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1.
Med J Aust ; 200(3): 157-60, 2014 Feb 17.
Article in English | MEDLINE | ID: mdl-24528431

ABSTRACT

OBJECTIVE: To evaluate the impact of the regionalised Integrated Cardiovascular Clinical Network (ICCNet) on 30-day mortality among patients with myocardial infarction (MI) in an Australian rural setting. DESIGN, SETTING AND PATIENTS: An integrated cardiac support network incorporating standardised risk stratification, point-of-care troponin testing and cardiologist-supported decision making was progressively implemented in non-metropolitan areas of South Australia from 2001 to 2008. Hospital administrative data and statewide death records from 1 July 2001 to 30 June 2010 were used to evaluate outcomes for patients diagnosed with MI in rural and metropolitan hospitals. MAIN OUTCOME MEASURE: Risk-adjusted 30-day mortality. RESULTS: 29 623 independent contiguous episodes of MI were identified. The mean predicted 30-day mortality was lower among rural patients compared with metropolitan patients, while actual mortality rates were higher (30-day mortality: rural, 705/5630 [12.52%] v metropolitan, 2140/23 993 [8.92%]; adjusted odds ratio [OR], 1.46; 95% CI, 1.33-1.60; P< 0.001). After adjustment for temporal improvement in MI outcome, availability of immediate cardiac support was associated with a 22% relative odds reduction in 30-day mortality (OR, 0.78; 95% CI, 0.65-0.93; P= 0.007). A strong association between network support and transfer of patients to metropolitan hospitals was observed (before ICCNet, 1102/2419 [45.56%] v after ICCNet, 2100/3211 [65.4%]; P< 0.001), with lower mortality observed among transferred patients. CONCLUSION: Cardiologist-supported remote risk stratification, management and facilitated access to tertiary hospital-based early invasive management are associated with an improvement in 30-day mortality for patients who initially present to rural hospitals and are diagnosed with MI. These interventions closed the gap in mortality between rural and metropolitan patients in South Australia.


Subject(s)
Cardiac Care Facilities/organization & administration , Myocardial Infarction/mortality , Rural Population/statistics & numerical data , Comorbidity , Coronary Angiography , Health Services Accessibility , Hospitals, Rural , Humans , Length of Stay , Myocardial Infarction/epidemiology , Patient Transfer , Primary Health Care/organization & administration , Risk Assessment , Rural Health Services , South Australia/epidemiology
2.
Med J Aust ; 193(9): 496-501, 2010 Nov 01.
Article in English | MEDLINE | ID: mdl-21034381

ABSTRACT

OBJECTIVE: To describe the contemporary management and outcomes of patients presenting with ST-segment-elevation myocardial infarction (STEMI) in Australia. DESIGN, PARTICIPANTS AND SETTING: Observational analysis of data for patients who presented with suspected STEMI and enrolled in the Australian Acute Coronary Syndrome Prospective Audit from 1 November 2005 to 31 July 2007. MAIN OUTCOME MEASURES: Factors associated with use of reperfusion therapy and timely use of reperfusion therapy, and the effects of reperfusion on mortality. RESULTS: In total, 755 patients had suspected STEMI. Median time to presentation was 105 minutes (IQR, 60-235 minutes). Reperfusion therapy was used in 66.9% of patients (505/755), and timely reperfusion therapy in 23.1% (174/755). Thombolysis was administered in 39.2% of those who received reperfusion therapy (198/505), while 60.8% (307/505) received primary percutaneous intervention. Cardiac arrest (OR, 2.83; P = 0.001) and treatment under the auspices of a cardiology unit (OR, 2.14; P = 0.02) were associated with use of reperfusion therapy. A normal electrocardiogram on presentation (OR, 0.42; P = 0.01), left bundle branch block (OR, 0.18; P = 0.001), acute pulmonary oedema (OR, 0.34; P < 0.01), history of diabetes (OR, 0.54; P < 0.01), and previous lesion on angiogram of > 50% (OR, 0.51; P = 0.001) were associated with not using reperfusion. In hospital mortality was 4.0% (30/755), mortality at 30 days was 4.8% (36/755), and mortality at 1 year was 7.8% (59/755). Receiving reperfusion therapy of any kind was associated with decreased 12-month mortality (hazard ratio [HR], 0.44; 95% CI, 0.25-0.78; P < 0.01). Timely reperfusion was associated with a reduction in mortality of 78% (HR, 0.22; P = 0.04). There were no significant differences in early and late mortality in rural patients compared with metropolitan patients (P = 0.66). CONCLUSION: Timely reperfusion, not the modality of reperfusion, was associated with significant outcome benefits. Australian use of timely or any reperfusion remains poor and incomplete.


Subject(s)
Angioplasty, Balloon, Coronary/statistics & numerical data , Myocardial Infarction/mortality , Myocardial Infarction/therapy , Thrombolytic Therapy/statistics & numerical data , Australia/epidemiology , Bundle-Branch Block/epidemiology , Cardiology Service, Hospital , Diabetes Mellitus/epidemiology , Electrocardiography , Female , Heart Arrest/epidemiology , Heart Arrest/therapy , Hospital Mortality , Humans , Male , Middle Aged , Patient Selection , Prospective Studies , Pulmonary Edema/epidemiology , Recurrence , Registries , Rural Population , Stroke/epidemiology , Time Factors , Urban Population
3.
Am J Cardiol ; 104(10): 1317-23, 2009 Nov 15.
Article in English | MEDLINE | ID: mdl-19892044

ABSTRACT

Atrial fibrillation (AF) has been established as an independent predictor of long-term mortality after acute myocardial infarction. However, this is less well defined across the whole spectrum of acute coronary syndromes (ACSs). The Acute Coronary Syndrome Prospective Audit is a prospective multicenter registry with 12-month outcome data for 3,393 patients (755 with ST-segment elevation myocardial infarction, 1942 with high-risk non-ST-segment elevation ACS [NSTE-ACS], and 696 with intermediate-risk NSTE-ACS). A total of 149 patients (4.4%) had new-onset AF and 387 (11.4%) had previous AF. New-onset AF was more, and previous AF was less frequent in those with ST-segment elevation myocardial infarction than in those with high-risk NSTE-ACS or intermediate-risk NSTE-ACS (p <0.001). Compared to patients without arrhythmia, patients with new-onset AF and previous AF were significantly older and had more high-risk features at presentation (p <0.004). Patients with new-onset AF more often had left main coronary artery disease, resulting in a greater rate of surgical revascularization (p <0.001). Only new-onset AF resulted in adverse in-hospital outcomes (p <0.001). Only patients with previous AF had greater long-term mortality (hazard ratio 1.42, p <0.05). New-onset AF was only associated with a worse long-term composite outcome (hazard ratio 1.66, p = 0.004). However, the odds ratio for the composite outcome was greatest for patients with new-onset AF with intermediate-risk NSTE-ACS (odds ratio 3.9, p = 0.02) than for those with high-risk NSTE-ACS (odds ratio 2.0, p = 0.01) or ST-segment elevation myocardial infarction (odds ratio 1.4, p = 0.4). In conclusion, new-onset AF was associated with worse short-term outcomes and previous AF was associated with greater mortality even at long-term follow-up. The prognostic burden of new-onset AF differed with the type of ACS presentation.


Subject(s)
Acute Coronary Syndrome/mortality , Atrial Fibrillation/mortality , Acute Coronary Syndrome/therapy , Acute Kidney Injury/epidemiology , Age Factors , Aged , Atrial Fibrillation/therapy , Australia/epidemiology , Cardiovascular Agents/therapeutic use , Coronary Artery Bypass/statistics & numerical data , Coronary Artery Disease/epidemiology , Coronary Artery Disease/therapy , Creatine Kinase/blood , Drug Utilization/statistics & numerical data , Electrocardiography , Female , Heart Failure/epidemiology , Heart Rate , Hemorrhage/epidemiology , Hospital Mortality , Humans , Length of Stay/statistics & numerical data , Male , Middle Aged , Myocardial Infarction/epidemiology , Prospective Studies , Recurrence , Registries , Risk Factors , Severity of Illness Index , Stroke/epidemiology
4.
Implement Sci ; 3: 23, 2008 Apr 25.
Article in English | MEDLINE | ID: mdl-18439250

ABSTRACT

BACKGROUND: How humans think and make decisions is important in understanding behaviour. Hence an understanding of cognitive processes among physicians may inform our understanding of behaviour in relation to evidence implementation strategies. A personality theory, Cognitive-Experiential Self Theory (CEST) proposes a relationship between different ways of thinking and behaviour, and articulates pathways for behaviour change. However prior to the empirical testing of interventions based on CEST, it is first necessary to demonstrate its suitability among a sample of healthcare workers. OBJECTIVES: To investigate the relationship between thinking styles and the knowledge and clinical practices of doctors directly involved in the management of acute coronary syndromes. METHODS: Self-reported doctors' thinking styles (N = 74) were correlated with results from a survey investigating knowledge, attitudes, and clinical practice, and evaluated against recently published acute coronary syndrome clinical guidelines. RESULTS: Guideline-discordant practice was associated with an experiential style of thinking. Conversely, guideline-concordant practice was associated with a higher preference for a rational style of reasoning. CONCLUSION: Findings support that while guidelines might be necessary to communicate evidence, other strategies may be necessary to target discordant behaviours. Further research designed to examine the relationships found in the current study is required.

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