52 13 50 3 10 128 174 35 6 2 69 107 0 144 38 575 2 1 3 Y Y Y Y Y Y Y Y Y 100% Y Y Y Y Y Y Y Y Y 100% Y N Y Y Y Y Y Y Y 89% Non-Intervention Centres (n=30) Auckland/Northland, North Is Kaitaia Dargaville Rawene Kawakawa Whangarei North Shore Waitakere 9 5 0 3 37 66 24 144 2 1 3 9 5 0 3 39 67 24 147 2 2 1 4 28 15 52 N N N N N N* N 0% N N N N N N* N 0% N N N N N N N 0% Waikato/Central, North Is Thames Tauranga Whakatane Rotorua Tokoroa Te Kuiti Taupo Gisborne Taumarunui New Plymouth 19 44 12 28 2 0 11 16 1 17 150 0 19 44 12 28 2 0 11 16 1 17 150 2 4 4 2 12 N Y N N N N N N N Y 20% N N N N N N N N N N 0% N N N N N N N N N N N 0% Wellington/Southern, North Island/top of South Island Hastings Wanganui Palmerston North Masterton Hutt Nelson Blenheim 76 26 25 10 25 14 12 188 1 2 3 77 26 25 10 25 16 12 191 17 6 13 5 4 4 2 51 Y N Y N N Y N 43% N N N N N Y N 14% N N N N N N N 0% Christchurch/Canterbury, South Island Greymouth Ashburton Timaru 6 3 31 40 0 6 3 31 40 2 1 2 5 N N N 0% N N N 0% N N N 0% Dunedin/Otago, South Island Oamaru Clyde Invercargill 10 3 21 34 0 10 3 21 34 4 1 5 10 N N N 0% N N N 0% N N N 0% Total 556 6 562 130 PCI: Percutaneous coronary intervention; CABG: Coronary artery bypass grafting, Y: yes; N: no; *Acquired angiography and PCI capability during working hours since the Audit in 2007. An additional four public hospitals (Tauranga, New Plymouth, Hastings and Palmerston North) were classified as non-intervention centres as they had the ability to perform some cardiac angiograms, but not PCI or CABG surgery. Cardiac angiography, PCI and CABG surgery was also performed at a private hospital in Christchurch; however this hospital does not plan to admit ACS patients and hence is not further considered with this audit. Investigations and revascularisation of transferred patients was attributed to the referring centre. Data were collected from 0000 hours on Monday 14 May to 2400 hours on Sunday 27 May 2007. StatisticsContinuous data were summarised as median and interquartile range (IQR) and compared using the Wilcoxon rank sums test. Differences in frequencies were tested using standard chi-squared procedures or Fishers exact test as appropriate. All analyses were conducted using SAS (SAS Institute Inc v9.1). All tests were two-tailed and a 5% significance level was maintained throughout. Results Admissions and transfersOver the 14-day period, 1003 suspected or definite ACS patients were admitted to an intervention centre (447) or to a non-intervention centre (556). Eight patients were re-admitted within the 2 weeks (seven once and one twice), all to the same hospital. One hundred and thirty-four patients were transferred to another institution for further management (128 (96%) to an intervention centre). Data from patients transferred were attributed only to the hospital to which they were initially admitted (Table 1). Table 2. Baseline demographic data of patients admitted to an intervention or non-intervention centre (n=1003) Variable Hospital type P Intervention (n=447) Non-intervention (n=556) Age median [years](range) 66 (18-97) 70 (23-95) 0.0097 Sex (male) 265 (59%) 315 (57%) 0.41 Ethnicity Caucasian M\u0101ori Pacifica Asian Indian Not reported Other 340 (76%) 26 (5.8%) 22 (4.9%) 13 (2.9%) 20 (4.5%) 18 (4.0%) 8 (1.8%) 435 (78%) 66 (12%) 11 (2.0%) 7 (1.3%) 7 (1.3%) 29 (5.2%) 1 (0.18%) 0.49 0.0009 0.012 0.072 0.0026 0.45 0.013 Tobacco smoker Current Previous Current and Previous Never Not reported 83 (19%) 157 (35%) 240 (56%) 188 (42%) 19 (4%) 96 (17%) 232 (42%) 328 (62%) 199 (36%) 29 (5%) 0.62 0.037 0.055 0.043 0.55 Hypertension (drug treatment) 231 (52%) 291 (52%) 0.85 Diabetes Type 1 Type 2 Not defined 93 (15%) 3 (3%) 89 (96%) 1 (1%) 89 (16%) 3 (3%) 86 (97%) 0 0.058 0.99 0.99 0.45
Summary
Abstract
Aim
To compare the management of acute coronary syndrome (ACS) patients presenting to interventional versus non-interventional New Zealand hospitals, with emphasis, on access delays for invasive assessment and revascularisation treatments.
Method
Using data collected by the New Zealand Cardiac Society ACS Audit Group over 14 days from each hospital in New Zealand (n=39) that admits ACS patients, patient management at intervention centres (6 public, 3 private) was compared with non-intervention centres (30 public). Investigations and revascularisation procedures performed on transferred patients were attributed to the referring centre.
Results
From 00.00 hours on 14 May 2007 to 24.00 hours on 27 May 2007, 1003 patients were admitted to a New Zealand hospital with a suspected or definite ACS: ST-segment-elevation myocardial infarction [STEMI] (8%), non-STEMI [NSTEMI] (41%), unstable angina pectoris [UAP] 33%, or another cardiac or medical diagnosis (17%). Patients admitted to a non-intervention centre (n=556) were older (median age 70 vs 66 years, p=0.0097), with similar risk factors, and were more likely to be of M ori (12% vs 5.8%, p
Conclusion
Patients admitted to a New Zealand hospital with an acute coronary syndrome experience delays in accessing investigations and subsequent revascularisation. Furthermore, inequity exists with delays being significantly longer for patients admitted to a non-intervention centre. A comprehensive national strategy is needed to improve access to optimal cardiac care.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Elliott J, Richards M. Heart attacks and unstable angina (acute coronary syndromes) have doubled in New Zealand since 1989: how do we best manage the epidemic? NZ Med J 2005;118(1223). http//www.nzma.org.nz/journal/118-1223/1674-- Bassand J, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of cardiology. Eur Heart J 2007;28:1598-1660.-- Van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of cardiology. Eur Heart J 2008;29:2909-2945.-- Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non ST-Elevation Myocardial Infarction Executive Summary. J Am Coll Cardiol 2007;50:652-726.-- Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2008;51:210-247.-- Non ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand. Non ST-elevation myocardial infarction: New Zealand management guidelines. NZ Med J 2005;118:1-19. http://www.nzma.org.nz/journal/118-1223/1680-- ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand. ST-elevation myocardial infarction: New Zealand management guidelines. NZ Med J 2005;118(1223).http://www.nzma.org.nz/journal/118-1223/1679-- Ellis C, Gamble G, French J, et al. Management of patients admitted with an Acute Coronary Syndrome in New Zealand: Results of a comprehensive nationwide audit. NZ Med J 2004;117(1197). http://www.nzma.org.nz/journal/117-1197/953-- Ellis C, Devlin G, Matsis P, et al. Acute Coronary Syndrome patients in New Zealand receive less invasive management when admitted to hospitals without invasive facilities. NZ Med J 2004;117(1197). http://www.nzma.org.nz/journal/117-1197/954-- Conaglen P, Sebastian C, Jayaraman C, et al. Management of unstable angina and non-ST elevation myocardial infarction: do cardiologists do it better? A comparison of secondary and tertiary centre management in New Zealand. NZ Med J 2004;117(1194). http://www.nzma.org.nz/journal/117-1194/890.-- Tang EW, Wong CK, Herbison P. Community hospital versus tertiary hospital comparison in the treatment and outcome of patients with acute coronary syndrome: a New Zealand experience. NZ Med J 2006;119(1238).http://www.nzma.org.nz/journal/119-1238/2078.-- Insull P, Kejriwal R, Patel H, et al. Is it possible to distribute a scarce resource equitably? Access to invasive procedures for patients with acute myocardial infarction. NZ Med J 2007;120(1250). http://www.nzma.org.nz/journal/120-1250/2446.-- Wong C, Tang EW, Herbison P. Survival over 5 years in the initial hospital survivors with acute coronary syndrome: a comparison between a community and a tertiary hospital in New Zealand. NZ Med J 2007;120(1261).http://www.nzma.org.nz/journal/120-1261/2713.-- Ellis C, Gamble G, Hamer A, et al. Patients admitted with an Acute Coronary Syndrome in New Zealand in 2007: Results of a second comprehensive nationwide audit and a comparison with the first audit from 2002. N Z Med J. 2010;123(1319).http://www.nzma.org.nz/journal/123-1319/4235-- Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet 2003;361:13-20.-- Boden EB, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment elevation myocardial infarction. A comprehensive review of contemporary management options. J Am Coll Cardiol 2007;50:917-929.-- Henry TD, Sharkey SW, Burke MN, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation 2007;116:721-728.-- Antman EM. Time is Muscle; Translation into practice. J Am Coll Cardiol 2008;52:1216-1221.-- Gershlick AH, Stephens-Lloyd A, Hughes S, et al. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 2005;353:2758-68.-- Patel T, Bavry AA, Khumbani D, Ellis SG. A meta-analysis of randomized trials of rescue percutaneous coronary intervention after failed fibrinolysis. Am J Cardiol 2006;97:1685-1690.-- White HD. Systems of Care. Need for hub-and-spoke systems for both primary and systematic percutaneous coronary intervention after fibrinolysis. Circulation 2008;118:219-222.-- Cantor WJ, Fitchett D, Borgundvaag B, et al. for the TRANSFER-AMI Trial Investigators. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med 2009;360:2705-2718.-- Verheugt FWA. Routine angioplasty after fibrinolysis-how early should early be? N Eng J Med 2009;360:2779-2781.-- Bavry AA, Kumbhani DJ, Rassi AN, et al. Benefit of early invasive therapy in acute coronary syndromes. A meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006;48:1319-1325.-- Fox KAA, Poole-Wilson P, Clayton TC, et al. 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet 2005;366:914-920.-- Briffa T, Hickling S, Knuiman M, et al. Long term survival after evidence based treatment of acute myocardial infarction and revascularisation: follow-up of population based Perth MONICA cohort, 1984-2005. BMJ 2009;338:b36 doi:10.1136/bmj.b36.-- Neutze J, Haydock D. Prioritisation and cardiac events while waiting for coronary bypass surgery in New Zealand. NZ Med J 2000;113:69-70.-- Ellis CJ, Hamer AW. Cardiovascular health in New Zealand: areas of concern and targets for improvement in 2008 and beyond. NZ Med J 2008;121:5-10. http://www.nzma.org.nz/journal/121-1269/2927-- Bonaca MP, Steg PG, Feldman LJ, et al. Antithrombotics in acute coronary syndromes. J Am Coll cardiol 2009;54:969-984.-- Ellis CJ, Zambanini A, French JK, et al. Inadequate control of lipid levels in patients with a previous myocardial infarction. NZ Med J 1998;111:464-467.-- White H, Ellis C. PHARMAC and the lack of funding for clopidogrel. NZ Med J 2006;119(1228).http://www.nzmj.com/journal/119-1228/1808/content.pdf-- Ellis C, White H. PHARMAC and the statin debacle. NZ Med J 2006;119(1236). http://www.nzma.org.nz/journal/119-1236/2003-- Swinburn B, Milne R, Richards M, et al. Reimbursement of pharmaceuticals in New Zealand: comments on PHARMACs processes. NZ Med J 2000;113:425-427.-- Mehta RH, Montoye CK, Faul JF, et al. Enhancing quality of care for acute myocardial infarction: shifting the focus of improvement from key indicators to process of care and tool use. J Am Coll Cardiol 2004;43:2166-2173.-- Eagle KA, Montoyne CK, Riba AL, et al. Guideline-based standardized care is associated with substantially lower mortality in Medicare patients with acute coronary infarction. The American College of Cardiologys Guidelines applied in practice (GAP) projects in Michigan. J Am Coll Cardiol 2005;46:1242-1248.-- Bridgman P. The challenge of improving cardiac care in secondary centres. NZ Med J 2004;117 (1194).http://www.nzma.org.nz/journal/117-1194/888-- Wong CK. Barriers to a better management for acute coronary syndrome-insights from the Otago-Southland ACS Registry, 2000-2002. NZ Med J 2009;122 (1290). http://www.nzma.org.nz/journal/122-1290/3492-
For the PDF of this article,
contact nzmj@nzma.org.nz
ACS patients in New Zealand experience significant delays to access cardiac investigations and revascularisation treatment especially when admitted to non-interventional centres: results of the second comprehensive national audit of ACS patients
View Article PDF
In New Zealand there has been a more than doubling of hospital discharges for a heart attack from 1989 to 2002/2003.1 Hence there is a significant clinical problem which mandates an efficient management strategy. Current management of high-risk ACS patients includes optimal medical treatment and an invasive revascularisation strategy guided by cardiac angiography, as recommended by international2-5 and local6, 7 clinical guidelines. A previous comprehensive nationwide audit of ACS patients undertaken in 2002,8 found inequitable management across New Zealand, as patients admitted to a hospital without cardiac interventional facilities received fewer investigations and less revascularisation treatment than patients admitted to intervention centres.9Smaller local studies in Taranaki/Waikato,10 Invercargill/Dunedin11 and North Shore Hospital/Auckland City Hospital, Auckland12 have all demonstrated a limited access to invasive investigations and revascularisation of ACS patients admitted to non-invasive centres. Patients from Invercargill11 experienced a 2.5-fold lower rate of angiography and revascularisation than those admitted directly to Dunedin hospital. In-hospital mortality differed by 3.3% (10.7% vs 6.4%) and then widened to approximately 10% at both 6 months (19.1% vs 9.6%), 12 months (22.1% vs 12.1%) and up to 5 years.13We aimed to determine the current management of ACS patients presenting to interventional and non-interventional New Zealand hospitals. The primary goal of this study, in particular, was to assess cardiac investigations and treatments received by patients and examine time delays experienced by patients in accessing management.Methods Data collectionThe development of the New Zealand Acute Coronary Syndrome (NZACS) Audit Group and the methodology for the national audit, which was supported by the Cardiac Society of New Zealand, has been published elsewhere.14 The inclusion criterion for the audit was a patient admitted overnight with a suspected or definite acute coronary syndrome. Following admission and investigations, a discharge diagnosis was subsequently determined by the local clinical team who confirmed the diagnosis of an ACS, as a STEMI, NSTEMI or UAP, or determined a non-ACS presentation resultant on investigations undertaken in hospital and the patients clinical course. An extensive four-page case report form was used to obtain patient demographics, initial and discharge diagnosis, medication use in hospital and at discharge, as well as investigations undertaken and invasive treatments received by patients. Ethnicity was self-reported at hospital admission. Data from the NZACS Audit were used to compare patients presentation and management at intervention centres (6 public hospitals and 3 private hospitals), with non-intervention centres (30 public hospital) [Table 1]. One centre (Middlemore Hospital, Auckland), was able to undertake cardiac angiograms and PCIs throughout the working week (08.00 to 16.00, Monday to Friday) but not cout of hoursd, and did not perform CABG operations, and was classified as an intervention centre. One centre (Nelson Hospital) was able to undertake some angiography and a limited number of PCI procedures, but had a limited operation with only one interventional cardiologist performing PCI, and was also unable to perform CABG operations, and hence was classified as a non-interventional centre. Table 1. Admissions and transfers to intervention (n=447) and non-intervention (n=556) centres Facilities No. of own patients Transferred in Total Admissions Transferred Out Angiogram PCI CABG Auckland City Hospital Middlemore, Auckland Mercy, Auckland (Private) Ascot, Auckland (Private) Waikato, Hamilton Wellington Wakefield, Wellington (Private) Christchurch Dunedin Total 122 35 6 2 56 57 0 141 28 447 52 13 50 3 10 128 174 35 6 2 69 107 0 144 38 575 2 1 3 Y Y Y Y Y Y Y Y Y 100% Y Y Y Y Y Y Y Y Y 100% Y N Y Y Y Y Y Y Y 89% Non-Intervention Centres (n=30) Auckland/Northland, North Is Kaitaia Dargaville Rawene Kawakawa Whangarei North Shore Waitakere 9 5 0 3 37 66 24 144 2 1 3 9 5 0 3 39 67 24 147 2 2 1 4 28 15 52 N N N N N N* N 0% N N N N N N* N 0% N N N N N N N 0% Waikato/Central, North Is Thames Tauranga Whakatane Rotorua Tokoroa Te Kuiti Taupo Gisborne Taumarunui New Plymouth 19 44 12 28 2 0 11 16 1 17 150 0 19 44 12 28 2 0 11 16 1 17 150 2 4 4 2 12 N Y N N N N N N N Y 20% N N N N N N N N N N 0% N N N N N N N N N N N 0% Wellington/Southern, North Island/top of South Island Hastings Wanganui Palmerston North Masterton Hutt Nelson Blenheim 76 26 25 10 25 14 12 188 1 2 3 77 26 25 10 25 16 12 191 17 6 13 5 4 4 2 51 Y N Y N N Y N 43% N N N N N Y N 14% N N N N N N N 0% Christchurch/Canterbury, South Island Greymouth Ashburton Timaru 6 3 31 40 0 6 3 31 40 2 1 2 5 N N N 0% N N N 0% N N N 0% Dunedin/Otago, South Island Oamaru Clyde Invercargill 10 3 21 34 0 10 3 21 34 4 1 5 10 N N N 0% N N N 0% N N N 0% Total 556 6 562 130 PCI: Percutaneous coronary intervention; CABG: Coronary artery bypass grafting, Y: yes; N: no; *Acquired angiography and PCI capability during working hours since the Audit in 2007. An additional four public hospitals (Tauranga, New Plymouth, Hastings and Palmerston North) were classified as non-intervention centres as they had the ability to perform some cardiac angiograms, but not PCI or CABG surgery. Cardiac angiography, PCI and CABG surgery was also performed at a private hospital in Christchurch; however this hospital does not plan to admit ACS patients and hence is not further considered with this audit. Investigations and revascularisation of transferred patients was attributed to the referring centre. Data were collected from 0000 hours on Monday 14 May to 2400 hours on Sunday 27 May 2007. StatisticsContinuous data were summarised as median and interquartile range (IQR) and compared using the Wilcoxon rank sums test. Differences in frequencies were tested using standard chi-squared procedures or Fishers exact test as appropriate. All analyses were conducted using SAS (SAS Institute Inc v9.1). All tests were two-tailed and a 5% significance level was maintained throughout. Results Admissions and transfersOver the 14-day period, 1003 suspected or definite ACS patients were admitted to an intervention centre (447) or to a non-intervention centre (556). Eight patients were re-admitted within the 2 weeks (seven once and one twice), all to the same hospital. One hundred and thirty-four patients were transferred to another institution for further management (128 (96%) to an intervention centre). Data from patients transferred were attributed only to the hospital to which they were initially admitted (Table 1). Table 2. Baseline demographic data of patients admitted to an intervention or non-intervention centre (n=1003) Variable Hospital type P Intervention (n=447) Non-intervention (n=556) Age median [years](range) 66 (18-97) 70 (23-95) 0.0097 Sex (male) 265 (59%) 315 (57%) 0.41 Ethnicity Caucasian M\u0101ori Pacifica Asian Indian Not reported Other 340 (76%) 26 (5.8%) 22 (4.9%) 13 (2.9%) 20 (4.5%) 18 (4.0%) 8 (1.8%) 435 (78%) 66 (12%) 11 (2.0%) 7 (1.3%) 7 (1.3%) 29 (5.2%) 1 (0.18%) 0.49 0.0009 0.012 0.072 0.0026 0.45 0.013 Tobacco smoker Current Previous Current and Previous Never Not reported 83 (19%) 157 (35%) 240 (56%) 188 (42%) 19 (4%) 96 (17%) 232 (42%) 328 (62%) 199 (36%) 29 (5%) 0.62 0.037 0.055 0.043 0.55 Hypertension (drug treatment) 231 (52%) 291 (52%) 0.85 Diabetes Type 1 Type 2 Not defined 93 (15%) 3 (3%) 89 (96%) 1 (1%) 89 (16%) 3 (3%) 86 (97%) 0 0.058 0.99 0.99 0.45
Summary
Abstract
Aim
To compare the management of acute coronary syndrome (ACS) patients presenting to interventional versus non-interventional New Zealand hospitals, with emphasis, on access delays for invasive assessment and revascularisation treatments.
Method
Using data collected by the New Zealand Cardiac Society ACS Audit Group over 14 days from each hospital in New Zealand (n=39) that admits ACS patients, patient management at intervention centres (6 public, 3 private) was compared with non-intervention centres (30 public). Investigations and revascularisation procedures performed on transferred patients were attributed to the referring centre.
Results
From 00.00 hours on 14 May 2007 to 24.00 hours on 27 May 2007, 1003 patients were admitted to a New Zealand hospital with a suspected or definite ACS: ST-segment-elevation myocardial infarction [STEMI] (8%), non-STEMI [NSTEMI] (41%), unstable angina pectoris [UAP] 33%, or another cardiac or medical diagnosis (17%). Patients admitted to a non-intervention centre (n=556) were older (median age 70 vs 66 years, p=0.0097), with similar risk factors, and were more likely to be of M ori (12% vs 5.8%, p
Conclusion
Patients admitted to a New Zealand hospital with an acute coronary syndrome experience delays in accessing investigations and subsequent revascularisation. Furthermore, inequity exists with delays being significantly longer for patients admitted to a non-intervention centre. A comprehensive national strategy is needed to improve access to optimal cardiac care.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Elliott J, Richards M. Heart attacks and unstable angina (acute coronary syndromes) have doubled in New Zealand since 1989: how do we best manage the epidemic? NZ Med J 2005;118(1223). http//www.nzma.org.nz/journal/118-1223/1674-- Bassand J, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of cardiology. Eur Heart J 2007;28:1598-1660.-- Van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of cardiology. Eur Heart J 2008;29:2909-2945.-- Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non ST-Elevation Myocardial Infarction Executive Summary. J Am Coll Cardiol 2007;50:652-726.-- Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2008;51:210-247.-- Non ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand. Non ST-elevation myocardial infarction: New Zealand management guidelines. NZ Med J 2005;118:1-19. http://www.nzma.org.nz/journal/118-1223/1680-- ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand. ST-elevation myocardial infarction: New Zealand management guidelines. NZ Med J 2005;118(1223).http://www.nzma.org.nz/journal/118-1223/1679-- Ellis C, Gamble G, French J, et al. Management of patients admitted with an Acute Coronary Syndrome in New Zealand: Results of a comprehensive nationwide audit. NZ Med J 2004;117(1197). http://www.nzma.org.nz/journal/117-1197/953-- Ellis C, Devlin G, Matsis P, et al. Acute Coronary Syndrome patients in New Zealand receive less invasive management when admitted to hospitals without invasive facilities. NZ Med J 2004;117(1197). http://www.nzma.org.nz/journal/117-1197/954-- Conaglen P, Sebastian C, Jayaraman C, et al. Management of unstable angina and non-ST elevation myocardial infarction: do cardiologists do it better? A comparison of secondary and tertiary centre management in New Zealand. NZ Med J 2004;117(1194). http://www.nzma.org.nz/journal/117-1194/890.-- Tang EW, Wong CK, Herbison P. Community hospital versus tertiary hospital comparison in the treatment and outcome of patients with acute coronary syndrome: a New Zealand experience. NZ Med J 2006;119(1238).http://www.nzma.org.nz/journal/119-1238/2078.-- Insull P, Kejriwal R, Patel H, et al. Is it possible to distribute a scarce resource equitably? Access to invasive procedures for patients with acute myocardial infarction. NZ Med J 2007;120(1250). http://www.nzma.org.nz/journal/120-1250/2446.-- Wong C, Tang EW, Herbison P. Survival over 5 years in the initial hospital survivors with acute coronary syndrome: a comparison between a community and a tertiary hospital in New Zealand. NZ Med J 2007;120(1261).http://www.nzma.org.nz/journal/120-1261/2713.-- Ellis C, Gamble G, Hamer A, et al. Patients admitted with an Acute Coronary Syndrome in New Zealand in 2007: Results of a second comprehensive nationwide audit and a comparison with the first audit from 2002. N Z Med J. 2010;123(1319).http://www.nzma.org.nz/journal/123-1319/4235-- Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet 2003;361:13-20.-- Boden EB, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment elevation myocardial infarction. A comprehensive review of contemporary management options. J Am Coll Cardiol 2007;50:917-929.-- Henry TD, Sharkey SW, Burke MN, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation 2007;116:721-728.-- Antman EM. Time is Muscle; Translation into practice. J Am Coll Cardiol 2008;52:1216-1221.-- Gershlick AH, Stephens-Lloyd A, Hughes S, et al. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 2005;353:2758-68.-- Patel T, Bavry AA, Khumbani D, Ellis SG. A meta-analysis of randomized trials of rescue percutaneous coronary intervention after failed fibrinolysis. Am J Cardiol 2006;97:1685-1690.-- White HD. Systems of Care. Need for hub-and-spoke systems for both primary and systematic percutaneous coronary intervention after fibrinolysis. Circulation 2008;118:219-222.-- Cantor WJ, Fitchett D, Borgundvaag B, et al. for the TRANSFER-AMI Trial Investigators. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med 2009;360:2705-2718.-- Verheugt FWA. Routine angioplasty after fibrinolysis-how early should early be? N Eng J Med 2009;360:2779-2781.-- Bavry AA, Kumbhani DJ, Rassi AN, et al. Benefit of early invasive therapy in acute coronary syndromes. A meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006;48:1319-1325.-- Fox KAA, Poole-Wilson P, Clayton TC, et al. 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet 2005;366:914-920.-- Briffa T, Hickling S, Knuiman M, et al. Long term survival after evidence based treatment of acute myocardial infarction and revascularisation: follow-up of population based Perth MONICA cohort, 1984-2005. BMJ 2009;338:b36 doi:10.1136/bmj.b36.-- Neutze J, Haydock D. Prioritisation and cardiac events while waiting for coronary bypass surgery in New Zealand. NZ Med J 2000;113:69-70.-- Ellis CJ, Hamer AW. Cardiovascular health in New Zealand: areas of concern and targets for improvement in 2008 and beyond. NZ Med J 2008;121:5-10. http://www.nzma.org.nz/journal/121-1269/2927-- Bonaca MP, Steg PG, Feldman LJ, et al. Antithrombotics in acute coronary syndromes. J Am Coll cardiol 2009;54:969-984.-- Ellis CJ, Zambanini A, French JK, et al. Inadequate control of lipid levels in patients with a previous myocardial infarction. NZ Med J 1998;111:464-467.-- White H, Ellis C. PHARMAC and the lack of funding for clopidogrel. NZ Med J 2006;119(1228).http://www.nzmj.com/journal/119-1228/1808/content.pdf-- Ellis C, White H. PHARMAC and the statin debacle. NZ Med J 2006;119(1236). http://www.nzma.org.nz/journal/119-1236/2003-- Swinburn B, Milne R, Richards M, et al. Reimbursement of pharmaceuticals in New Zealand: comments on PHARMACs processes. NZ Med J 2000;113:425-427.-- Mehta RH, Montoye CK, Faul JF, et al. Enhancing quality of care for acute myocardial infarction: shifting the focus of improvement from key indicators to process of care and tool use. J Am Coll Cardiol 2004;43:2166-2173.-- Eagle KA, Montoyne CK, Riba AL, et al. Guideline-based standardized care is associated with substantially lower mortality in Medicare patients with acute coronary infarction. The American College of Cardiologys Guidelines applied in practice (GAP) projects in Michigan. J Am Coll Cardiol 2005;46:1242-1248.-- Bridgman P. The challenge of improving cardiac care in secondary centres. NZ Med J 2004;117 (1194).http://www.nzma.org.nz/journal/117-1194/888-- Wong CK. Barriers to a better management for acute coronary syndrome-insights from the Otago-Southland ACS Registry, 2000-2002. NZ Med J 2009;122 (1290). http://www.nzma.org.nz/journal/122-1290/3492-
Contact diana@nzma.org.nz
for the PDF of this article
ACS patients in New Zealand experience significant delays to access cardiac investigations and revascularisation treatment especially when admitted to non-interventional centres: results of the second comprehensive national audit of ACS patients
View Article PDF
In New Zealand there has been a more than doubling of hospital discharges for a heart attack from 1989 to 2002/2003.1 Hence there is a significant clinical problem which mandates an efficient management strategy. Current management of high-risk ACS patients includes optimal medical treatment and an invasive revascularisation strategy guided by cardiac angiography, as recommended by international2-5 and local6, 7 clinical guidelines. A previous comprehensive nationwide audit of ACS patients undertaken in 2002,8 found inequitable management across New Zealand, as patients admitted to a hospital without cardiac interventional facilities received fewer investigations and less revascularisation treatment than patients admitted to intervention centres.9Smaller local studies in Taranaki/Waikato,10 Invercargill/Dunedin11 and North Shore Hospital/Auckland City Hospital, Auckland12 have all demonstrated a limited access to invasive investigations and revascularisation of ACS patients admitted to non-invasive centres. Patients from Invercargill11 experienced a 2.5-fold lower rate of angiography and revascularisation than those admitted directly to Dunedin hospital. In-hospital mortality differed by 3.3% (10.7% vs 6.4%) and then widened to approximately 10% at both 6 months (19.1% vs 9.6%), 12 months (22.1% vs 12.1%) and up to 5 years.13We aimed to determine the current management of ACS patients presenting to interventional and non-interventional New Zealand hospitals. The primary goal of this study, in particular, was to assess cardiac investigations and treatments received by patients and examine time delays experienced by patients in accessing management.Methods Data collectionThe development of the New Zealand Acute Coronary Syndrome (NZACS) Audit Group and the methodology for the national audit, which was supported by the Cardiac Society of New Zealand, has been published elsewhere.14 The inclusion criterion for the audit was a patient admitted overnight with a suspected or definite acute coronary syndrome. Following admission and investigations, a discharge diagnosis was subsequently determined by the local clinical team who confirmed the diagnosis of an ACS, as a STEMI, NSTEMI or UAP, or determined a non-ACS presentation resultant on investigations undertaken in hospital and the patients clinical course. An extensive four-page case report form was used to obtain patient demographics, initial and discharge diagnosis, medication use in hospital and at discharge, as well as investigations undertaken and invasive treatments received by patients. Ethnicity was self-reported at hospital admission. Data from the NZACS Audit were used to compare patients presentation and management at intervention centres (6 public hospitals and 3 private hospitals), with non-intervention centres (30 public hospital) [Table 1]. One centre (Middlemore Hospital, Auckland), was able to undertake cardiac angiograms and PCIs throughout the working week (08.00 to 16.00, Monday to Friday) but not cout of hoursd, and did not perform CABG operations, and was classified as an intervention centre. One centre (Nelson Hospital) was able to undertake some angiography and a limited number of PCI procedures, but had a limited operation with only one interventional cardiologist performing PCI, and was also unable to perform CABG operations, and hence was classified as a non-interventional centre. Table 1. Admissions and transfers to intervention (n=447) and non-intervention (n=556) centres Facilities No. of own patients Transferred in Total Admissions Transferred Out Angiogram PCI CABG Auckland City Hospital Middlemore, Auckland Mercy, Auckland (Private) Ascot, Auckland (Private) Waikato, Hamilton Wellington Wakefield, Wellington (Private) Christchurch Dunedin Total 122 35 6 2 56 57 0 141 28 447 52 13 50 3 10 128 174 35 6 2 69 107 0 144 38 575 2 1 3 Y Y Y Y Y Y Y Y Y 100% Y Y Y Y Y Y Y Y Y 100% Y N Y Y Y Y Y Y Y 89% Non-Intervention Centres (n=30) Auckland/Northland, North Is Kaitaia Dargaville Rawene Kawakawa Whangarei North Shore Waitakere 9 5 0 3 37 66 24 144 2 1 3 9 5 0 3 39 67 24 147 2 2 1 4 28 15 52 N N N N N N* N 0% N N N N N N* N 0% N N N N N N N 0% Waikato/Central, North Is Thames Tauranga Whakatane Rotorua Tokoroa Te Kuiti Taupo Gisborne Taumarunui New Plymouth 19 44 12 28 2 0 11 16 1 17 150 0 19 44 12 28 2 0 11 16 1 17 150 2 4 4 2 12 N Y N N N N N N N Y 20% N N N N N N N N N N 0% N N N N N N N N N N N 0% Wellington/Southern, North Island/top of South Island Hastings Wanganui Palmerston North Masterton Hutt Nelson Blenheim 76 26 25 10 25 14 12 188 1 2 3 77 26 25 10 25 16 12 191 17 6 13 5 4 4 2 51 Y N Y N N Y N 43% N N N N N Y N 14% N N N N N N N 0% Christchurch/Canterbury, South Island Greymouth Ashburton Timaru 6 3 31 40 0 6 3 31 40 2 1 2 5 N N N 0% N N N 0% N N N 0% Dunedin/Otago, South Island Oamaru Clyde Invercargill 10 3 21 34 0 10 3 21 34 4 1 5 10 N N N 0% N N N 0% N N N 0% Total 556 6 562 130 PCI: Percutaneous coronary intervention; CABG: Coronary artery bypass grafting, Y: yes; N: no; *Acquired angiography and PCI capability during working hours since the Audit in 2007. An additional four public hospitals (Tauranga, New Plymouth, Hastings and Palmerston North) were classified as non-intervention centres as they had the ability to perform some cardiac angiograms, but not PCI or CABG surgery. Cardiac angiography, PCI and CABG surgery was also performed at a private hospital in Christchurch; however this hospital does not plan to admit ACS patients and hence is not further considered with this audit. Investigations and revascularisation of transferred patients was attributed to the referring centre. Data were collected from 0000 hours on Monday 14 May to 2400 hours on Sunday 27 May 2007. StatisticsContinuous data were summarised as median and interquartile range (IQR) and compared using the Wilcoxon rank sums test. Differences in frequencies were tested using standard chi-squared procedures or Fishers exact test as appropriate. All analyses were conducted using SAS (SAS Institute Inc v9.1). All tests were two-tailed and a 5% significance level was maintained throughout. Results Admissions and transfersOver the 14-day period, 1003 suspected or definite ACS patients were admitted to an intervention centre (447) or to a non-intervention centre (556). Eight patients were re-admitted within the 2 weeks (seven once and one twice), all to the same hospital. One hundred and thirty-four patients were transferred to another institution for further management (128 (96%) to an intervention centre). Data from patients transferred were attributed only to the hospital to which they were initially admitted (Table 1). Table 2. Baseline demographic data of patients admitted to an intervention or non-intervention centre (n=1003) Variable Hospital type P Intervention (n=447) Non-intervention (n=556) Age median [years](range) 66 (18-97) 70 (23-95) 0.0097 Sex (male) 265 (59%) 315 (57%) 0.41 Ethnicity Caucasian M\u0101ori Pacifica Asian Indian Not reported Other 340 (76%) 26 (5.8%) 22 (4.9%) 13 (2.9%) 20 (4.5%) 18 (4.0%) 8 (1.8%) 435 (78%) 66 (12%) 11 (2.0%) 7 (1.3%) 7 (1.3%) 29 (5.2%) 1 (0.18%) 0.49 0.0009 0.012 0.072 0.0026 0.45 0.013 Tobacco smoker Current Previous Current and Previous Never Not reported 83 (19%) 157 (35%) 240 (56%) 188 (42%) 19 (4%) 96 (17%) 232 (42%) 328 (62%) 199 (36%) 29 (5%) 0.62 0.037 0.055 0.043 0.55 Hypertension (drug treatment) 231 (52%) 291 (52%) 0.85 Diabetes Type 1 Type 2 Not defined 93 (15%) 3 (3%) 89 (96%) 1 (1%) 89 (16%) 3 (3%) 86 (97%) 0 0.058 0.99 0.99 0.45
Summary
Abstract
Aim
To compare the management of acute coronary syndrome (ACS) patients presenting to interventional versus non-interventional New Zealand hospitals, with emphasis, on access delays for invasive assessment and revascularisation treatments.
Method
Using data collected by the New Zealand Cardiac Society ACS Audit Group over 14 days from each hospital in New Zealand (n=39) that admits ACS patients, patient management at intervention centres (6 public, 3 private) was compared with non-intervention centres (30 public). Investigations and revascularisation procedures performed on transferred patients were attributed to the referring centre.
Results
From 00.00 hours on 14 May 2007 to 24.00 hours on 27 May 2007, 1003 patients were admitted to a New Zealand hospital with a suspected or definite ACS: ST-segment-elevation myocardial infarction [STEMI] (8%), non-STEMI [NSTEMI] (41%), unstable angina pectoris [UAP] 33%, or another cardiac or medical diagnosis (17%). Patients admitted to a non-intervention centre (n=556) were older (median age 70 vs 66 years, p=0.0097), with similar risk factors, and were more likely to be of M ori (12% vs 5.8%, p
Conclusion
Patients admitted to a New Zealand hospital with an acute coronary syndrome experience delays in accessing investigations and subsequent revascularisation. Furthermore, inequity exists with delays being significantly longer for patients admitted to a non-intervention centre. A comprehensive national strategy is needed to improve access to optimal cardiac care.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Elliott J, Richards M. Heart attacks and unstable angina (acute coronary syndromes) have doubled in New Zealand since 1989: how do we best manage the epidemic? NZ Med J 2005;118(1223). http//www.nzma.org.nz/journal/118-1223/1674-- Bassand J, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of cardiology. Eur Heart J 2007;28:1598-1660.-- Van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of cardiology. Eur Heart J 2008;29:2909-2945.-- Anderson JL, Adams CD, Antman EM, et al. 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ACS patients in New Zealand experience significant delays to access cardiac investigations and revascularisation treatment especially when admitted to non-interventional centres: results of the second comprehensive national audit of ACS patients
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