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Purpose: We studied the unselected population of all acute coronary syndrome (ACS) patients of an entire nation in order to evaluate differences in coronary angiography (CAG) rate.Denmark (population 5.5 million) has a universal health insurance coverage system and uniform national guidelines for the treatment of ACS.There are 5 tertiary invasive centres performing CAG, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), 8 hospitals with diagnostic units performing CAG only, and a further 36 hospitals without these facilities receiving patients with ACS.We investigated if there was a difference in the rate of CAG after admission with ACS depending on distance between place of residence and invasive centre.Methods: All patients, hospitalised with a first ACS from January 2005 to December 2007, were included from the National Patient Register. Age, gender and information on co-morbidity were recorded for each patient.Information on distance from each patients place of residence to the nearest invasive centre was obtained from Statistics Denmark along with information on education, family income, previous medicine use and vital status.Patients were grouped in tertiles according to distance to centre.Outcome was CAG within 60 days identified in the Danish Heart Registry.Cox proportional-hazard models were used to estimate the difference in the rate of CAG related to distance when adjusting for explanatory variables.Results: Of 24 910 patients with first ACS 33% lived less than 21 km from one of the 5 invasive centres, 33% lived between 21-64 km, and 33% >64 km away.Longer distance to an invasive centre was associated with less invasive examination after the event. The cumulative incidence of CAG was 77% for the third living closest to a centre vs. 68% for those living farthest away.When adjusting for patient characteristics such as gender, age, income, education, admission year, previous revascularisation, co-morbidity and medicine use there was a hazard ratio (HR) of 0.79 (95% CI 0. 73-0.85, p < 0.0001) of receiving CAG for the patients living farthest away in comparison to those living closest to the centres.Conclusion: Despite uniform national guidelines, patients hospitalised with a first acute ACS are treated with a less aggressive invasive diagnostic approach the farther away they live from an invasive centre. When planning the management of ACS patients it is imperative that all parts of the healthcare system perform equally well so patients can rely on the same optimal treatment regardless of their place of residence.

PurposeWe studied the population of all acute coronary syndrome (ACS) patients examined with coronary angiography (CAG) in order to evaluate differences in invasive revascularisation rate. Denmark (population 5.5 million) has a universal health insurance coverage system and uniform national guidelines for the treatment of ACS. There are 5 tertiary invasive centres performing CAG, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), 8 hospitals with diagnostic units performing CAG only, and a further 36 hospitals without these facilities receiving patients with ACS. We investigated if there was a difference in revascularisation after CAG following admission with ACS, depending on distance between place of residence and invasive centre.Methods All patients hospitalised with a first ACS from January 2005 to December 2007 were identified in the National Patient Register. We included those examined with CAG in the analysis. Information on distance from the patient's home to nearest invasive centre was obtained from Statistics Denmark along with information on education, personal income, previous medicine use and vital status. Patients were grouped in tertiles according to distance to centre. From the Danish Heart Registry procedures (CAG, PCI and CABG) were identified along with information on the result of CAG. A Cox proportional-hazard models with revascularisation as outcome was used to estimate the difference related to distance within 60 days of the admission. ResultOf 24 910 patients with first ACS, 33% lived less than 21 km from one of the 5 invasive centres, 33% lived between 21-64 km and 33% >64 km away. Revascularisation was performed in 13 964 (73%) of the 18263 patients examined with a CAG. Among those examined with a CAG, the cumulative incidence of revascularisation was 79% for the third living closest to a centre vs. 74% for those living farthest away. When adjusting for variables like gender, age, vessel disease and the others mentioned above, there was a hazard ratio (HR) of 0.80 (95% CI 0. 73-0.85, p < 0.0001) of receiving revascularisation for the patients living farthest away compared to those living closest. CAG was performed at a tertiary centre in 68% among those living farthest away vs. 90% among those living closest to a centre.ConclusionDespite uniform national guidelines, patients who receive CAG following ACS are treated with a less aggressive invasive approach the farther away they live from an invasive centre. This difference could be due to differences in the treatment strategy between invasive centres and hospitals with only diagnostic units.