Research Article: Regional to tertiary inter-hospital transfer versus in-house percutaneous coronary intervention in acute coronary syndrome

Date Published: June 21, 2018

Publisher: Public Library of Science

Author(s): Delara Javat, Clare Heal, Jennifer Banks, Stefan Buchholz, Zhihua Zhang, Andrea Ballotta.

http://doi.org/10.1371/journal.pone.0198272

Abstract

To address the inaccessibility of interventional cardiac services in North Queensland a new cardiac catheterisation laboratory (CCL) was established in Mackay Base Hospital (MBH) in February 2014.

To determine whether the provision of in-house angiography and/or percutaneous coronary intervention (PCI) 1) minimises treatment delays 2) further reduces the risk of mortality, recurrent myocardial infarction (MI) and recurrent ischaemia 3) improves patient satisfaction and 4) minimises cost expenditure compared with inter-hospital transfer for patients with acute coronary syndrome (ACS).

We compared ACS patients who were transferred to tertiary centres from July 2012 to June 2013 with those who received in-house angiography and/or PCI from February 2015 to January 2016. The primary outcome was the composite of all-cause mortality, recurrent myocardial infarction (MI) or recurrent ischaemia at six months. Pre-specified secondary outcomes were the composite of all-cause mortality, recurrent MI or recurrent ischaemia at one month, a summated patient satisfaction score and the proportional cost savings generated between 2015 and 2016.

We included consecutive samples of 203 patients from July 2012 to June 2013 and 229 patients from February 2015 to January 2016. There was a reduction in the median time to treatment of 3.2 days and a reduction in the median length of stay of four days amongst all ACS patients receiving in-house angiography and/or PCI. The primary outcome occurred in 14 (6.9%) patients in the 2012 to 2013 group, as compared with 18 (7.9%) patients in the 2015 to 2016 group (OR = 0.71, 95% CI 0.24–2.1, P = 0.54). The secondary outcome at one month occurred in four (2.0%) patients in the 2012 to 2013 group, as compared with three (1.3%) patients in the 2015 to 2016 group (OR = 1.2, 95% CI 0.11–13.1, P = 0.87). There was a statistically significant improvement in the summated patient satisfaction score amongst patients who received in-house angiography and/or PCI (U = 1918, P <0.05 two tailed). A calculation of estimated cost savings showed a reduction in proportional cost of $14 481 (51%) per ACS patient receiving in house angiography and/or PCI between 2015 and 2016. This study suggests that the provision of regional in-house angiography and/or PCI for the treatment of ACS minimises delays to invasive treatment by 3.2 days, minimises the median length of stay by four days, significantly improves patient satisfaction and reduces proportional treatment costs by $14 481 (51%) per patient. Currently, however, it appears that that in-house treatment does not further reduce the risk of mortality, recurrent MI and recurrent ischaemia at one and six months.

Partial Text

Cardiovascular diseases are currently the leading cause of deaths globally.[1] Amongst these, coronary artery disease (CAD) is the single leading cause for mortality in Australia.[2] Acute coronary syndrome (ACS) is a manifestation of CAD which includes ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTEACS). Current Australian ACS guidelines recommend invasive management with diagnostic angiography and/or percutaneous coronary intervention (PCI) for all STEMI and high risk NSTEACS patients.[3] This is based on recent literature which demonstrates superior long term outcomes with primary PCI compared to in-hospital fibrinolysis for STEMI patients.[4] Furthermore randomised controlled trials demonstrate a long-term mortality benefit at one and five years with a routine invasive strategy compared with a conservative approach for high risk NSTEACS patients.[5, 6] Further research also showed a reduction in major cardiac events amongst patients randomised to an early invasive strategy with concomitant glycoprotein IIb/IIIa treatment.[7] Unfortunately, compared to their metropolitan counterparts, regional communities in Australia are frequently characterised by geographical isolation, limited access to advanced medical facilities and protracted treatment delays.[8] As such regional populations may be at higher risk of adverse outcomes following an acute coronary event.[9] In particular, the provision of cardiac catheterisation remains a challenge in North Queensland, where more than 50% of the population resides outside the state’s capital.[10]

Our study strongly supports the provision of regional in-house angiography and/or PCI for the management of ACS patients in MBH. The present study shows that in-house angiography and/or PCI minimises delays to treatment by 3.2 days, reduces the median length of stay by four days, significantly improves patient satisfaction and reduces proportional treatment costs by $14 481 (51%) per patient. Currently, however it appears that the introduction of a CCL for the management of ACS does not translate to a further reduction in the risk of mortality, recurrent MI and recurrent ischaemia at one and six months. The findings of our study have considerable clinical and economic implications for the regional hospitals, tertiary referral hospitals and the area health networks.

This study suggests that the provision of in-house angiography and/or PCI represents a unique innovation that simultaneously minimises delays to treatment by 3.2 days, reduces the median length of stay by four days, significantly improves patient satisfaction and reduces proportional treatment costs by $14 481 (51%) per patient. Currently, from this study, it appears that in-house catheterisation does not further reduce the risk of mortality, recurrent MI and recurrent ischaemia at one and six months.

 

Source:

http://doi.org/10.1371/journal.pone.0198272

 

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