Search

Background: The Australian healthcare system is complex. Assessing the quality of the care provided in the management of acute coronary syndromes (ACS) is problematic because of disparate systems that constrain an integrated reporting approach. Registry data reported within a comparative effectiveness research (CER) framework establishes the case for clinical process indicators to measure and report hospital performance. Objectives: To aggregate data from The Global Registry of Acute Coronary Events (GRACE) and the Cooperative National Registry of Acute Coronary Care Guideline Adherence and Clinical Events (CONCORDANCE) to describe temporal trends in the management of ACS and associations with in-hospital events, hospital readmission and six month mortality; to develop a composite score of hospital performance quality; to determine associations between adherence to the quality composite score and in-hospital events, hospital readmission and six month mortality and develop a benchmarked stakeholder hospital performance report. Methods: A single case study embedding three units of analysis was used to explore and explain how data reported in a CER framework measures hospital performance in the management of ACS. Analysis: Descriptive analyses of prospectively collected data on the management and outcomes of over 7000 patients admitted to 46 hospitals from 1999 to 2016. Findings: The first Unit of Analysis reports temporal trends in the management of ACS across 11 hospitals in the GRACE registry from 2000 to 2007 which informed the design of the CONCORDANCE registry; The second Unit of Analysis combines both GRACE and CONCORDANCE registries and reports on the management of ST-elevation acute myocardial infarction (STEMI ) from 1999 to 2016 revealing gains in pre-hospital care and fewer in-hospital clinical events, and readmission for urgent revascularisation without a significant reduction in in-hospital or six month mortality. The third Unit of Analysis reports the observed and risk-adjusted association between adherence to the quality composite score and reduced in-hospital events, and increased survival at hospital discharge and at six months post discharge. Conclusion: Case-study analysis of CER in the context of ACS registries provides evidence on adherence to evidence-based care and a quality composite measure of hospital performance in the management of ACS.

Aims Acute coronary syndrome (ACS) is a costly condition for health service provision yet variation in the delivery of care between hospitals persists. A composite measure of adherence with evidence-based clinical-process indicators (CPIs) could better inform hospital performance reporting and clinical outcomes in the management of ACS. Methods Data on 7444 ACS patients from 39 Australian hospitals were used to derive a hospital-specific composite quality score by calculating mean adherence to 14 evidence-based CPIs. Using the generalized estimating equation to account for clustering of patients within hospitals and the GRACE risk score to adjust for differences in presenting risk, we evaluated associations between the hospital-specific composite quality score, in-hospital major adverse events, in-hospital mortality and mortality and readmission for ACS at 6 months. Results Hospitals had a mean adherence of 68.3% (SD 21.7) with the composite quality score. There was significant variation between hospital adherence tertile 1 (79%) and tertile 3 (56%), P < 0.0001. With risk adjustment, there was an association between hospitals with a higher composite quality score and reduced in-hospital adverse events (OR: 0.85, CI: 0.71–0.99) and survival at hospital discharge (OR: 0.47; 95% CI: 0.28–0.77). There was trending improvement in survival at 6 months (OR 0.48; CI: 0.20–1.16) and fewer readmissions to hospital for ACS at 6 months (OR 0.79; CI 0.60–1.05). Conclusion The association between the quality composite score and reduced in-hospital events and survival at hospital discharge supports the utility of reporting CPIs in routine hospital performance reporting on the management of ACS. Australia and New Zealand Clinical Trial Registration (ANZCTR) CONCORDANCE Registry ACTRN12614000887673.

© 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ) Background: Increased access to reperfusion for ST elevation myocardial infarction (STEMI) has contributed to reduced mortality internationally. We describe temporal trends in pre-hospital care, in-hospital management and outcomes of the STEMI population in Australia. Methods: Temporal trends with multiple regression analysis on the management and outcomes of STEMI patients enrolled across 46 Australian hospitals in the Australian cohort of the Global Registry of Acute Coronary Events (GRACE) and the Cooperative National Registry of Acute Coronary Care Guideline Adherence and Clinical Events (CONCORDANCE) between February 1999 and August 2016. Results: 4,110 patients were treated for STEMI, mean age 62.5 ± 13.7years (SD). The median door-to-balloon time of primary percutaneous coronary intervention (PPCI) decreased by 11 minutes (p < 0.01) although there was no increase in rates of PPCI (p = 0.35). Access to non-primary PCI increased by 39% (p < 0.01), provisioning of fibrinolysis decreased by 13% (p < 0.01) and the median door-to-needle time of 35 minutes remained unchanged (p = 0.09). Prescription of medical therapies in-hospital remained high, and at discharge there was an increase in prescription of statins (p < 0.01); aspirin including antiplatelets (p < 0.01), beta blockers (p = 0.023) and ACE/ARB (p = 0.02). The occurrence of any in-hospital adverse clinical events declined by 78% (p < 0.01) albeit, there was no reduction in mortality in-hospital (p = 0.84) or within 6 months (p = 0.81). Conclusions: Over time, there has been increased access to non-primary PCI; shorter door-to-balloon times for PPCI; less adverse events in-hospital and fewer readmissions for unplanned revascularisation without the realisation of reduced mortality in-hospital or at 6 months. Trial registration: CONCORDANCE Registry ACTRN: 12614000887673.