Acute coronary syndrome care across Australia and New Zealand

Abstract

Improving the uptake of guideline-recommended therapy for suspected acute coronary syndrome (ACS) is a global health priority. Australia and New Zealand (NZ) undertook a snapshot of ACS to compare in-hospital care and prevention measures at discharge to published guidelines. Methods: Demographic and clinical details of individuals hospitalised with suspected ACS between 14-27th May 2012 were collected. Some 525 hospitals (39 in NZ) were identified from public records and peers as accepting ACS cases and considered for participation. Descriptive and logistic regression analysis was performed. The main indicators included: rates of guideline-advocated investigations, therapies, referral to cardiac rehabilitation. Outcomes included, in-hospital case-fatality, new myocardial infarction (MI), stroke, cardiac arrest, worsening heart failure. Results: 478 hospitals (91%) agreed to participate, 285 of which saw ACS patients and contributed data over the 2-week collection (46% large urban public/private hospitals, 26% regional and 28% small rural). The other 193 participating predominantly small rural facilities did not have ACS admissions over the two-week study period. 4,365 patients were enrolled, mean age 67 (SD 14) years, 60% men and median GRACE score of 118 (IQR: 96-143). Although the majority of presentations were to large urban hospitals (74%), the audit also captured information on 1,135 patient presenting to regional or rural hospitals. At discharge, 34% were diagnosed as MI, 21% unstable angina, 26% unlikely ischaemia, and 19% had other diagnoses. For the 1474 with MI; angiography was performed in 70%, angioplasty in 41% and cardiac surgery in 8%. As patient risk increased invasive management was less likely (GRACE score <100: 85.0% vs. 101-150: 79.4% vs. 151-200: 49.0% vs. >200: 36.1%, p<0.0001). Case-fatality was 4.4% and new MI 5.0%. Adjusted for GRACE score, there was significant variation in care, clinical course, and secondary prevention measures at discharge, by hospital type/regionality and state/province. Conclusions: This first comprehensive audit of ACS care in large urban, regional and small rural hospitals in Australia and NZ confirms there are significant variations in the application of the guideline-recommended treatment across both countries. Underutilisation of guideline recommended therapy occurred across all hospital types, in particular for the patients deemed at higher risk by the calculated GRACE score. Focus on quality improvement supported by integrated clinical service delivery is warranted to improve access to, and utilisation of, evidence-based ACS care in both countries.