Expertise and infrastructure capacity impacts acute coronary syndrome outcomesCarolyn M. Astley A L , Isuru Ranasinghe B , David Brieger C , Chris J. Ellis D , Julie Redfern E , Tom Briffa F , Bernadette Aliprandi-Costa G , Tegwen Howell E J , Stephen G. Bloomer H , Greg Gamble I , Andrea Driscoll J , Karice K. Hyun E , Chris J. Hammett K and Derek P. Chew A
A Flinders University, SA 5042, Australia. Email: email@example.com
B University of Adelaide, SA 5000, Australia. Email: firstname.lastname@example.org
C University of Sydney, Department of Cardiology, Concord Repatriation General Hospital, NSW 2137, Australia. Email: email@example.com
D Cardiology Department, Auckland City Hospital, Auckland, 1023, New Zealand. Email: ChrisE@adhb.govt.nz
F School of Population Health, University of Western Australia, WA 6009, Australia. Email: firstname.lastname@example.org
G Sydney School of Nursing, University of Sydney, NSW 2050, Australia. Email: email@example.com
H Cardiovascular Health Network of Western Australia, Hospital Avenue, Nedlands, WA 6009, Australia. Email: firstname.lastname@example.org
I Department Medicine, University of Auckland, 1023, New Zealand. Email: email@example.com
J School of Nursing and Midwifery, Deakin University, Vic. 3125, Australia. Email: firstname.lastname@example.org
K Royal Brisbane and Women’s Hospital, Qld 4029, Australia. Email: Christopher_Hammett@health.qld.gov.au
L Corresponding author. Email: email@example.com
Australian Health Review - https://doi.org/10.1071/AH16244
Submitted: 31 October 2016 Accepted: 24 February 2017 Published online: 20 April 2017
Objective Effective translation of evidence to practice may depend on systems of care characteristics within the health service. The present study evaluated associations between hospital expertise and infrastructure capacity and acute coronary syndrome (ACS) care as part of the SNAPSHOT ACS registry.
Methods A survey collected hospital systems and process data and our analysis developed a score to assess hospital infrastructure and expertise capacity. Patient-level data from a registry of 4387 suspected ACS patients enrolled over a 2-week period were used and associations with guideline care and in-hospital and 6-, 12- and 18-month outcomes were measured.
Results Of 375 participating hospitals, 348 (92.8%) were included in the analysis. Higher expertise was associated with increased coronary angiograms (440/1329; 33.1%), 580/1656 (35.0%) and 609/1402 (43.4%) for low, intermediate and high expertise capacity respectively; P < 0.001) and the prescription of guideline therapies observed a tendency for an association with (531/1329 (40.0%), 733/1656 (44.3%) and 603/1402 (43.0%) for low, intermediate and high expertise capacity respectively; P = 0.056), but not rehabilitation (474/1329 (35.7%), 603/1656 (36.4%) and 535/1402 (38.2%) for low, intermediate and high expertise capacity respectively; P = 0.377). Higher expertise capacity was associated with a lower incidence of major adverse events (152/1329 (11.4%), 142/1656 (8.6%) and 149/149 (10.6%) for low, intermediate and high expertise capacity respectively; P = 0.026), as well as adjusted mortality within 18 months (low vs intermediate expertise capacity: odds ratio (OR) 0.79, 95% confidence interval (CI) 0.58–1.08, P = 0.153; intermediate vs high expertise capacity: OR 0.64, 95% CI 0.48–0.86, P = 0.003).
Conclusions Both higher-level expertise in decision making and infrastructure capacity are associated with improved evidence translation and survival over 18 months of an ACS event and have clear healthcare design and policy implications.
What is known about the topic? There are comprehensive guidelines for treating ACS patients, but Australia and New Zealand registry data reveal substantial gaps in delivery of best practice care across metropolitan, regional, rural and remote health services, raising questions of equity of access and outcome. Greater mortality and morbidity gains can be achieved by increasing the application of current evidence-based therapies than by developing new therapy innovations. Health service system characteristics may be barriers or enablers to the delivery of best practice care and need to be identified and evaluated for correlations with performance indicators and outcomes in order to improve health service design.
What does this paper add? This study measures two system characteristics, namely expertise and infrastructure, evaluating the relationship with ACS guideline application and clinical outcomes in a large and diverse cohort of Australian and New Zealand hospitals. The study identifies decision-making expertise and infrastructure capacity, to a lesser degree, as enabling characteristics to help improve patient outcomes.
What are the implications for practitioners? In the design of health services to improve access and equity, expertise must be preserved. However, it is difficult to have experienced personnel at the bedside no matter where the health service, and engineering innovative systems and processes of care to facilitate delivery of expertise should be considered.
References Aroney CN, Aylward P, Kelly AM, Chew DP, Clune E, Acute Coronary Syndrome Guidelines Working Group Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184 S1–30.
 Chew DP, Aroney CN, Aylward PE, Kelly AM, White HD, Tideman PA, Waddell J, Azadi L, Wilson AJ, Ruta LAM. 2011 Addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the Management of Acute Coronary Syndromes (ACS) 2006. Heart Lung Circ 2012; 20 487–502.
 Steg PG, James SK, Atar D, Badano LP, Blomstrom-Lundquist C, Borger MA, Di Carlo M, Didistein K, Ducrocq G, Fernandez-Aviles F, Gerschlick AH, Gianuzzi P, Halvoren S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, van’t Hof A, Widimsky P, Zahger D. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the taskforce on the management of ST-segment elevation myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012; 33 2569–619.
| ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the taskforce on the management of ST-segment elevation myocardial infarction of the European Society of Cardiology (ESC).CrossRef | 1:CAS:528:DC%2BC38XhsFektbrE&md5=6ef3884f91c6086cf8b4573b5a7f6749CAS |
 Bassand JP, Hamm CW, Ardissino D, Boersma E, Budaj A, Fernandez-Aviles F, Fox KA, Hasdai D, Ohman EM, Wallentin L, Wijns W, Vahanian A, Camm J, De Caterina R, Dean V, Dickstein K, Filippatos G, Kristensen SD, Widimsky P, McGregor K, Sechtem U, Tendera M, Hellemans I, Gomez JL, Silber S, Funck-Brentano C, Kristensen SD, Andreotti F, Benzer W, Bertrand M, Betriu A, De Caterina R, DeSutter J, Falk V, Ortiz AF, Gitt A, Hasin Y, Huber K, Kornowski R, Lopez-Sendon J, Morais J, Nordrehaug JE, Silber S, Steg PG, Thygesen K, Tubaro M, Turpie AG, Verheugt F, Windecker S. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. The task force for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes of the European Society of Cardiology. Eur Heart J 2007; 28 1598–660.
| Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. The task force for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes of the European Society of Cardiology.CrossRef | 1:CAS:528:DC%2BD2sXpslKmtLw%3D&md5=d38e9125d283a7742fe66808fa3a5076CAS |
 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 123 e426–579.
| 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.CrossRef |
 Chew DP, French J, Briffa TG, Hammett CJ, Ellis CJ, Ranasinghe I, Alliprandi-Costa BJ, Astley CM, Turnbull FM, Lefkovits J, Redfern J, Carr B, Gamble GD, Lintern KJ, Howell TEJ, Parker H, Tavella R, Bloomer SG, Hyun KK, Brieger DB. Acute coronary syndromes care across Australia and New Zealand: the SNAPSHOT ACS study. Med J Aust 2013; 199 185–91.
| Acute coronary syndromes care across Australia and New Zealand: the SNAPSHOT ACS study.CrossRef |
 Chew D, Amerena J, Coverdale S, Rankin JM, Astley CM, Soman A, Brieger DB, ACACIA Investigators Invasive management and late clinical outcomes in contemporary Australian management of ACS: observations from the ACACIA registry. Med J Aust 2008; 188 691–7.
 Commonwealth of Australia. Australia to 2050: future challenges. 2010. Available at: https://archive.treasury.gov.au/igr/igr2010/Overview/pdf/IGR_2010_Overview.pdf [verified 3 March 2017].
 Australian Institute of Health and Welfare (AIHW). Rural, regional and remote health: a guide to remoteness classifications. Rural Health Series no. 4. Catalogue no. PHE 53. Canberra: AIHW; 2004. Available at: http://www.aihw.gov.au/publication-detail/?id=6442467589 [verified 22 June 2015].
 Bamford EJ, Dunne L, Taylor DS, Symon BG, Hugo GJ, Wilkinson D. Accessibility to general practitioners in rural South Australia. A case study using geographic information system technology. Med J Aust 1999; 171 614–16.
| 1:STN:280:DC%2BD3c7os1Whtg%3D%3D&md5=b55c4d85c2c8509992fe91dd92115552CAS |
 Ellis C, Devlin G, Matsis P, Elliot J, Williams M, Gamble G, Mann S, French J, White H. Acute coronary syndrome patients in New Zealand receive less invasive management when admitted to hospitals without invasive facilities. NZ Med J 2004; 117 U954
 Ellis C, Devlin G, Elliot J, Matsis P, Williams M, Gamble G, Hamer A, Richards M, White H. ACS patients in New Zealand experience significant delays to access cardiac investigations and revascularization treatment especially when admitted to non-interventional centre: results of the second comprehensive national audit of ACS patients. N Z Med J 2010; 123 44–60.
 Chew DP, Huynh LT, Liew D, Astley C, Soman A, Brieger D. Potential survival gains in the treatment of myocardial infarction. Heart 2009; 95 1844–50.
| Potential survival gains in the treatment of myocardial infarction.CrossRef | 1:STN:280:DC%2BD1MjisVeluw%3D%3D&md5=3c19e6730211c504c4fc0d8651c3520fCAS |
 Joynt KE, Harris Y, Orav J, Jha AK. Quality of care and patient outcomes in critical access hospitals. JAMA 2011; 306 45–52.
| 1:CAS:528:DC%2BC3MXoslGiu7Y%3D&md5=aa94f89212173071f86e8d00cafb0de1CAS |
 Astley CM, MacDougall CJ, Davidson PM, Chew DP. Lost in translation: health resource variability in the achievement of optimal performance and clinical outcome. Circ Cardiovasc Qual Outcomes 2011; 4 512–20.
| Lost in translation: health resource variability in the achievement of optimal performance and clinical outcome.CrossRef |
 Tideman P, Tirimacco R, Senior DP, Setchell JJ, Huynh L, Tavella R, Aylward PEG, Chew DPB. Impact of a regionalised clinical cardiac support network on mortality among rural patients with myocardial infarction. Med J Aust 2014; 200 157–60.
| Impact of a regionalised clinical cardiac support network on mortality among rural patients with myocardial infarction.CrossRef |
 Fox KAA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Van de Werf F, Avezum A, Goodman SG, Flather MD, Anderson FA, Granger CB. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ 2006; 333 1091
| Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE).CrossRef |
 Coiera E. Four rules for the reinvention of health care. BMJ 2004; 328 1197–9.
| Four rules for the reinvention of health care.CrossRef |
 Clark RA, Inglis SC, McAlister FA, Cleland JG, Stewart S. Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis. BMJ 2007; 334 942
| Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis.CrossRef |
 Redfern J, Hyun K, Chew DP, Astley C, Chow C, Aliprandi-Costa B, Howell T, Carr B, Lintern K, Ranasinghe I, Nallaiah K, Turnbull F, Ferry C, Hammett C, Ellis CJ, French J, Brieger D, Briffa T. Prescription of secondary prevention medications, lifestyle advice and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand. Heart 2014; 100 1281–8.
| Prescription of secondary prevention medications, lifestyle advice and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand.CrossRef |
 Jelinek MV, Thompson DR, Ski S, Bunker S, Vale MJ. 40 years of cardiac rehabilitation and secondary prevention in post cardiac ischaemic patients. Are we still in the wilderness? Int J Cardiol 2015; 179 153–9.
| 40 years of cardiac rehabilitation and secondary prevention in post cardiac ischaemic patients. Are we still in the wilderness?CrossRef |