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Since the late 1960s, the age-standardised mortality rate for ischaemic heart disease in New Zealand has decreased from 253 to 66 per 100,000.1 This improvement across many Western countries, including New Zealand, has been attributed to a combination of improved lifestyle (smoking cessation, diet) and utilisation of evidence-based therapies (primary and secondary prevention medications, coronary revascularisation).2-5 Despite this, cardiovascular disease (CVD), and in particular coronary heart disease (CHD), remains the most common cause of death worldwide.6 In New Zealand, age-standardised mortality rates for vascular disease are still higher than those in many other Western countries (www.mortality-trends.org) and, of concern, important disparities exist in the burden of CVD mortality borne by some ethnic groups and by those living in areas of greater deprivation.7-9 In 2010, the age-standardised rate of ischaemic heart disease mortality was 55% higher among New Zealand Mori men compared with the rate for non-Mori men, while the rate for Mori women was nearly twice as high (99%) as that for non-Mori women.10 Those living in greater deprivation also have disproportionately higher CVD event rates. There is a formidable evidence base supporting the use of a range of lifestyle, pharmaceutical, and interventional treatments to improve outcomes in patients with acute CVD events. For example, national and international guidelines recommend timely coronary angiography and revascularisation as appropriate for patients with acute coronary syndrome (ACS).11-15 There is robust evidence to support the use of antiplatelet/anticoagulant,16,17 BP-lowering18-20 and statin21-23 medications, to improve outcomes in patients with established atherosclerotic CVD. This evidence base is constantly developing, with new treatments and technologies becoming available every year. However, in practice, there is often a substantial gap between ideal treatment based on clinical trials and what is achieved in practice the evidence-practice gap with suboptimal initiation and longer-term maintenance of evidence-based therapy across the spectrum of CVD.24-28 Prior studies have reported that revascularisation rates in non-Mori, non-Pacific New Zealanders are significantly higher when compared with Mori and Pacific people and in non-Mori compared with Mori.29,30 A series of three audits of ACS patient management in New Zealand over the last 10 years have demonstrated suboptimal provision of cardiac investigation in ACS patients. Marked variation in both the use of coronary intervention procedures and delay in treatment have also been documented.31-33 Gaps in the utilisation of secondary prevention therapy in New Zealand have been well documented.34-36 The identification of these evidence-practice gaps, and the implementation of programmes to close them, represent an important opportunity to improve the outcomes of patients with CVD in New Zealand.Why was ANZACS-QI established?The primary aim of the All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI) is to support appropriate, evidence-based management of ACS and subsequently of other cardiac patients regardless of age, sex, ethnicity, socioeconomic status, or rural or city dwelling. The ANZACS-QI programme supports this aim through its two arms a quality improvement arm and a research arm. Figure 1: ANZACS-QI programme cohorts, data flow and outputs. The interactions with the associated ANZACS-QI registry trials are shown. ANZACS-QI programme cohorts and processesThe ANZACS-QI programme utilises two complementary data sources to generate two overlapping cohorts: The ACS-CathPCI Registry cohort, generated using web-based software that enables secondary care clinicians to systematically collect data on ACS patients, coronary angiography and percutaneous coronary intervention (PCI) procedures in all New Zealand hospitals. The ACS Routine Information cohort, derived directly from national health datasets. While the ACS Routine Information cohort includes all New Zealand ACS patients, it is relatively limited in content. In contrast, the ACS-CathPCI Registry cohort captures more in-depth data on every ACS patient who has a coronary angiogram in New Zealand, all other patients having coronary angiography procedures and on some other ACS patients. The two overlapping data sources can be linked using the National Health Index (NHI) number, as discussed further below.The ACS-CathPCI Registry cohort (2007-2015)Patients with a suspected diagnosis of ACS in New Zealand are admitted to one of 41 public hospitals and cared for by a mixture of cardiology and general medical teams. From mid-2012, the national goal, supported by a New Zealand Ministry of Health (MOH) indicator and directive to DHBs, was to achieve complete CathPCI registration in all patients undergoing coronary angiography regardless of indication, and a complete Cath-PCI and ACS dataset in all patients suspected by clinicians to have ACS at admission, who are referred for coronary angiography. Therefore, the goal was the registration of all New Zealand patients with a final diagnosis of ACS who had undergone coronary angiography (note: coronary angiography is indicated after ACS in most high-risk ACS patients in national and international guidelines).11-15 Centres were also encouraged to continue including other ACS patients in the Registry, but this was not mandatory and the comprehensiveness of capture varies by centre. The Registry was also implemented in all six private hospitals that provide coronary angiography, for predominantly non-ACS indications.Development, funding and implementationThe Registry cohort was established in mid-2007, when a web-based ACS registry was introduced into Middlemore Hospital in Auckland, New Zealand. In 2010, a CathPCI registry for use in the cardiac catheterisation laboratory was added to capture data for patients undergoing coronary angiography and PCI. Electronic linkage of common data fields between the ACS and CathPCI forms allows data items to be entered in the location where it is most appropriate and therefore most accurate coronary angiography and PCI data in the cardiac catheterisation laboratory, risk factor and in-hospital outcomes in the cardiology ward.In late 2011, the New Zealand National Cardiac Network proposed the establishment of a national combined ACS-CathPCI Registry to be governed under the auspices of the New Zealand branch of the Cardiac Society of Australia and New Zealand (CSANZ). This initiative was supported by the then Minister of Health, Tony Ryall, and funded by the MOH, and after a competitive tender process, a partnership between Enigma Solutions (software developers) and the National Institute for Health Innovation (NIHI, University of Auckland) was contracted to implement the national roll out of the ANZACS-QI Registry.By November 2013, the Registry was implemented in all 20 publically funded District Health Boards (DHBs) and their 41 hospitals which admit ACS patients. In New Zealand, virtually all ACS patients are admitted and managed in a public hospital.Connected Health Network IntegrationThe ANZACS-QI web platform uses the Connected Health Network (CHN), a standards-based, commercial model for the secure delivery of universal connectivity across the New Zealand health sector. The CHN is a network of networks delivered by multiple telecommunication service providers on a competitive basis, using industry standard, commodity capability. It is overseen by the MOH. Connected Health aims to improve reliability, safety, and security of transferring health information, as only products or services certified against approved network connectivity standards, such as ANZACS-QI, will be allowed to connect to the network. All authorised users have individual usernames and passwords allocated by a system administrator.Who enters data?On arrival at the Coronary Care Unit or catheterisation laboratory, patients are registered by clerical or clinical staff using an ANZACS-QI web form. The MOH Health Identity Programme (http://www.health.govt.nz/our-work/health-identity/health-identity-programme) provides the ability within the ANZACS-QI Registry for users to perform a search to find the demographic data for their patients. The data are automatically populated into the registration section of the web form. Clinical staff medical, nursing and radiology enter individual patient data into mandatory fields on the web form. At discharge, all fields are checked for completeness and missing data entered as required. The Cardiac Network and MOH set minimum requirements for form completion, which is assessed by monthly DHB completion reports, and provider-initiated ANZACS-QI system reports.Data qualityThis is facilitated by having a mandatory dataset, in-form definition statements, in-form automatic validation rules, automatic data capture from source datasets on demographics and laboratory results, as well as standardised user training and regular auditing. Each participating hospital is audited annually by a visiting audit nurse, with 20 randomly-selected CathPCI and ACS forms assessed, covering all data used for key performance indicator reporting. To date, the national data accuracy is 95% with a range of 83% to 99% across hospitals.Data linkageAudit and research activity is augmented by anonymised linkage of the Registry dataset to the national Routine Information dataset. Over 98%37 of New Zealanders have a unique health identifier (the National Health Index number, or NHI) which identifies individuals in multiple national and regional health system databases.38 With provider permission, patient registry data are anonymised by encrypting the NHI and then transferred from ANZACS-QI servers to the University of Auckland. The ever-growing Registry dataset can be regularly linked to national Routine Information dataset, via similarly encrypted NHIs, to measure processes (drug dispensing, subsequent cardiac procedures and laboratory monitoring) and outcomes (CVD hospitalisations and deaths).What is measured?A complete list of the data items in the ACS and CathPCI forms with definition statements and variable histories are available in the ANZACS-QI data dictionaries available at: https://www.fmhs.auckland.ac.nz/en/soph/about/our-departments/epidemiology-and-biostatistics/research/view-study/research.htmlACS formThis form collects demographic, risk factor, investigation, management, and in-hospital outcome data for all patients admitted with a suspected ACS.CathPCI formThe original 2010 CathPCI form was designed to collect a basic dataset on all patients undergoing coronary angiography including demographics, procedure indication, arterial access route, extent of coronary artery disease, performance of PCI and in-hospital outcomes. In September 2014 (see Figure 2), an expanded form was introduced nationally which retained the core dataset, but also captured risk factors and coronary lesion level recording of both lesion characteristics and interventional treatment in PCI patients. Figure 2: ANZACS-QI CathPCI data collection workflow. The current ANZACS-QI registry cohortThe national roll-out of the ANZACS-QI Registry across the DHBs was staggered over 6 months. The growth of the separate CathPCI and ACS admission cohorts are shown in Figure 3.Figure 3: ANZACS-QI ACS-CathPCI registry cohort growth. Admissions with completed datasets are shown. ACS registrationA total of 27,936 public hospital admissions with suspected ACS have been registered between 1 August 2007, and 20 June 2015. Complete data is available for 24,555 (87.9%) admissions, with a final confirmed diagnosis of ACS in 19,488 (79.4%) of admissions. The confirmed ACS diagnosis recorded is the clinician determined diagnosis at discharge according to standard definitions.39,40CathPCI registrationA total of 33,538 referrals for coronary angiography in 30,696 people have been registered since 1 November 2010. Of these referrals, complete data are available in 33,049 (98.5%).Using the ANZACS-QI combined ACS-CathPCI Registry cohort, various sub-cohorts can be defined. In Tables 2 and 3 we show two illustrative sub-cohorts.Sub-cohort 1 (Table 1)All patients with a confirmed ACS diagnosis and complete registry dataset. Data from each participating hospital is included in this sub-cohort from the first month when each hospital achieved at least 90% completion of their registered ACS forms. This cohort excludes admissions before 2012 to reflect contemporary practice.Table 1: ANZACS-QI ACS sub-cohort from 1 July 2012 to 30 June 2015. Overall (N=14,190) Age Group <50y (n=1,400) 50-<60y (n=2,819) 60-<70y (n=3,895) 70-<80y (n=3,666) \u226580y (n=2,410) Demographics Gender, n (%) Male Female 9,426 (66.4) 4,764 (33.6) 1,054 (75.3) 346 (24.7) 2,123 (75.3) 696 (24.7) 2,724 (69.9) 1,171 (30.1) 2,279 (62.2) 1,387 (37.8) 1,246 (51.7) 1,164 (48.3) Ethnicity, n (%) Mori Pacific Indian Asian New Zealand European/Other ,1579 (11.1) 803 (5.7) 633 (4.5) 357 (2.5) 10,818 (76.2) 273 (19.5) 187 (13.4) 113 (8.1) 52 (3.7) 775 (55.4) 501 (17.8) 252 (8.9) 185 (6.6) 95 (3.4) 1,786 (63.4) 476 (12.2) 221 (5.7) 171 (4.4) 108 (2.8) 2,919 (74.9) 262 (7.1) 125 (3.4) 119 (3.2) 75 (2.0) 3,085 (84.2) 67 (2.8) 18 (0.7) 45 (1.9) 27 (1.1) 2,253 (93.5) Sub-cohort 2 (Table 2)All coronary angiograms (all episodes) in New Zealand public hospitals from November 2013 (when CathPCI registration completion rates approached 100% in all New Zealand public hospital cardiac catheterisation laboratories).Table 2: ANZACS-QI CathPCI sub-cohort (coronary angiography) from 1 November 2013 to 30 June 2015. Overall (N=22,445) Age Group <50y (n=2,356) 50-<60y (n=4,693) 60-<70y (n=6,898) 70-<80y (n=6,309) \u226580y (n=2,189) Demographics Gender, n (%) Male Female 14,969 (66.7) 7,476 (33.3) 1,721 (73.1) 635 (27.0) 3,377 (72.0) 1,316 (28.0) 4,733 (68.6) 2,165 (31.4) 3,887 (61.6) 2,422 (38.4) 1,251 (57.1) 938 (42.9) Ethnicity, n (%) Mori Pacific Indian Asian New Zealand European/Other 2,303 (10.3) 1,068 (4.8) 899 (4.0) 719 (3.2) 17,456 (77.8) 479 (20.3) 267 (11.3) 155 (6.6) 98 (4.2) 1,357 (57.6) 766 (16.3) 329 (7.0) 272 (5.8) 175 (3.7) 3,151 (67.1) 681 (9.9) 310 (4.5) 282 (4.1) 231 (3.3) 5,394 (78.2) 344 (5.5) 149 (2.4) 166 (2.6) 174 (2.8) 5,476 (86.8) 33 (1.5) 13 (0.6) 24 (1.1) 41 (1.9) 2,078 (94.9) Indication Suspected ACS, n (%) STEMI <12 hrs Other ACS 12,214 (54.4) 2,165 (9.6) 10,049 (44.8) 1,501 (63.7) 373 (15.8) 1, 128 (47.9) 2,732 (58.2) 558 (11.9) 2,174 (46.3) 3,578 (51.9) 591 (8.6) 2,987 (43.3) 3,140 (49.8) 421 (6.7) 2,719 (43.1) 1,263 (57.7) 222 (10.1) 1,041 (47.6) Non-ACS Suspected or known chronic IHD Other indications 10,231 (45.6) 6,577 (29.3) 3,654 (16.3) 855 (36.3) 453 (19.2) 402 (17.1) 1,961 (41.8) 1,276 (27.2) 685 (14.6) 3,320 (48.1) 2,287 (33.1) 1,033 (15.0) 3,169 (50.2) 2,093 (33.2) 1,076 (17.1) 926 (42.3) 468 (21.4) 458 (20.9) The ANZACS-QI national Routine Information (ACS) cohortThis cohort is used to describe and investigate national trends in ACS incidence, investigation, management and outcomes and can also be linked to the ANZACS-QI registries for these purposes.The Routine Information cohort comprises anonymously linked baseline and longitudinal secondary data sourced directly from routinely collected New Zealand health datasets obtained from the New Zealand MOH (see Table 3). All New Zealand residents aged 20 years or over who are admitted to hospital with a primary or secondary International Classification of Disease 10 (ICD10) code consistent with ACS (I20.0, I21x, I22x) are included in the cohort.Table 3: Variables available in the ANZACS-QI Routine Information Cohort. Name of dataset and data contained Variables National Minimum Dataset41 (publicly funded hospitalisations) Admission-related data: date of admission, date of discharge, ICD-coded discharge diagnoses, ICD-coded procedural diagnoses (including angiography, PCI, CABG), DHB of domicile. Demographic data: age at admission, sex, ethnicity, deprivation quintile, domicile, rurality of residence. Previous hospitalisations: previous ACS and ischaemic heart disease admissions; Charlson comorbidities (MI, peripheral vascular disease, heart failure, chronic obstructive pulmonary disease, connective tissue disease, ulcers, dementia, cerebrovascular disease, hemiplegia, diabetes, liver disease, renal disease, neoplasms, AIDS); total Charlson comorbidity score. Pharmaceutical Collection42 Government-subsidised medication dispensing claims from community pharmacies. Mortality Collection43 Date of death and ICD-coded underlying and contributing causes of death. CABG, coronary artery bypass grafting; AIDS, acquired immune deficiency syndrome All source data were subject to quality checks by the MOH prior to delivery to the University of Auckland and again by the research team following integration. These data are updated annually.Baseline characteristics of the 100,579 subjects admitted with ACS from 1 January 2006 to 31 December 2013 with complete demographic data (144,279 ACS hospitalisations) are shown in Table 4.Table 4: Baseline characteristics of National ACS cohort (2006-2013), by age group. Overall (N=100,579) Age Group <50y (n=8,005) 50-<60y (n=14,531) 60-<70y (n=20,967) 70-<80y (n=25,292) \u226580y (n=31,784) Characteristics Gender, n (%) Male Female 58,885 (58.5) 41,694 (41.5) 5,969 (74.6) 2,036 (25.4) 10,521 (72.4) 4,010 (27.6) 1,3904 (66.3) 7,063 (33.7) 14,619 (57.8) 10,673 (42.2) 17,912 (56.4) 13,872 (43.6) Ethnicity, n (%) Mori Pacific Asian New Zealand European/Other 8,981 (8.9) 4,268 (4.2) 3,737 (3.7) 83,593 (83.1) 1,702 (21.3) 834 (10.4) 593 (7.4) 4,876 (60.9) 2,409 (16.6) 1,086 (7.5) 870 (6.0) 10,166 (70.0) 2,389 (11.4) 1,111 (5.3) 895 (4.3) 16,572 (79.0) 1,768 (7.0) 800 (3.2) 876 (3.4) 21,848 (86.4) 713 (2.2) 437 (1.4) 503 (1.6) 30,131 (94.8) ACS type, n (%) STEMI NSTEMI MI unspecified Unstable angina 16,645 (16.6) 54,531 (54.2) 5,119 (5.1) 24,284 (24.1) 2,224 (27.8) 3,725 (46.5) 226 (2.8) 1,830 (22.9) 3,522 (24.2) 6,726 (46.3) 386 (2.7) 3,897 (26.8) 3,907 (18.6) 10,288 (49.1) 660 (3.1) 6,112 (29.2) 3,554 (14.1) 13,596 (53.8) 1,217 (4.8) 6,925 (27.4) 3,438 (10.8) 20,196 (63.5) 2,630 (8.3) 5,520 (17.4) Deprivation Quintile 1 2 3 4 5 13,178 (13.3) 15,595 (15.8) 20,249 (20.5) 26,125 (26.5) 23,638 (23.9) 952 (12.1) 1,041 (13.3) 1,364 (17.4) 1,955 (25.0) 2,518 (32.2) 1,693 (13.8) 2,108 (14.8) 2,630 (18.4) 3,460 (24.2) 4,104 (28.8) 2,869 (13.9) 3,168 (15.4) 4,151 (20.1) 5,060 (24.6) 5,363 (26.0) 3,130 (12.6) 3,916 (15.8) 5,292 (21.3) 6,732 (27.1) 5,736 (23.1) 4,264 (13.6) 5,362 (17.2) 6,812 (21.8) 8,918 (28.5) 5,917 (18.9) Charlson comorbidity score, n (%) 0 (no comorbidity) 1-2 (moderate) \u22653 (severe) 57,407 (57.1) 25,225 (25.1) 17,947 (17.8) 6,443 (80.5) 1,048 (13.1) 514 (6.4) 10,742 (73.9) 2,529 (17.4) 1,260 (8.7) 13,587 (64.8) 4,523 (21.6) 2,857 (13.6) 12,962 (51.3) 6,870 (27.2) 5,460 (21.6) 13,673 (43.0) 10,255 (32.3) 7,856 (24.7) Ethics approval and governanceGovernance of the ANZACS-QI registry data is by the ANZACS-QI governance group on behalf of the New Zealand branch of the Cardiac Society of Australia and New Zealand (CSANZ). The governance group includes the clinical leaders of the Cardiac Clinical Networks for the four New Zealand regions, the Chairs of the New Zealand interventional working group, and CSANZ, Heart Rhythm New Zealand, nursing, consumer, MOH and the national Health Information Technology Board representatives. Written protocols and processes have been established to ensure appropriate data access and use through the ANZACS-QI Governance group. The ANZACS-QI Privacy Framework (available on request) has been approved by the New Zealand Privacy Commission and the ANZACS-QI governance group. Information about the ANZACS-QI Registry is available at all hospital sites, and patients may opt out of having their data being included in the cohort on request.ANZACS-QI is also part of the wider Health Research Council (HRC) and National Heart Foundation (NHF) funded Vascular Informatics using Epidemiology and the Web (VIEW) research programme based at the University of Auckland. The VIEW research team oversee the use and governance of any audit or research use of the national routine information datasets. As all ANZACS-QI Registry data and national Routine data is anonymised before being sent to the VIEW researchers, individual patient consent is not required by ethics committees. The VIEW study was approved by the Northern Region Ethics Committee Y in 2003 (AKY/03/12/314), with subsequent amendments to include the ANZACS-QI registries, and with annual approvals by the National Multi-Region Ethics Committee since 2007 (MEC07/19/EXP).ANZACS-QI outputsRegular reportingDHB- and hospital-level quality improvement activity is supported by user access to real-time reporting of evidence-based indicators using ANZACS-QI web tools which allows for the examination of individual-level data on patients not meeting particular criteria. Monthly, quarterly and annual summary reports containing nationally agreed indicator data using both the Registry and national Routine Data datasets are generated and distributed. The indicators reported are derived from national and international guidelines and agreed by the National Cardiac Cli

Summary

Abstract

The All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI) uses a web-based system to create a clinical registry of patients with acute coronary syndrome (ACS) and other cardiac problems admitted to hospitals across New Zealand. This detailed clinical registry is complemented by parallel analyses of, and individual linkage to, New Zealand s multiple routine health information datasets. The programme is primarily designed to support secondary care clinicians to implement evidence based guidelines and to meet national performance targets for New Zealand cardiac patients. ANZACS-QI simultaneously generates a large-scale research database and provides an electronic data infrastructure for clinical registry studies. ANZACS-QI has been successfully implemented in all the 41 public hospitals across New Zealand where acute cardiac patients are admitted. By June 2015 25,273 patients with suspected ACS and 30,696 referred for coronary angiography were registered in ANZACS-QI. In this report we describe the development and national implementation of ANZACS-QI, its governance, the data collection processes and the current ANZACS-QI cohorts and available outputs.

Aim

Method

Results

Conclusion

Author Information

Andrew Kerr, Cardiologist, Cardiology Department, Middlemore Hospital, Auckland, and Honorary Associate Professor of Medicine, University of Auckland, Auckland; Michael JA Williams, Cardiologist, Cardiology Department, Dunedin Hospital, Dunedin, and Clinical Professor, Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Harvey White, Cardiologist, Green Lane Cardiovascular Service, Auckland City Hospital, and Honorary Professor of Medicine, University of Auckland; Rob Doughty, Cardiologist Green Lane Cardiovascular Service, Auckland City Hospital, and Heart Foundation Chair of Heart Health, University of Auckland; Chris Nunn, Cardiologist, Cardiology Department, Waikato Hospital, Hamilton; Gerard Devlin, Cardiologist, Cardiology Department, Waikato Hospital, Hamilton, and Honorary Associate Professor of Medicine, University of Auckland; Corina Grey, Public Health Physician, and National Heart Foundation Fellow; Mildred Lee, Health Analyst, Middlemore Hospital, Auckland; Charmaine Flynn, Staff nurse, Middlemore Hospital, Auckland; Maxine Rhodes, Staff nurse, Christchurch Hospital, Christchurch; Kristin Sutherland, Project manager, National Institute of Health Care Innovation, University of Auckland; Sue Wells, Associate Professor, School of Population Health, University of Auckland; Rod Jackson, Professor, School of Population Health, University of Auckland; Ralph Stewart, Green Lane Cardiovascular Service, Auckland City Hospital, and Honorary Professor of Medicine, University of Auckland.

Acknowledgements

'- ANZACS-QI programme implementation, coordination and analysis: The ANZACS-QI software was developed and supported by Enigma Solutions. Programme implementation is coordinated by the National Institute for Health Innovation (NIHI) at the University of

Correspondence

Andrew Kerr, Department of Cardiology, Middlemore Hospital, Otahuhu, Auckland 93311, New Zealand.

Correspondence Email

Andrew.Kerr@middlemore.co.nz

Competing Interests

Nil.

-- - Ministry of Health. Mortality: Historical Summary 1948-2010. Wellington, 2010. Bjorck L, Rosengren A, Bennett K, et al. Modelling the decreasing coronary heart disease mortality in Sweden between 1986 and 2002. European Heart Journal

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Since the late 1960s, the age-standardised mortality rate for ischaemic heart disease in New Zealand has decreased from 253 to 66 per 100,000.1 This improvement across many Western countries, including New Zealand, has been attributed to a combination of improved lifestyle (smoking cessation, diet) and utilisation of evidence-based therapies (primary and secondary prevention medications, coronary revascularisation).2-5 Despite this, cardiovascular disease (CVD), and in particular coronary heart disease (CHD), remains the most common cause of death worldwide.6 In New Zealand, age-standardised mortality rates for vascular disease are still higher than those in many other Western countries (www.mortality-trends.org) and, of concern, important disparities exist in the burden of CVD mortality borne by some ethnic groups and by those living in areas of greater deprivation.7-9 In 2010, the age-standardised rate of ischaemic heart disease mortality was 55% higher among New Zealand Mori men compared with the rate for non-Mori men, while the rate for Mori women was nearly twice as high (99%) as that for non-Mori women.10 Those living in greater deprivation also have disproportionately higher CVD event rates. There is a formidable evidence base supporting the use of a range of lifestyle, pharmaceutical, and interventional treatments to improve outcomes in patients with acute CVD events. For example, national and international guidelines recommend timely coronary angiography and revascularisation as appropriate for patients with acute coronary syndrome (ACS).11-15 There is robust evidence to support the use of antiplatelet/anticoagulant,16,17 BP-lowering18-20 and statin21-23 medications, to improve outcomes in patients with established atherosclerotic CVD. This evidence base is constantly developing, with new treatments and technologies becoming available every year. However, in practice, there is often a substantial gap between ideal treatment based on clinical trials and what is achieved in practice the evidence-practice gap with suboptimal initiation and longer-term maintenance of evidence-based therapy across the spectrum of CVD.24-28 Prior studies have reported that revascularisation rates in non-Mori, non-Pacific New Zealanders are significantly higher when compared with Mori and Pacific people and in non-Mori compared with Mori.29,30 A series of three audits of ACS patient management in New Zealand over the last 10 years have demonstrated suboptimal provision of cardiac investigation in ACS patients. Marked variation in both the use of coronary intervention procedures and delay in treatment have also been documented.31-33 Gaps in the utilisation of secondary prevention therapy in New Zealand have been well documented.34-36 The identification of these evidence-practice gaps, and the implementation of programmes to close them, represent an important opportunity to improve the outcomes of patients with CVD in New Zealand.Why was ANZACS-QI established?The primary aim of the All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI) is to support appropriate, evidence-based management of ACS and subsequently of other cardiac patients regardless of age, sex, ethnicity, socioeconomic status, or rural or city dwelling. The ANZACS-QI programme supports this aim through its two arms a quality improvement arm and a research arm. Figure 1: ANZACS-QI programme cohorts, data flow and outputs. The interactions with the associated ANZACS-QI registry trials are shown. ANZACS-QI programme cohorts and processesThe ANZACS-QI programme utilises two complementary data sources to generate two overlapping cohorts: The ACS-CathPCI Registry cohort, generated using web-based software that enables secondary care clinicians to systematically collect data on ACS patients, coronary angiography and percutaneous coronary intervention (PCI) procedures in all New Zealand hospitals. The ACS Routine Information cohort, derived directly from national health datasets. While the ACS Routine Information cohort includes all New Zealand ACS patients, it is relatively limited in content. In contrast, the ACS-CathPCI Registry cohort captures more in-depth data on every ACS patient who has a coronary angiogram in New Zealand, all other patients having coronary angiography procedures and on some other ACS patients. The two overlapping data sources can be linked using the National Health Index (NHI) number, as discussed further below.The ACS-CathPCI Registry cohort (2007-2015)Patients with a suspected diagnosis of ACS in New Zealand are admitted to one of 41 public hospitals and cared for by a mixture of cardiology and general medical teams. From mid-2012, the national goal, supported by a New Zealand Ministry of Health (MOH) indicator and directive to DHBs, was to achieve complete CathPCI registration in all patients undergoing coronary angiography regardless of indication, and a complete Cath-PCI and ACS dataset in all patients suspected by clinicians to have ACS at admission, who are referred for coronary angiography. Therefore, the goal was the registration of all New Zealand patients with a final diagnosis of ACS who had undergone coronary angiography (note: coronary angiography is indicated after ACS in most high-risk ACS patients in national and international guidelines).11-15 Centres were also encouraged to continue including other ACS patients in the Registry, but this was not mandatory and the comprehensiveness of capture varies by centre. The Registry was also implemented in all six private hospitals that provide coronary angiography, for predominantly non-ACS indications.Development, funding and implementationThe Registry cohort was established in mid-2007, when a web-based ACS registry was introduced into Middlemore Hospital in Auckland, New Zealand. In 2010, a CathPCI registry for use in the cardiac catheterisation laboratory was added to capture data for patients undergoing coronary angiography and PCI. Electronic linkage of common data fields between the ACS and CathPCI forms allows data items to be entered in the location where it is most appropriate and therefore most accurate coronary angiography and PCI data in the cardiac catheterisation laboratory, risk factor and in-hospital outcomes in the cardiology ward.In late 2011, the New Zealand National Cardiac Network proposed the establishment of a national combined ACS-CathPCI Registry to be governed under the auspices of the New Zealand branch of the Cardiac Society of Australia and New Zealand (CSANZ). This initiative was supported by the then Minister of Health, Tony Ryall, and funded by the MOH, and after a competitive tender process, a partnership between Enigma Solutions (software developers) and the National Institute for Health Innovation (NIHI, University of Auckland) was contracted to implement the national roll out of the ANZACS-QI Registry.By November 2013, the Registry was implemented in all 20 publically funded District Health Boards (DHBs) and their 41 hospitals which admit ACS patients. In New Zealand, virtually all ACS patients are admitted and managed in a public hospital.Connected Health Network IntegrationThe ANZACS-QI web platform uses the Connected Health Network (CHN), a standards-based, commercial model for the secure delivery of universal connectivity across the New Zealand health sector. The CHN is a network of networks delivered by multiple telecommunication service providers on a competitive basis, using industry standard, commodity capability. It is overseen by the MOH. Connected Health aims to improve reliability, safety, and security of transferring health information, as only products or services certified against approved network connectivity standards, such as ANZACS-QI, will be allowed to connect to the network. All authorised users have individual usernames and passwords allocated by a system administrator.Who enters data?On arrival at the Coronary Care Unit or catheterisation laboratory, patients are registered by clerical or clinical staff using an ANZACS-QI web form. The MOH Health Identity Programme (http://www.health.govt.nz/our-work/health-identity/health-identity-programme) provides the ability within the ANZACS-QI Registry for users to perform a search to find the demographic data for their patients. The data are automatically populated into the registration section of the web form. Clinical staff medical, nursing and radiology enter individual patient data into mandatory fields on the web form. At discharge, all fields are checked for completeness and missing data entered as required. The Cardiac Network and MOH set minimum requirements for form completion, which is assessed by monthly DHB completion reports, and provider-initiated ANZACS-QI system reports.Data qualityThis is facilitated by having a mandatory dataset, in-form definition statements, in-form automatic validation rules, automatic data capture from source datasets on demographics and laboratory results, as well as standardised user training and regular auditing. Each participating hospital is audited annually by a visiting audit nurse, with 20 randomly-selected CathPCI and ACS forms assessed, covering all data used for key performance indicator reporting. To date, the national data accuracy is 95% with a range of 83% to 99% across hospitals.Data linkageAudit and research activity is augmented by anonymised linkage of the Registry dataset to the national Routine Information dataset. Over 98%37 of New Zealanders have a unique health identifier (the National Health Index number, or NHI) which identifies individuals in multiple national and regional health system databases.38 With provider permission, patient registry data are anonymised by encrypting the NHI and then transferred from ANZACS-QI servers to the University of Auckland. The ever-growing Registry dataset can be regularly linked to national Routine Information dataset, via similarly encrypted NHIs, to measure processes (drug dispensing, subsequent cardiac procedures and laboratory monitoring) and outcomes (CVD hospitalisations and deaths).What is measured?A complete list of the data items in the ACS and CathPCI forms with definition statements and variable histories are available in the ANZACS-QI data dictionaries available at: https://www.fmhs.auckland.ac.nz/en/soph/about/our-departments/epidemiology-and-biostatistics/research/view-study/research.htmlACS formThis form collects demographic, risk factor, investigation, management, and in-hospital outcome data for all patients admitted with a suspected ACS.CathPCI formThe original 2010 CathPCI form was designed to collect a basic dataset on all patients undergoing coronary angiography including demographics, procedure indication, arterial access route, extent of coronary artery disease, performance of PCI and in-hospital outcomes. In September 2014 (see Figure 2), an expanded form was introduced nationally which retained the core dataset, but also captured risk factors and coronary lesion level recording of both lesion characteristics and interventional treatment in PCI patients. Figure 2: ANZACS-QI CathPCI data collection workflow. The current ANZACS-QI registry cohortThe national roll-out of the ANZACS-QI Registry across the DHBs was staggered over 6 months. The growth of the separate CathPCI and ACS admission cohorts are shown in Figure 3.Figure 3: ANZACS-QI ACS-CathPCI registry cohort growth. Admissions with completed datasets are shown. ACS registrationA total of 27,936 public hospital admissions with suspected ACS have been registered between 1 August 2007, and 20 June 2015. Complete data is available for 24,555 (87.9%) admissions, with a final confirmed diagnosis of ACS in 19,488 (79.4%) of admissions. The confirmed ACS diagnosis recorded is the clinician determined diagnosis at discharge according to standard definitions.39,40CathPCI registrationA total of 33,538 referrals for coronary angiography in 30,696 people have been registered since 1 November 2010. Of these referrals, complete data are available in 33,049 (98.5%).Using the ANZACS-QI combined ACS-CathPCI Registry cohort, various sub-cohorts can be defined. In Tables 2 and 3 we show two illustrative sub-cohorts.Sub-cohort 1 (Table 1)All patients with a confirmed ACS diagnosis and complete registry dataset. Data from each participating hospital is included in this sub-cohort from the first month when each hospital achieved at least 90% completion of their registered ACS forms. This cohort excludes admissions before 2012 to reflect contemporary practice.Table 1: ANZACS-QI ACS sub-cohort from 1 July 2012 to 30 June 2015. Overall (N=14,190) Age Group <50y (n=1,400) 50-<60y (n=2,819) 60-<70y (n=3,895) 70-<80y (n=3,666) \u226580y (n=2,410) Demographics Gender, n (%) Male Female 9,426 (66.4) 4,764 (33.6) 1,054 (75.3) 346 (24.7) 2,123 (75.3) 696 (24.7) 2,724 (69.9) 1,171 (30.1) 2,279 (62.2) 1,387 (37.8) 1,246 (51.7) 1,164 (48.3) Ethnicity, n (%) Mori Pacific Indian Asian New Zealand European/Other ,1579 (11.1) 803 (5.7) 633 (4.5) 357 (2.5) 10,818 (76.2) 273 (19.5) 187 (13.4) 113 (8.1) 52 (3.7) 775 (55.4) 501 (17.8) 252 (8.9) 185 (6.6) 95 (3.4) 1,786 (63.4) 476 (12.2) 221 (5.7) 171 (4.4) 108 (2.8) 2,919 (74.9) 262 (7.1) 125 (3.4) 119 (3.2) 75 (2.0) 3,085 (84.2) 67 (2.8) 18 (0.7) 45 (1.9) 27 (1.1) 2,253 (93.5) Sub-cohort 2 (Table 2)All coronary angiograms (all episodes) in New Zealand public hospitals from November 2013 (when CathPCI registration completion rates approached 100% in all New Zealand public hospital cardiac catheterisation laboratories).Table 2: ANZACS-QI CathPCI sub-cohort (coronary angiography) from 1 November 2013 to 30 June 2015. Overall (N=22,445) Age Group <50y (n=2,356) 50-<60y (n=4,693) 60-<70y (n=6,898) 70-<80y (n=6,309) \u226580y (n=2,189) Demographics Gender, n (%) Male Female 14,969 (66.7) 7,476 (33.3) 1,721 (73.1) 635 (27.0) 3,377 (72.0) 1,316 (28.0) 4,733 (68.6) 2,165 (31.4) 3,887 (61.6) 2,422 (38.4) 1,251 (57.1) 938 (42.9) Ethnicity, n (%) Mori Pacific Indian Asian New Zealand European/Other 2,303 (10.3) 1,068 (4.8) 899 (4.0) 719 (3.2) 17,456 (77.8) 479 (20.3) 267 (11.3) 155 (6.6) 98 (4.2) 1,357 (57.6) 766 (16.3) 329 (7.0) 272 (5.8) 175 (3.7) 3,151 (67.1) 681 (9.9) 310 (4.5) 282 (4.1) 231 (3.3) 5,394 (78.2) 344 (5.5) 149 (2.4) 166 (2.6) 174 (2.8) 5,476 (86.8) 33 (1.5) 13 (0.6) 24 (1.1) 41 (1.9) 2,078 (94.9) Indication Suspected ACS, n (%) STEMI <12 hrs Other ACS 12,214 (54.4) 2,165 (9.6) 10,049 (44.8) 1,501 (63.7) 373 (15.8) 1, 128 (47.9) 2,732 (58.2) 558 (11.9) 2,174 (46.3) 3,578 (51.9) 591 (8.6) 2,987 (43.3) 3,140 (49.8) 421 (6.7) 2,719 (43.1) 1,263 (57.7) 222 (10.1) 1,041 (47.6) Non-ACS Suspected or known chronic IHD Other indications 10,231 (45.6) 6,577 (29.3) 3,654 (16.3) 855 (36.3) 453 (19.2) 402 (17.1) 1,961 (41.8) 1,276 (27.2) 685 (14.6) 3,320 (48.1) 2,287 (33.1) 1,033 (15.0) 3,169 (50.2) 2,093 (33.2) 1,076 (17.1) 926 (42.3) 468 (21.4) 458 (20.9) The ANZACS-QI national Routine Information (ACS) cohortThis cohort is used to describe and investigate national trends in ACS incidence, investigation, management and outcomes and can also be linked to the ANZACS-QI registries for these purposes.The Routine Information cohort comprises anonymously linked baseline and longitudinal secondary data sourced directly from routinely collected New Zealand health datasets obtained from the New Zealand MOH (see Table 3). All New Zealand residents aged 20 years or over who are admitted to hospital with a primary or secondary International Classification of Disease 10 (ICD10) code consistent with ACS (I20.0, I21x, I22x) are included in the cohort.Table 3: Variables available in the ANZACS-QI Routine Information Cohort. Name of dataset and data contained Variables National Minimum Dataset41 (publicly funded hospitalisations) Admission-related data: date of admission, date of discharge, ICD-coded discharge diagnoses, ICD-coded procedural diagnoses (including angiography, PCI, CABG), DHB of domicile. Demographic data: age at admission, sex, ethnicity, deprivation quintile, domicile, rurality of residence. Previous hospitalisations: previous ACS and ischaemic heart disease admissions; Charlson comorbidities (MI, peripheral vascular disease, heart failure, chronic obstructive pulmonary disease, connective tissue disease, ulcers, dementia, cerebrovascular disease, hemiplegia, diabetes, liver disease, renal disease, neoplasms, AIDS); total Charlson comorbidity score. Pharmaceutical Collection42 Government-subsidised medication dispensing claims from community pharmacies. Mortality Collection43 Date of death and ICD-coded underlying and contributing causes of death. CABG, coronary artery bypass grafting; AIDS, acquired immune deficiency syndrome All source data were subject to quality checks by the MOH prior to delivery to the University of Auckland and again by the research team following integration. These data are updated annually.Baseline characteristics of the 100,579 subjects admitted with ACS from 1 January 2006 to 31 December 2013 with complete demographic data (144,279 ACS hospitalisations) are shown in Table 4.Table 4: Baseline characteristics of National ACS cohort (2006-2013), by age group. Overall (N=100,579) Age Group <50y (n=8,005) 50-<60y (n=14,531) 60-<70y (n=20,967) 70-<80y (n=25,292) \u226580y (n=31,784) Characteristics Gender, n (%) Male Female 58,885 (58.5) 41,694 (41.5) 5,969 (74.6) 2,036 (25.4) 10,521 (72.4) 4,010 (27.6) 1,3904 (66.3) 7,063 (33.7) 14,619 (57.8) 10,673 (42.2) 17,912 (56.4) 13,872 (43.6) Ethnicity, n (%) Mori Pacific Asian New Zealand European/Other 8,981 (8.9) 4,268 (4.2) 3,737 (3.7) 83,593 (83.1) 1,702 (21.3) 834 (10.4) 593 (7.4) 4,876 (60.9) 2,409 (16.6) 1,086 (7.5) 870 (6.0) 10,166 (70.0) 2,389 (11.4) 1,111 (5.3) 895 (4.3) 16,572 (79.0) 1,768 (7.0) 800 (3.2) 876 (3.4) 21,848 (86.4) 713 (2.2) 437 (1.4) 503 (1.6) 30,131 (94.8) ACS type, n (%) STEMI NSTEMI MI unspecified Unstable angina 16,645 (16.6) 54,531 (54.2) 5,119 (5.1) 24,284 (24.1) 2,224 (27.8) 3,725 (46.5) 226 (2.8) 1,830 (22.9) 3,522 (24.2) 6,726 (46.3) 386 (2.7) 3,897 (26.8) 3,907 (18.6) 10,288 (49.1) 660 (3.1) 6,112 (29.2) 3,554 (14.1) 13,596 (53.8) 1,217 (4.8) 6,925 (27.4) 3,438 (10.8) 20,196 (63.5) 2,630 (8.3) 5,520 (17.4) Deprivation Quintile 1 2 3 4 5 13,178 (13.3) 15,595 (15.8) 20,249 (20.5) 26,125 (26.5) 23,638 (23.9) 952 (12.1) 1,041 (13.3) 1,364 (17.4) 1,955 (25.0) 2,518 (32.2) 1,693 (13.8) 2,108 (14.8) 2,630 (18.4) 3,460 (24.2) 4,104 (28.8) 2,869 (13.9) 3,168 (15.4) 4,151 (20.1) 5,060 (24.6) 5,363 (26.0) 3,130 (12.6) 3,916 (15.8) 5,292 (21.3) 6,732 (27.1) 5,736 (23.1) 4,264 (13.6) 5,362 (17.2) 6,812 (21.8) 8,918 (28.5) 5,917 (18.9) Charlson comorbidity score, n (%) 0 (no comorbidity) 1-2 (moderate) \u22653 (severe) 57,407 (57.1) 25,225 (25.1) 17,947 (17.8) 6,443 (80.5) 1,048 (13.1) 514 (6.4) 10,742 (73.9) 2,529 (17.4) 1,260 (8.7) 13,587 (64.8) 4,523 (21.6) 2,857 (13.6) 12,962 (51.3) 6,870 (27.2) 5,460 (21.6) 13,673 (43.0) 10,255 (32.3) 7,856 (24.7) Ethics approval and governanceGovernance of the ANZACS-QI registry data is by the ANZACS-QI governance group on behalf of the New Zealand branch of the Cardiac Society of Australia and New Zealand (CSANZ). The governance group includes the clinical leaders of the Cardiac Clinical Networks for the four New Zealand regions, the Chairs of the New Zealand interventional working group, and CSANZ, Heart Rhythm New Zealand, nursing, consumer, MOH and the national Health Information Technology Board representatives. Written protocols and processes have been established to ensure appropriate data access and use through the ANZACS-QI Governance group. The ANZACS-QI Privacy Framework (available on request) has been approved by the New Zealand Privacy Commission and the ANZACS-QI governance group. Information about the ANZACS-QI Registry is available at all hospital sites, and patients may opt out of having their data being included in the cohort on request.ANZACS-QI is also part of the wider Health Research Council (HRC) and National Heart Foundation (NHF) funded Vascular Informatics using Epidemiology and the Web (VIEW) research programme based at the University of Auckland. The VIEW research team oversee the use and governance of any audit or research use of the national routine information datasets. As all ANZACS-QI Registry data and national Routine data is anonymised before being sent to the VIEW researchers, individual patient consent is not required by ethics committees. The VIEW study was approved by the Northern Region Ethics Committee Y in 2003 (AKY/03/12/314), with subsequent amendments to include the ANZACS-QI registries, and with annual approvals by the National Multi-Region Ethics Committee since 2007 (MEC07/19/EXP).ANZACS-QI outputsRegular reportingDHB- and hospital-level quality improvement activity is supported by user access to real-time reporting of evidence-based indicators using ANZACS-QI web tools which allows for the examination of individual-level data on patients not meeting particular criteria. Monthly, quarterly and annual summary reports containing nationally agreed indicator data using both the Registry and national Routine Data datasets are generated and distributed. The indicators reported are derived from national and international guidelines and agreed by the National Cardiac Cli

Summary

Abstract

The All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI) uses a web-based system to create a clinical registry of patients with acute coronary syndrome (ACS) and other cardiac problems admitted to hospitals across New Zealand. This detailed clinical registry is complemented by parallel analyses of, and individual linkage to, New Zealand s multiple routine health information datasets. The programme is primarily designed to support secondary care clinicians to implement evidence based guidelines and to meet national performance targets for New Zealand cardiac patients. ANZACS-QI simultaneously generates a large-scale research database and provides an electronic data infrastructure for clinical registry studies. ANZACS-QI has been successfully implemented in all the 41 public hospitals across New Zealand where acute cardiac patients are admitted. By June 2015 25,273 patients with suspected ACS and 30,696 referred for coronary angiography were registered in ANZACS-QI. In this report we describe the development and national implementation of ANZACS-QI, its governance, the data collection processes and the current ANZACS-QI cohorts and available outputs.

Aim

Method

Results

Conclusion

Author Information

Andrew Kerr, Cardiologist, Cardiology Department, Middlemore Hospital, Auckland, and Honorary Associate Professor of Medicine, University of Auckland, Auckland; Michael JA Williams, Cardiologist, Cardiology Department, Dunedin Hospital, Dunedin, and Clinical Professor, Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Harvey White, Cardiologist, Green Lane Cardiovascular Service, Auckland City Hospital, and Honorary Professor of Medicine, University of Auckland; Rob Doughty, Cardiologist Green Lane Cardiovascular Service, Auckland City Hospital, and Heart Foundation Chair of Heart Health, University of Auckland; Chris Nunn, Cardiologist, Cardiology Department, Waikato Hospital, Hamilton; Gerard Devlin, Cardiologist, Cardiology Department, Waikato Hospital, Hamilton, and Honorary Associate Professor of Medicine, University of Auckland; Corina Grey, Public Health Physician, and National Heart Foundation Fellow; Mildred Lee, Health Analyst, Middlemore Hospital, Auckland; Charmaine Flynn, Staff nurse, Middlemore Hospital, Auckland; Maxine Rhodes, Staff nurse, Christchurch Hospital, Christchurch; Kristin Sutherland, Project manager, National Institute of Health Care Innovation, University of Auckland; Sue Wells, Associate Professor, School of Population Health, University of Auckland; Rod Jackson, Professor, School of Population Health, University of Auckland; Ralph Stewart, Green Lane Cardiovascular Service, Auckland City Hospital, and Honorary Professor of Medicine, University of Auckland.

Acknowledgements

'- ANZACS-QI programme implementation, coordination and analysis: The ANZACS-QI software was developed and supported by Enigma Solutions. Programme implementation is coordinated by the National Institute for Health Innovation (NIHI) at the University of

Correspondence

Andrew Kerr, Department of Cardiology, Middlemore Hospital, Otahuhu, Auckland 93311, New Zealand.

Correspondence Email

Andrew.Kerr@middlemore.co.nz

Competing Interests

Nil.

-- - Ministry of Health. Mortality: Historical Summary 1948-2010. Wellington, 2010. Bjorck L, Rosengren A, Bennett K, et al. Modelling the decreasing coronary heart disease mortality in Sweden between 1986 and 2002. European Heart Journal

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Since the late 1960s, the age-standardised mortality rate for ischaemic heart disease in New Zealand has decreased from 253 to 66 per 100,000.1 This improvement across many Western countries, including New Zealand, has been attributed to a combination of improved lifestyle (smoking cessation, diet) and utilisation of evidence-based therapies (primary and secondary prevention medications, coronary revascularisation).2-5 Despite this, cardiovascular disease (CVD), and in particular coronary heart disease (CHD), remains the most common cause of death worldwide.6 In New Zealand, age-standardised mortality rates for vascular disease are still higher than those in many other Western countries (www.mortality-trends.org) and, of concern, important disparities exist in the burden of CVD mortality borne by some ethnic groups and by those living in areas of greater deprivation.7-9 In 2010, the age-standardised rate of ischaemic heart disease mortality was 55% higher among New Zealand Mori men compared with the rate for non-Mori men, while the rate for Mori women was nearly twice as high (99%) as that for non-Mori women.10 Those living in greater deprivation also have disproportionately higher CVD event rates. There is a formidable evidence base supporting the use of a range of lifestyle, pharmaceutical, and interventional treatments to improve outcomes in patients with acute CVD events. For example, national and international guidelines recommend timely coronary angiography and revascularisation as appropriate for patients with acute coronary syndrome (ACS).11-15 There is robust evidence to support the use of antiplatelet/anticoagulant,16,17 BP-lowering18-20 and statin21-23 medications, to improve outcomes in patients with established atherosclerotic CVD. This evidence base is constantly developing, with new treatments and technologies becoming available every year. However, in practice, there is often a substantial gap between ideal treatment based on clinical trials and what is achieved in practice the evidence-practice gap with suboptimal initiation and longer-term maintenance of evidence-based therapy across the spectrum of CVD.24-28 Prior studies have reported that revascularisation rates in non-Mori, non-Pacific New Zealanders are significantly higher when compared with Mori and Pacific people and in non-Mori compared with Mori.29,30 A series of three audits of ACS patient management in New Zealand over the last 10 years have demonstrated suboptimal provision of cardiac investigation in ACS patients. Marked variation in both the use of coronary intervention procedures and delay in treatment have also been documented.31-33 Gaps in the utilisation of secondary prevention therapy in New Zealand have been well documented.34-36 The identification of these evidence-practice gaps, and the implementation of programmes to close them, represent an important opportunity to improve the outcomes of patients with CVD in New Zealand.Why was ANZACS-QI established?The primary aim of the All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI) is to support appropriate, evidence-based management of ACS and subsequently of other cardiac patients regardless of age, sex, ethnicity, socioeconomic status, or rural or city dwelling. The ANZACS-QI programme supports this aim through its two arms a quality improvement arm and a research arm. Figure 1: ANZACS-QI programme cohorts, data flow and outputs. The interactions with the associated ANZACS-QI registry trials are shown. ANZACS-QI programme cohorts and processesThe ANZACS-QI programme utilises two complementary data sources to generate two overlapping cohorts: The ACS-CathPCI Registry cohort, generated using web-based software that enables secondary care clinicians to systematically collect data on ACS patients, coronary angiography and percutaneous coronary intervention (PCI) procedures in all New Zealand hospitals. The ACS Routine Information cohort, derived directly from national health datasets. While the ACS Routine Information cohort includes all New Zealand ACS patients, it is relatively limited in content. In contrast, the ACS-CathPCI Registry cohort captures more in-depth data on every ACS patient who has a coronary angiogram in New Zealand, all other patients having coronary angiography procedures and on some other ACS patients. The two overlapping data sources can be linked using the National Health Index (NHI) number, as discussed further below.The ACS-CathPCI Registry cohort (2007-2015)Patients with a suspected diagnosis of ACS in New Zealand are admitted to one of 41 public hospitals and cared for by a mixture of cardiology and general medical teams. From mid-2012, the national goal, supported by a New Zealand Ministry of Health (MOH) indicator and directive to DHBs, was to achieve complete CathPCI registration in all patients undergoing coronary angiography regardless of indication, and a complete Cath-PCI and ACS dataset in all patients suspected by clinicians to have ACS at admission, who are referred for coronary angiography. Therefore, the goal was the registration of all New Zealand patients with a final diagnosis of ACS who had undergone coronary angiography (note: coronary angiography is indicated after ACS in most high-risk ACS patients in national and international guidelines).11-15 Centres were also encouraged to continue including other ACS patients in the Registry, but this was not mandatory and the comprehensiveness of capture varies by centre. The Registry was also implemented in all six private hospitals that provide coronary angiography, for predominantly non-ACS indications.Development, funding and implementationThe Registry cohort was established in mid-2007, when a web-based ACS registry was introduced into Middlemore Hospital in Auckland, New Zealand. In 2010, a CathPCI registry for use in the cardiac catheterisation laboratory was added to capture data for patients undergoing coronary angiography and PCI. Electronic linkage of common data fields between the ACS and CathPCI forms allows data items to be entered in the location where it is most appropriate and therefore most accurate coronary angiography and PCI data in the cardiac catheterisation laboratory, risk factor and in-hospital outcomes in the cardiology ward.In late 2011, the New Zealand National Cardiac Network proposed the establishment of a national combined ACS-CathPCI Registry to be governed under the auspices of the New Zealand branch of the Cardiac Society of Australia and New Zealand (CSANZ). This initiative was supported by the then Minister of Health, Tony Ryall, and funded by the MOH, and after a competitive tender process, a partnership between Enigma Solutions (software developers) and the National Institute for Health Innovation (NIHI, University of Auckland) was contracted to implement the national roll out of the ANZACS-QI Registry.By November 2013, the Registry was implemented in all 20 publically funded District Health Boards (DHBs) and their 41 hospitals which admit ACS patients. In New Zealand, virtually all ACS patients are admitted and managed in a public hospital.Connected Health Network IntegrationThe ANZACS-QI web platform uses the Connected Health Network (CHN), a standards-based, commercial model for the secure delivery of universal connectivity across the New Zealand health sector. The CHN is a network of networks delivered by multiple telecommunication service providers on a competitive basis, using industry standard, commodity capability. It is overseen by the MOH. Connected Health aims to improve reliability, safety, and security of transferring health information, as only products or services certified against approved network connectivity standards, such as ANZACS-QI, will be allowed to connect to the network. All authorised users have individual usernames and passwords allocated by a system administrator.Who enters data?On arrival at the Coronary Care Unit or catheterisation laboratory, patients are registered by clerical or clinical staff using an ANZACS-QI web form. The MOH Health Identity Programme (http://www.health.govt.nz/our-work/health-identity/health-identity-programme) provides the ability within the ANZACS-QI Registry for users to perform a search to find the demographic data for their patients. The data are automatically populated into the registration section of the web form. Clinical staff medical, nursing and radiology enter individual patient data into mandatory fields on the web form. At discharge, all fields are checked for completeness and missing data entered as required. The Cardiac Network and MOH set minimum requirements for form completion, which is assessed by monthly DHB completion reports, and provider-initiated ANZACS-QI system reports.Data qualityThis is facilitated by having a mandatory dataset, in-form definition statements, in-form automatic validation rules, automatic data capture from source datasets on demographics and laboratory results, as well as standardised user training and regular auditing. Each participating hospital is audited annually by a visiting audit nurse, with 20 randomly-selected CathPCI and ACS forms assessed, covering all data used for key performance indicator reporting. To date, the national data accuracy is 95% with a range of 83% to 99% across hospitals.Data linkageAudit and research activity is augmented by anonymised linkage of the Registry dataset to the national Routine Information dataset. Over 98%37 of New Zealanders have a unique health identifier (the National Health Index number, or NHI) which identifies individuals in multiple national and regional health system databases.38 With provider permission, patient registry data are anonymised by encrypting the NHI and then transferred from ANZACS-QI servers to the University of Auckland. The ever-growing Registry dataset can be regularly linked to national Routine Information dataset, via similarly encrypted NHIs, to measure processes (drug dispensing, subsequent cardiac procedures and laboratory monitoring) and outcomes (CVD hospitalisations and deaths).What is measured?A complete list of the data items in the ACS and CathPCI forms with definition statements and variable histories are available in the ANZACS-QI data dictionaries available at: https://www.fmhs.auckland.ac.nz/en/soph/about/our-departments/epidemiology-and-biostatistics/research/view-study/research.htmlACS formThis form collects demographic, risk factor, investigation, management, and in-hospital outcome data for all patients admitted with a suspected ACS.CathPCI formThe original 2010 CathPCI form was designed to collect a basic dataset on all patients undergoing coronary angiography including demographics, procedure indication, arterial access route, extent of coronary artery disease, performance of PCI and in-hospital outcomes. In September 2014 (see Figure 2), an expanded form was introduced nationally which retained the core dataset, but also captured risk factors and coronary lesion level recording of both lesion characteristics and interventional treatment in PCI patients. Figure 2: ANZACS-QI CathPCI data collection workflow. The current ANZACS-QI registry cohortThe national roll-out of the ANZACS-QI Registry across the DHBs was staggered over 6 months. The growth of the separate CathPCI and ACS admission cohorts are shown in Figure 3.Figure 3: ANZACS-QI ACS-CathPCI registry cohort growth. Admissions with completed datasets are shown. ACS registrationA total of 27,936 public hospital admissions with suspected ACS have been registered between 1 August 2007, and 20 June 2015. Complete data is available for 24,555 (87.9%) admissions, with a final confirmed diagnosis of ACS in 19,488 (79.4%) of admissions. The confirmed ACS diagnosis recorded is the clinician determined diagnosis at discharge according to standard definitions.39,40CathPCI registrationA total of 33,538 referrals for coronary angiography in 30,696 people have been registered since 1 November 2010. Of these referrals, complete data are available in 33,049 (98.5%).Using the ANZACS-QI combined ACS-CathPCI Registry cohort, various sub-cohorts can be defined. In Tables 2 and 3 we show two illustrative sub-cohorts.Sub-cohort 1 (Table 1)All patients with a confirmed ACS diagnosis and complete registry dataset. Data from each participating hospital is included in this sub-cohort from the first month when each hospital achieved at least 90% completion of their registered ACS forms. This cohort excludes admissions before 2012 to reflect contemporary practice.Table 1: ANZACS-QI ACS sub-cohort from 1 July 2012 to 30 June 2015. Overall (N=14,190) Age Group <50y (n=1,400) 50-<60y (n=2,819) 60-<70y (n=3,895) 70-<80y (n=3,666) \u226580y (n=2,410) Demographics Gender, n (%) Male Female 9,426 (66.4) 4,764 (33.6) 1,054 (75.3) 346 (24.7) 2,123 (75.3) 696 (24.7) 2,724 (69.9) 1,171 (30.1) 2,279 (62.2) 1,387 (37.8) 1,246 (51.7) 1,164 (48.3) Ethnicity, n (%) Mori Pacific Indian Asian New Zealand European/Other ,1579 (11.1) 803 (5.7) 633 (4.5) 357 (2.5) 10,818 (76.2) 273 (19.5) 187 (13.4) 113 (8.1) 52 (3.7) 775 (55.4) 501 (17.8) 252 (8.9) 185 (6.6) 95 (3.4) 1,786 (63.4) 476 (12.2) 221 (5.7) 171 (4.4) 108 (2.8) 2,919 (74.9) 262 (7.1) 125 (3.4) 119 (3.2) 75 (2.0) 3,085 (84.2) 67 (2.8) 18 (0.7) 45 (1.9) 27 (1.1) 2,253 (93.5) Sub-cohort 2 (Table 2)All coronary angiograms (all episodes) in New Zealand public hospitals from November 2013 (when CathPCI registration completion rates approached 100% in all New Zealand public hospital cardiac catheterisation laboratories).Table 2: ANZACS-QI CathPCI sub-cohort (coronary angiography) from 1 November 2013 to 30 June 2015. Overall (N=22,445) Age Group <50y (n=2,356) 50-<60y (n=4,693) 60-<70y (n=6,898) 70-<80y (n=6,309) \u226580y (n=2,189) Demographics Gender, n (%) Male Female 14,969 (66.7) 7,476 (33.3) 1,721 (73.1) 635 (27.0) 3,377 (72.0) 1,316 (28.0) 4,733 (68.6) 2,165 (31.4) 3,887 (61.6) 2,422 (38.4) 1,251 (57.1) 938 (42.9) Ethnicity, n (%) Mori Pacific Indian Asian New Zealand European/Other 2,303 (10.3) 1,068 (4.8) 899 (4.0) 719 (3.2) 17,456 (77.8) 479 (20.3) 267 (11.3) 155 (6.6) 98 (4.2) 1,357 (57.6) 766 (16.3) 329 (7.0) 272 (5.8) 175 (3.7) 3,151 (67.1) 681 (9.9) 310 (4.5) 282 (4.1) 231 (3.3) 5,394 (78.2) 344 (5.5) 149 (2.4) 166 (2.6) 174 (2.8) 5,476 (86.8) 33 (1.5) 13 (0.6) 24 (1.1) 41 (1.9) 2,078 (94.9) Indication Suspected ACS, n (%) STEMI <12 hrs Other ACS 12,214 (54.4) 2,165 (9.6) 10,049 (44.8) 1,501 (63.7) 373 (15.8) 1, 128 (47.9) 2,732 (58.2) 558 (11.9) 2,174 (46.3) 3,578 (51.9) 591 (8.6) 2,987 (43.3) 3,140 (49.8) 421 (6.7) 2,719 (43.1) 1,263 (57.7) 222 (10.1) 1,041 (47.6) Non-ACS Suspected or known chronic IHD Other indications 10,231 (45.6) 6,577 (29.3) 3,654 (16.3) 855 (36.3) 453 (19.2) 402 (17.1) 1,961 (41.8) 1,276 (27.2) 685 (14.6) 3,320 (48.1) 2,287 (33.1) 1,033 (15.0) 3,169 (50.2) 2,093 (33.2) 1,076 (17.1) 926 (42.3) 468 (21.4) 458 (20.9) The ANZACS-QI national Routine Information (ACS) cohortThis cohort is used to describe and investigate national trends in ACS incidence, investigation, management and outcomes and can also be linked to the ANZACS-QI registries for these purposes.The Routine Information cohort comprises anonymously linked baseline and longitudinal secondary data sourced directly from routinely collected New Zealand health datasets obtained from the New Zealand MOH (see Table 3). All New Zealand residents aged 20 years or over who are admitted to hospital with a primary or secondary International Classification of Disease 10 (ICD10) code consistent with ACS (I20.0, I21x, I22x) are included in the cohort.Table 3: Variables available in the ANZACS-QI Routine Information Cohort. Name of dataset and data contained Variables National Minimum Dataset41 (publicly funded hospitalisations) Admission-related data: date of admission, date of discharge, ICD-coded discharge diagnoses, ICD-coded procedural diagnoses (including angiography, PCI, CABG), DHB of domicile. Demographic data: age at admission, sex, ethnicity, deprivation quintile, domicile, rurality of residence. Previous hospitalisations: previous ACS and ischaemic heart disease admissions; Charlson comorbidities (MI, peripheral vascular disease, heart failure, chronic obstructive pulmonary disease, connective tissue disease, ulcers, dementia, cerebrovascular disease, hemiplegia, diabetes, liver disease, renal disease, neoplasms, AIDS); total Charlson comorbidity score. Pharmaceutical Collection42 Government-subsidised medication dispensing claims from community pharmacies. Mortality Collection43 Date of death and ICD-coded underlying and contributing causes of death. CABG, coronary artery bypass grafting; AIDS, acquired immune deficiency syndrome All source data were subject to quality checks by the MOH prior to delivery to the University of Auckland and again by the research team following integration. These data are updated annually.Baseline characteristics of the 100,579 subjects admitted with ACS from 1 January 2006 to 31 December 2013 with complete demographic data (144,279 ACS hospitalisations) are shown in Table 4.Table 4: Baseline characteristics of National ACS cohort (2006-2013), by age group. Overall (N=100,579) Age Group <50y (n=8,005) 50-<60y (n=14,531) 60-<70y (n=20,967) 70-<80y (n=25,292) \u226580y (n=31,784) Characteristics Gender, n (%) Male Female 58,885 (58.5) 41,694 (41.5) 5,969 (74.6) 2,036 (25.4) 10,521 (72.4) 4,010 (27.6) 1,3904 (66.3) 7,063 (33.7) 14,619 (57.8) 10,673 (42.2) 17,912 (56.4) 13,872 (43.6) Ethnicity, n (%) Mori Pacific Asian New Zealand European/Other 8,981 (8.9) 4,268 (4.2) 3,737 (3.7) 83,593 (83.1) 1,702 (21.3) 834 (10.4) 593 (7.4) 4,876 (60.9) 2,409 (16.6) 1,086 (7.5) 870 (6.0) 10,166 (70.0) 2,389 (11.4) 1,111 (5.3) 895 (4.3) 16,572 (79.0) 1,768 (7.0) 800 (3.2) 876 (3.4) 21,848 (86.4) 713 (2.2) 437 (1.4) 503 (1.6) 30,131 (94.8) ACS type, n (%) STEMI NSTEMI MI unspecified Unstable angina 16,645 (16.6) 54,531 (54.2) 5,119 (5.1) 24,284 (24.1) 2,224 (27.8) 3,725 (46.5) 226 (2.8) 1,830 (22.9) 3,522 (24.2) 6,726 (46.3) 386 (2.7) 3,897 (26.8) 3,907 (18.6) 10,288 (49.1) 660 (3.1) 6,112 (29.2) 3,554 (14.1) 13,596 (53.8) 1,217 (4.8) 6,925 (27.4) 3,438 (10.8) 20,196 (63.5) 2,630 (8.3) 5,520 (17.4) Deprivation Quintile 1 2 3 4 5 13,178 (13.3) 15,595 (15.8) 20,249 (20.5) 26,125 (26.5) 23,638 (23.9) 952 (12.1) 1,041 (13.3) 1,364 (17.4) 1,955 (25.0) 2,518 (32.2) 1,693 (13.8) 2,108 (14.8) 2,630 (18.4) 3,460 (24.2) 4,104 (28.8) 2,869 (13.9) 3,168 (15.4) 4,151 (20.1) 5,060 (24.6) 5,363 (26.0) 3,130 (12.6) 3,916 (15.8) 5,292 (21.3) 6,732 (27.1) 5,736 (23.1) 4,264 (13.6) 5,362 (17.2) 6,812 (21.8) 8,918 (28.5) 5,917 (18.9) Charlson comorbidity score, n (%) 0 (no comorbidity) 1-2 (moderate) \u22653 (severe) 57,407 (57.1) 25,225 (25.1) 17,947 (17.8) 6,443 (80.5) 1,048 (13.1) 514 (6.4) 10,742 (73.9) 2,529 (17.4) 1,260 (8.7) 13,587 (64.8) 4,523 (21.6) 2,857 (13.6) 12,962 (51.3) 6,870 (27.2) 5,460 (21.6) 13,673 (43.0) 10,255 (32.3) 7,856 (24.7) Ethics approval and governanceGovernance of the ANZACS-QI registry data is by the ANZACS-QI governance group on behalf of the New Zealand branch of the Cardiac Society of Australia and New Zealand (CSANZ). The governance group includes the clinical leaders of the Cardiac Clinical Networks for the four New Zealand regions, the Chairs of the New Zealand interventional working group, and CSANZ, Heart Rhythm New Zealand, nursing, consumer, MOH and the national Health Information Technology Board representatives. Written protocols and processes have been established to ensure appropriate data access and use through the ANZACS-QI Governance group. The ANZACS-QI Privacy Framework (available on request) has been approved by the New Zealand Privacy Commission and the ANZACS-QI governance group. Information about the ANZACS-QI Registry is available at all hospital sites, and patients may opt out of having their data being included in the cohort on request.ANZACS-QI is also part of the wider Health Research Council (HRC) and National Heart Foundation (NHF) funded Vascular Informatics using Epidemiology and the Web (VIEW) research programme based at the University of Auckland. The VIEW research team oversee the use and governance of any audit or research use of the national routine information datasets. As all ANZACS-QI Registry data and national Routine data is anonymised before being sent to the VIEW researchers, individual patient consent is not required by ethics committees. The VIEW study was approved by the Northern Region Ethics Committee Y in 2003 (AKY/03/12/314), with subsequent amendments to include the ANZACS-QI registries, and with annual approvals by the National Multi-Region Ethics Committee since 2007 (MEC07/19/EXP).ANZACS-QI outputsRegular reportingDHB- and hospital-level quality improvement activity is supported by user access to real-time reporting of evidence-based indicators using ANZACS-QI web tools which allows for the examination of individual-level data on patients not meeting particular criteria. Monthly, quarterly and annual summary reports containing nationally agreed indicator data using both the Registry and national Routine Data datasets are generated and distributed. The indicators reported are derived from national and international guidelines and agreed by the National Cardiac Cli

Summary

Abstract

The All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI) uses a web-based system to create a clinical registry of patients with acute coronary syndrome (ACS) and other cardiac problems admitted to hospitals across New Zealand. This detailed clinical registry is complemented by parallel analyses of, and individual linkage to, New Zealand s multiple routine health information datasets. The programme is primarily designed to support secondary care clinicians to implement evidence based guidelines and to meet national performance targets for New Zealand cardiac patients. ANZACS-QI simultaneously generates a large-scale research database and provides an electronic data infrastructure for clinical registry studies. ANZACS-QI has been successfully implemented in all the 41 public hospitals across New Zealand where acute cardiac patients are admitted. By June 2015 25,273 patients with suspected ACS and 30,696 referred for coronary angiography were registered in ANZACS-QI. In this report we describe the development and national implementation of ANZACS-QI, its governance, the data collection processes and the current ANZACS-QI cohorts and available outputs.

Aim

Method

Results

Conclusion

Author Information

Andrew Kerr, Cardiologist, Cardiology Department, Middlemore Hospital, Auckland, and Honorary Associate Professor of Medicine, University of Auckland, Auckland; Michael JA Williams, Cardiologist, Cardiology Department, Dunedin Hospital, Dunedin, and Clinical Professor, Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Harvey White, Cardiologist, Green Lane Cardiovascular Service, Auckland City Hospital, and Honorary Professor of Medicine, University of Auckland; Rob Doughty, Cardiologist Green Lane Cardiovascular Service, Auckland City Hospital, and Heart Foundation Chair of Heart Health, University of Auckland; Chris Nunn, Cardiologist, Cardiology Department, Waikato Hospital, Hamilton; Gerard Devlin, Cardiologist, Cardiology Department, Waikato Hospital, Hamilton, and Honorary Associate Professor of Medicine, University of Auckland; Corina Grey, Public Health Physician, and National Heart Foundation Fellow; Mildred Lee, Health Analyst, Middlemore Hospital, Auckland; Charmaine Flynn, Staff nurse, Middlemore Hospital, Auckland; Maxine Rhodes, Staff nurse, Christchurch Hospital, Christchurch; Kristin Sutherland, Project manager, National Institute of Health Care Innovation, University of Auckland; Sue Wells, Associate Professor, School of Population Health, University of Auckland; Rod Jackson, Professor, School of Population Health, University of Auckland; Ralph Stewart, Green Lane Cardiovascular Service, Auckland City Hospital, and Honorary Professor of Medicine, University of Auckland.

Acknowledgements

'- ANZACS-QI programme implementation, coordination and analysis: The ANZACS-QI software was developed and supported by Enigma Solutions. Programme implementation is coordinated by the National Institute for Health Innovation (NIHI) at the University of

Correspondence

Andrew Kerr, Department of Cardiology, Middlemore Hospital, Otahuhu, Auckland 93311, New Zealand.

Correspondence Email

Andrew.Kerr@middlemore.co.nz

Competing Interests

Nil.

-- - Ministry of Health. Mortality: Historical Summary 1948-2010. Wellington, 2010. Bjorck L, Rosengren A, Bennett K, et al. Modelling the decreasing coronary heart disease mortality in Sweden between 1986 and 2002. European Heart Journal

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