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Information derived from randomised clinical trials are used to formulate recommended treatment guidelines1,2 for the management of acute coronary syndrome (ACS). Registry studies published locally3-5 and overseas6-8 have demonstrated the underuse of evidence-based therapies (both medications and revascularisation) in 'real-life' high-risk ACS patients. The lower rate of revascularisation in community hospitals could be due to the lack of facilities, necessitating transfer of patients to tertiary centres.
Although revascularisation is generally beneficial for high-risk ACS patients,3,4 the GRACE registry9 showed similar short-term (6 months) outcome between patients admitted into community hospitals for whom revascularisation required transferral and patients admitted directly into tertiary centres.
There is currently no local data comparing the treatment and outcome of ACS patients admitted into a community hospital (staffed by general physician without catheterisation facilities) versus a tertiary teaching hospital (with cardiologists and catheterisation laboratory). However this information is crucial to both the public and health professionals / policymakers when we strive to offer an equitable healthcare service to all New Zealanders.
Hence the aim of this study was to compare the management (use of evidence-based medications and revascularisation) and mortality of patients with ACS managed in a community hospital versus those managed in a tertiary hospital.
Methods
This is a retrospective registry study including all consecutive patients with ACS admitted into the coronary care units (CCUs) of two related centres in New Zealand, including the tertiary hospital in Dunedin, Otago Province (Dunedin Hospital) and the regional hospital in Invercargill, Southland Province (Invercargill Hospital) from the years 2000-2002 inclusive. Dunedin Hospital served as the referral centre for Invercargill Hospital during the study. Stable patients were transferred from Invercargill to Dunedin via ambulance, a 3-hour journey. Unstable patients were retrieved via helicopter (Dunedin Hospital has a helipad).
All patients had ACS as their discharge diagnosis and were above 18 years of age. Patients having ACS precipitated by significant non-cardiac comorbidity, trauma, or surgery were excluded. The first admission with ACS was used for analysis if readmissions with ACS were present. Patients initially admitted to Invercargill Hospital and subsequently transferred to Dunedin Hospital were categorised as Invercargill patients. This study protocol was in accordance with local hospital research guidelines.
All clinical data were collected by a research physician, which includes:
* Baseline demographic characteristics:...