Cardiovascular disease, particularly coronary heart disease (CHD), is the major cause of premature death for Aboriginal and Torres Strait Islander peoples, accounting for 26% of all deaths.1 Cardiovascular disease is also a major contributor to the gaps in life expectancy between Indigenous and non-Indigenous Australians,2 with recent statistics suggesting that Australian Aboriginal and Torres Strait Islander men and women can expect to live 10.6 and 9.5 fewer years, respectively, than other Australians.3

Acute coronary syndromes (ACS) include a broad spectrum of clinical presentations including ST-elevation myocardial infarction (STEMI), non-STEMI and an accelerated pattern of angina without evidence of myonecrosis (unstable angina); the latter two are often grouped as non-ST-elevation acute coronary syndromes (NSTEACS). Current National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines highlight the importance of effective systems of care in delivering optimal management of ACS.4–6

In 2006, the Australian Institute of Health and Welfare (AIHW) released a landmark report on access to ACS treatment by Aboriginal and Torres Strait Islander patients. The report found that, compared with other Australians, Indigenous Australians hospitalised with ACS had:

• more than twice the rate of death from CHD
• a 40% lower rate of being investigated by angiography
• a 40% lower rate of percutaneous coronary intervention (PCI)
• a 20% lower rate of coronary artery bypass graft (CABG) surgery.7

Further studies have indicated that, over and above inhospital treatment disparities for ACS, Aboriginal and Torres Strait Islander patients have greater mortality 6–12 months after a coronary event than non-Indigenous Australians, owing to suboptimal follow-up care.8–11 These disparities in outcomes underpin the development of this patient-oriented framework for the diagnosis and management of ACS in Aboriginal and Torres Strait Islander peoples. The process of developing the framework is described in Appendix 1.

Aboriginal and Torres Strait Islander people represent 2.5% of the Australian population,7 dispersed at varying density levels across urban, regional and remote locations. In 2006, almost one-third of the Indigenous population lived in major cities; 21% in inner regional areas; 22% in outer regional areas; 10% in remote areas; and 16% in very remote areas.12 While Aboriginal and Torres Strait Islander people make up a small proportion of the population in the large cities, there are higher population densities of Indigenous Australians in regional and remote communities — in the Torres Strait, 83% of the population is Torres Strait Islander; in the Northern Territory, 32% of the total population is Indigenous (> 75% in Arnhem Land); and in Central Australia, Aboriginal people make up 50% of the population.11,13 The diversity of this linguistic, cultural and geographic landscape provides many challenges to the delivery of appropriate cardiac services for these populations.

Patient pathways: barriers and enablers

It is a commonly held misconception that Aboriginal and Torres Strait Islander peoples living in urban centres have outcomes similar to the non-Indigenous urban population. There are a number of systemic issues that detrimentally affect the outcomes of all Indigenous Australians, although these issues are likely to be exacerbated by remoteness. Contributing to negative outcomes across the geographic spectrum are issues of fear, institutional racism,14 cultural misunderstandings, waiting times, transport issues, financial constraints and poor health literacy.

Generic pathways to timely diagnosis and management as recommended by best-practice guidelines for patients with ACS living in urban communities are shown in Appendix 2. The more complex pathway for those living in regional or remote communities is tracked in Appendix 3.

Key barriers contribute to the disparities in care and outcomes experienced by Aboriginal and Torres Strait Islander patients regardless of whether they follow a regional/remote or less convoluted urban pathway. These, along with key strategies for addressing them, are discussed below.

Early response and access

There is strong evidence that Aboriginal and Torres Strait Islander patients with a suspected heart attack may delay presentation to hospital.11 Urgent access to care is firstly dependent on patients and/or their families understanding the potentially serious nature of the situation and the need to seek medical help urgently.

Aboriginal and Torres Straits Islander peoples’ culture, spirituality and health literacy all play major roles in potential communication gaps, particularly in remote and isolated communities where English is likely to be a second language. Qualitative internal research undertaken by the Heart Foundation in 2010 identified factors linked with patient delay (unpublished report; Heart Foundation of Australia. Warning signs Aboriginal and Torres Strait Islander Research. Report of qualitative research. Melbourne: The Social Research Centre, 2010) for Aboriginal and Torres Strait Islander people with ACS, including limited knowledge of symptoms and a lack of awareness of the need for urgent treatment: the symptoms associated with ACS are often not acted on until they are unbearable. Other factors contributing to delay include:15,16

• competing personal and family demands that may be seen as higher priorities than the individual’s own health (eg, caring for family members, and cultural or community events)
• cultural beliefs
• fear of hospitals, which may be perceived as places to go to die or as being unfriendly to Aboriginal and Torres Strait Islander patients based on previous personal or family encounters
• lack of available or affordable transport
• lack of communication options for calling for assistance
• long distance to the nearest hospital
• lack of understanding of the diagnostic and treatment pathways, and inability to have family involvement in decision making
• going to the nearest Aboriginal community controlled health service before going to hospital or calling an ambulance
• inappropriate triage at first contact between a health service provider and patient due to inadequate understanding of the symptoms and signs of ACS on the part of the health care provider.

To overcome these barriers, health care providers must look at effective strategies to improve Aboriginal and Torres Strait Islander peoples’ understanding of the warning signs of a heart attack. This requires the development and provision of culturally appropriate health education through community and primary health care networks, including media organisations. Such programs must not only improve understanding of the warning signs of heart attack within local communities, but also advise how to access immediate help and provide information about the patient journey so that patients and their families understand what might happen once they seek help, and can make informed decisions about treatment. In an urban setting, this includes culturally specific education around the triple zero (000) emergency service and the availability and potential cost of the ambulance service.

Minimising delay: pre-tertiary pathways

Beyond health education and basic access to emergency services, patients require access to timely and effective treatment through a system of care that supports early diagnosis and is responsive to patient need, including digital 12-lead electrocardiogram capability, point-of-care pathology testing and, where relevant, prehospital fibrinolysis.

It is essential that centres providing initial care for patients with suspected ACS are part of a clinical network for the provision of cardiac care, and are appropriately equipped to follow up-to-date evidence-based protocols17 (Appendix 4). For urban populations, tertiary “receiving” hospitals need to develop formalised networks with smaller secondary “referring” hospitals that provide initial triage, as well as with the local ambulance services. In regional and remote settings where patient transfer times to centres with PCI capability are greater than 1 hour, it is essential that there is a formalised “designated provider clinical network” of cardiac care providers — essentially a mechanism for providing or obtaining expert clinical advice at short notice — that includes appropriate infrastructure and treatment and transfer protocols.18,19

NSTEACS

All patients with NSTEACS should have their risk of adverse clinical outcomes assessed to direct management decisions.4 Patients identified as being at high risk should be treated with dual antiplatelet therapy and an antithrombin agent, and arrangements should be made for coronary angiography and (where indicated) revascularisation as soon as possible. Regional and remote communities have the added difficulty of seeking distant, expert medical advice with appropriate and timely transfers to facilities that have at least full diagnostic and risk stratification capability. NSTEACS patients stratified as intermediate risk or high risk are best managed within a structured clinical pathway,4 as ad hoc management can lead to delays in seeking advice and the potential for inappropriate and/or conflicting advice, as well as inefficient use of emergency medical transport services.

Early reperfusion for STEMI

The initial diagnosis, treatment and subsequent outcomes for patients experiencing STEMI are determined by the patient’s location, the level of medical expertise of the first emergency medical contact, and the infrastructure available. Patients with STEMI who present within 12 hours of the onset of ischaemic symptoms should have reperfusion therapy implemented as soon as possible, using either fibrinolytic therapy or PCI.4

Urban and some inner regional populations often have direct access or immediate access through interhospital transfer to primary PCI facilities with first emergency medical contact to PCI delays of less than 90 minutes. Where such access exists, clearly, primary PCI is the preferred modality for reperfusion. Patients in other inner regional, most outer regional and all remote areas will not have such access and require early fibrinolysis (door-to-needle time of less than 30 minutes4) with immediate or early transfer (within 24–48 hours) to a tertiary cardiac facility with revascularisation capability (PCI and/or CABG surgery). For most patients in non-urban settings, the local hospital emergency department will be the most appropriate facility for early STEMI diagnosis and fibrinolysis. However, where inherent delays between first emergency medical contact and access to any facility capable of delivering reperfusion therapy exceed 60 minutes, routine access to prehospital fibrinolysis is strongly recommended.

There are essential infrastructure and standards requirements for prehospital fibrinolysis, either in an ambulance or a remote health clinic (Appendix 5). Currently, in the Northern Territory, remote health clinics provide prehospital fibrinolysis without a doctor being present, and several state ambulance services are effectively providing prehospital fibrinolysis via intensive care paramedics.20

Designated provider clinical networks should be configured to reduce the number of medical transport legs and time delays to tertiary care (including bed access block) to a minimum, given that remote area patients will often unavoidably require up to three transfers (Appendix 3) over very long distances. Historically, this has resulted in tertiary access delays of 5 days or more (own unpublished data; M K I, 2012).

Hospital treatment

As highlighted in the 2006 AIHW and subsequent reports, the inhospital disparities in ACS care experienced by Aboriginal and Torres Strait Islander peoples warrant special consideration by health service providers.7,18

It is well documented that Aboriginal and Torres Strait Islander people suffering from ACS are less likely to undergo angiography in hospital and receive PCI or CABG surgery than non-Indigenous patients.7 Although there has been no extensive study of why these disparities exist, potential reasons include:18

• poor health literacy and understanding of invasive procedures
• inadequate cultural competence of health care providers and hospitals
• bias favouring conservative management based on perceptions of more comorbidities among Aboriginal and Torres Strait Islander patients and lower compliance with medications
• disengagement of family members in the decision-making process10
• delayed patient transfer to hospitals with PCI facilities compounded by the complexity of the patient journey (highlighted in Appendix 3) in requiring multiple transfers
• patient choice.

Difficulties in transferring patients to hospitals with revascularisation facilities may be overcome with improved communication to enhance uptake of these crucial interventions. Patients frequently have a poor understanding and fear of these procedures, and studies indicate that they often feel disengaged from medical staff.8 The support of Indigenous cardiac coordinators (described below) is important in this process.

Other key strategies for improvement, involving Aboriginal health practitioners (where access is available), general hospital staff, retrieval services and the state health departments, include:

• establishing a coordinated transfer system as part of the overall designated provider clinical network (fewer steps in the patient pathway will reduce the number of transfers and inherent delays)
• providing a system that allows a family member to accompany the patient throughout the continuum of care
• developing a patient care plan in conjunction with the patient and his or her family, with involvement of the hospital Aboriginal liaison officer (ALO) and interpreters as needed
• commencing patient education in hospital using culturally appropriate educational tools, so that both the patient and his or her family are fully informed of the clinical process and timelines for returning home
• ensuring financial and social support to facilitate transfer to other hospitals, even in the urban environment.

Discharge against medical advice

Aboriginal and Torres Strait Islander patients have a much higher rate than other patients of discharge from hospital against medical advice, which increases with remoteness.21 This reflects problems in communication and a lack of engagement with and respect for Aboriginal and Torres Strait Islander patients and their families that contributes significantly to a fear of hospitals and invasive procedures. A lack of culturally competent health care providers accentuates this problem.

Aboriginal and Torres Strait Islander patients and their families need considerable explanation of their diagnosis and proposed procedures to minimise the risk of discharge against medical advice. Patients who have had PCI procedures or CABG surgery should be encouraged to become patient advocates and discuss their story with other patients and family members.

In the urban environment, language is usually not presumed to be an issue (although literacy levels may be22), but for patients referred from regional and remote settings English is likely to be a second language, resulting in additional communication barriers.18 It is essential that interpreters are made available on request and that considerably more time is set aside for discussions with Aboriginal and Torres Strait Islander patients and their families than might be expected for non-Indigenous patients.

Follow-up care, cardiac rehabilitation and secondary prevention

Proven short- and long-term health benefits and reductions in mortality form the basis for recommendations that all patients with ACS be referred for appropriate cardiac rehabilitation.23,24 Unfortunately, rates of participation in cardiac rehabilitation programs by Aboriginal and Torres Strait Islander peoples are extremely low due to extended family responsibilities, sociocultural inappropriateness of programs, poor understanding of cardiac rehabilitation, the connection between colonialism and health services, heart health messages in the media and the younger age of the affected Indigenous population.25

Patients returning home after ACS must have an understanding of their medical condition, and require education regarding medication use, wound care (in the event of recent surgery), risk factor modification, potentially reduced functional capacity, and prognosis. Therefore, patient education must be commenced while in hospital and include culturally appropriate education tools26 and the development of an individualised care plan that provides the basis of the outpatient and maintenance cardiac rehabilitation programs after patients return to their communities (Appendix 6).

The care plan is essential in providing support to the local medical officer and clinics regarding a patient’s:

• medications
• targeted program for outpatient and maintenance cardiac rehabilitation
• overall prognosis
• returning to work and personal independence issues (eg, driving).

This requires the treating hospital to have a comprehensive understanding of the services available on the patient’s return home as well as his or her risk-factor profile, home circumstances (specifically, family support, occupation and capacity to return to work) and education and literacy levels. To improve outcomes it is also important to assess the patient’s and family’s understanding of the importance of ongoing cardiac rehabilitation and adherence to an individualised, formalised care plan.

The care plan should be developed with the patient and his or her family in liaison with the Indigenous cardiac coordinator. At discharge, the plan should be forwarded to the appropriate cardiac rehabilitation services nearest to the patient’s home. Follow-up care and outpatient and ongoing maintenance programs should include the elements highlighted in Appendix 7. Appendix 8 outlines key considerations in planning cardiac rehabilitation programs for Indigenous patients, as recommended by National Health and Medical Research Council guidelines.26

The longer-term maintenance of secondary prevention strategies is perhaps the most important element of postacute care for Aboriginal and Torres Strait Islander patients after an ACS, as ineffective strategies result in poorer long-term outcomes among Indigenous patients even when short-term hospital outcomes are similar.11,27 Cardiac coordinators are required to facilitate regular appointments for general and specialist review and investigation (including echocardiography when necessary). In addition, regular coordinated outreach clinics are required to service Aboriginal and Torres Strait Islander populations in urban, regional and remote areas because of inherent difficulties in attending hospital outpatient clinics and private cardiology practices.

Pathway coordination

The ACS continuum-of-care pathway needs coordination, enabling timely access to investigation and treatment and making efficient use of the resources available within that clinical network. Appropriate infrastructure, protocols and policies that are specific to each designated provider clinical network provide the framework for investigations and decision making28 (for requirements, see Appendix 4). However, there is also a need to coordinate patient and escort transfers for coronary procedures and the return home.

Indigenous cardiac coordinators have been trialled in the Northern Territory and at Flinders Medical Centre in South Australia, with significant improvements in patient flow, attendance for procedures and revascularisation rates (unpublished report; Heart Foundation of Australia; as above). Coordinators receive support from ALOs or interpreters as appropriate, as well as administrative support — a key factor in the success of the network. The Indigenous cardiac coordinators:

• review patients and have contact with their families within 24 hours of hospital admission
• monitor and coordinate patients’ progress before and after diagnosis, including procedures and clinical reviews up to 3 months after an event
• liaise with cardiologists, remote health clinics and general practitioners
• coordinate transfers of Indigenous cardiac patients, with the relevant patient information, between hospitals, health clinics and other relevant agencies
• assess patients returning from tertiary services, including clinical assessment and consideration of social issues
• ensure cultural factors are considered when organising patients’ appointments.

The success of the designated provider clinical network requires coordination of patient information from all elements of the network. Electronic transfer of patient records, including referrals, discharge information (to the local medical officer and local cardiac rehabilitation service or equivalents), medications and follow-up care plans, needs to be incorporated, and the development of electronic records will contribute significantly to this process.

Conclusion

To improve the quality of care across the health care continuum for Aboriginal and Torres Strait Islander patients with ACS, a properly structured and clearly defined patient-oriented clinical pathway (comprising adequate human, pharmacological and equipment resources) is essential for the delivery of evidence-based, high-quality care. The generic ACS management framework outlined is designed to provide guidance to policymakers, health planners and health care providers on the establishment of jurisdiction-specific designated provider clinical networks that significantly reduce inappropriate delays to treatment and enhance the uptake of medical services.

Coordinated pathways of care — involving Indigenous cardiac coordinators, facilitated by designated provider clinical networks and supported by ALOs — ensure the following for all Aboriginal and Torres Strait Islander patients, regardless of where they live:

• availability of culturally appropriate information regarding warning signs
• appropriate inhospital treatment
• individualised inpatient care plans developed jointly with the patient and his or her family
• education involving culturally appropriate tools within the hospital setting and inclusion of families, with support from ALOs and interpreters as appropriate
• adequate follow-up care, secondary prevention programs and specific outpatient cardiac rehabilitation programs.

As the designated provider clinical networks need to be specific for each jurisdiction, they must be developed in collaboration with all involved in the patient pathway. This includes discussions and coordination with patients, families, Aboriginal health practitioners, primary care teams, retrieval services, emergency and cardiology services and health educators. The system should provide adequate cultural support throughout the process so that patients and families are engaged and adequately informed. Although cost-effectiveness has not been investigated in this consensus statement, the recommended framework should offer greater efficiencies in the use of existing resources.

With the advent of the ACS National Goal (announced by the Australian Commission on Safety and Quality in Health Care) and the recently funded Lighthouse Hospital initiative, improved data collection for monitoring effectiveness (including uptake and outcomes) is essential for the successful ongoing management and modification of the networks. The data from the designated provider clinical networks will also provide a more complete understanding of the issues confronting Indigenous patients. However, any delays in establishing the networks will only maintain the current disparities in service delivery and gaps in life expectancy. Therefore, the current lack of data should not delay the establishment of these networks.

This is the first published case of onset of tachycardia despite triple rate-controlling medication during a rugby league match. The case highlights the importance of a thorough history to exclude Origin-induced tachycardia.

Discussion

This case illustrates a sustained run of tachycardia in a continuously monitored inpatient with cardiomyopathy, which terminated itself after trying circumstances and which occurred despite multiple rate-limiting medications.

Had the patient’s defibrillator still been in place, it mercifully would not have been activated, as his defibrillation threshold was set at 180 beats per minute. Origin-induced tachycardia should be a differential diagnosis for asymptomatic sinus tachycardia in passionate Queensland rugby league supporters, whose only cure when watching televised coverage is to turn off their televisions.

Cardiac telemetry trace

Despite well developed guidelines for managing acute coronary syndrome (ACS),1-6 local registries in Australia and New Zealand have demonstrated incomplete implementation of evidence-based recommendations,7-10 with variations in care appearing to correlate with differences in clinical outcomes. Geographical challenges, patient characteristics (including cultural diversity), health workforce and the health policy environment are likely factors affecting the optimal translation of this evidence base into timely, effective and risk-appropriate ACS care.11,12

Audits of hospitalisation for ACS in New Zealand have been crucial in defining treatment and resource gaps in practice.9,13 In Australia, registries have included relatively few patients from regional and remote centres.7 However, health service design and workforce provision have been found to be associated with variations in clinical outcomes in Australia.14 Hence, gaining a binational perspective from multiple health services of current ACS management is an essential step in health services redesign. The SNAPSHOT ACS study sought to inform these efforts by documenting care and outcomes among patients with suspected ACS through a comprehensive audit encompassing all hospitals and jurisdictions in Australia and New Zealand.

Methods

Study design and organisation

The SNAPSHOT ACS study was a prospective audit of the care provided to consecutive patients admitted with suspected ACS during a 2-week period in Australia and New Zealand. The study was designed by a binational academic network of clinicians and researchers, and managed by a steering committee with key stakeholder representation. It was developed as a collaborative quality improvement initiative between the Cardiac Society of Australia and New Zealand, the Heart Foundation of Australia, the Australian Commission on Safety and Quality in Health Care, the George Institute for Global Health, and health networks or state governments in New South Wales, Queensland, Victoria, South Australia and Western Australia (Appendix 1). The national organisations provided endorsement, in-kind resources and seed funding for central study management. State governments and health networks provided study coordinators to engage facilities, educate staff and assist with gaining ethics committee approval and data collection. The George Institute built the online database and coordinated data management.

All hospitals (public or private, metropolitan or rural) receiving patients with suspected ACS were identified through public records and health networks and approached about participating. Although sites were given training and support with data entry, each hospital’s participation was discretionary and resourced locally. Written study protocols were provided to all participating sites, and state-based education forums were held to standardise recruitment and data collection. Results were fed back to each site, benchmarked against the relevant state or territory and national aggregate at the end of the audit.

In Australia, ethics approval for opt-out consent was granted in all but two sites in Victoria, where opt-in consent was implemented. In New Zealand, expedited review by the National Multicentre Ethics Committee concluded that this was an audit of health service delivery, and a consent waiver was applied. In Australia, a consent waiver was applied to all inhospital deaths among patients with suspected ACS.

Patient eligibility and classification

Patients were eligible for inclusion if they were admitted for suspected or confirmed ACS between 14 and 27 May 2012 (inclusive). Consecutive first admissions within the audit window were included. Patients were tracked for the duration of the acute care episode, including all transfers between hospitals.

Patients were classified by primary discharge diagnosis into the following groups:

• ST-segment-elevation myocardial infarction/left bundle branch block (STEMI/LBBB): patients with ST-segment elevation or LBBB on an electrocardiogram (ECG) at any time during the admission, with elevation of cardiac biomarkers (except where the patient died before biomarkers were measured).
• Non-STEMI (NSTEMI): patients with evidence of biomarker elevation, with or without ECG changes consistent with ischaemia.
• Unstable angina: recorded separately but combined with “likely ischaemic chest pain” for analysis.
• Likely ischaemic chest pain: patients for whom the diagnosis remained uncertain in the absence of definitive ECG changes and/or biomarker elevation, but who received inhospital coronary revascularisation with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).
• Unlikely ischaemic chest pain: extracted from the medical record, reflecting local clinician determination.
• Other diagnosis: patients for whom a clear alternative primary diagnosis emerged, or where evidence of myonecrosis was considered secondary to another disease process (eg, pulmonary embolus).

Patient risk, inhospital care and events

Using a common case-record form with standardised completion note, data collection focused on patients’ presenting characteristics, including clinical variables enabling calculation of the Global Registry of Acute Coronary Events (GRACE) risk score, as well as logistical details of patient presentation and transfers between hospitals.15 Care provided across all institutions involved in acute care was documented, focusing on therapies recommended by published guidelines and inhospital events. Each participating hospital was also asked to complete a survey describing local resources, including cardiac investigation and management capabilities and workforce characteristics.

Inhospital events were defined as shown in Box 1. Reporting of clinical events relied on local documentation using the standardised completion note. Formal adjudication of events was not possible, but monitoring of 2%–5% of all case-record forms for data accuracy and quality was performed during and in the weeks after enrolment by coordinators across all jurisdictions.

Statistical analysis

Patient demographic and clinical characteristics, and rates of interhospital transfer, investigations, invasive procedures, provision of guideline-recommended therapies to patients surviving to hospital discharge, and inhospital events are presented as standard descriptive statistics stratified by discharge diagnosis, Australian Institute of Health and Welfare hospital classification, and health jurisdiction (Australian states or territories and New Zealand).4,5 Due to small sample sizes, the two tiers of medium regional hospital classification were combined, as were the other smaller hospital classifications. Private hospitals were considered as a separate group. These criteria were also applied to New Zealand hospitals. For stratification by jurisdiction, the Australian Capital Territory was combined with NSW, and Tasmania with the Northern Territory.

Dichotomous variables are reported as numbers and percentages and compared using the χ2 test. Continuous variables are reported as medians and interquartile ranges (IQRs) and compared using the Kruskal–Wallis test.

Propensity score-adjusted estimates of the influence of hospital classification and health jurisdiction on provision of angiography, provision of four or five guideline-recommended medications at discharge, referral to cardiac rehabilitation, and major adverse cardiac events (MACE) were generated using logistic regression modelling, stratified by discharge diagnosis. Assessment of angiography and MACE used all patients, while evaluation of rehabilitation referral and discharge medications was confined to patients with a discharge diagnosis of ACS. Propensity scores using age, sex, GRACE score, diagnostic group, heart failure at presentation, renal impairment, diabetes, hypertension, nursing home residence, dementia or cognitive impairment, private insurance, and primary language other than English were constructed for the likelihood of living in each jurisdiction and presenting to a hospital of each classification. Each model included the hospital classifications and jurisdictions as indicator variables, as well as their respective propensity scores, when reporting the jurisdiction or hospital estimates. Interaction terms of each jurisdiction and hospital classification were explored for significance, but no interactions were found. Given the observational and hypothesis-generating nature of these analyses, no adjustment of significance levels was undertaken.

Analyses were performed using Stata 11.2 (StataCorp), and P < 0.05 was considered statistically significant.

Results

Participating hospitals

Of 525 hospitals approached to participate, 478 gained ethics approval, and 435 provided site survey data describing their local resources. Within the 2-week enrolment period, 286 hospitals enrolled 4398 patients with suspected or confirmed ACS. Hospitals not enrolling patients were smaller centres and did not treat patients with suspected ACS during the audit window.

Most patients (65.7%; 2891/4398) presented to principal referral hospitals or hospitals in major cities (7.7%; 337/4398), while 7.3% (319/4398) presented to private hospitals. In terms of cardiac services available at the first presenting hospital, 79.7% of patients (3415/4283) presented where fibrinolysis could be administered, and 59.0% (2528/4283) presented to hospitals capable of providing primary PCI. Only 1.4% of patients (59/4283) presented to hospitals with no reperfusion therapy for STEMI. A quarter of patients (25.9%; 1138/4398) required transfer to at least one other hospital.

The distribution of hospital types by jurisdiction was comparable, except for Victoria, where a selective hospital recruitment strategy operated and there were fewer small regional hospitals (Box 2). Patient characteristics by health jurisdiction and hospital classification are presented in Appendix 2 and Appendix 3, respectively.

Patients with ACS

The risk profile of enrolled patients was high, with a median GRACE risk score of 119 (IQR, 96–144) across the entire population, and 138 (IQR, 114–161) among those with a discharge diagnosis of myocardial infarction (MI), including STEMI and NSTEMI.

Of the 4398 patients, 252 (5.7%) were Indigenous, Pacific Islander or Maori, and 165 (3.8%) were Asian. A primary language other than English was spoken by 294 patients (6.7%). Patient characteristics by discharge diagnosis are shown in Box 3. Among the 837 patients who were discharged with a diagnosis other than ACS, 317 (37.9%) had a troponin level above the local upper reference limit.

Provision of ACS care

Among the 421 patients with a discharge diagnosis of STEMI/LBBB, 106 (25.2%) received fibrinolytic therapy, 163 (38.7%) received primary PCI, and 152 (36.1%) received no reperfusion therapy. Of 1436 patients with STEMI or NSTEMI, coronary angiography was performed in 1019 (71.0%), PCI in 610 (42.5%), and CABG in 116 (8.1%). Reduced provision of invasive management with increasing risk was evident (GRACE score < 100, 90.1% v 101–150, 81.3% v 151–200, 49.4% v > 200, 36.1%; P < 0.001).

Guideline-recommended investigations and therapies were provided less frequently to patients presenting to non-principal referral hospitals, regardless of patient transfers (Box 4). Similar heterogeneity in the provision of care was observed when the results were stratified by jurisdiction (Appendix 4). Variation in the timeliness of care was also evident across jurisdictions; this was most marked in the median time to angiography and, to a lesser extent, in the overall length of stay (Appendix 5).

Inhospital events

Among the patients diagnosed with MI, the inhospital mortality rate was 4.5% (65/1436) and recurrent MI rate was 5.1% (73/1436). Inhospital adverse clinical events were highest among patients with STEMI/LBBB (Box 5). Inhospital mortality and recurrent cardiac failure were frequent among patients discharged with a diagnosis thought not to be ACS. Box 6 shows substantial heterogeneity in clinical events between hospital classifications, in all patients and in those discharged with a diagnosis of ACS.

Adjusted analyses

The propensity-adjusted odds ratios and confidence intervals describing the likelihood of undergoing inpatient angiography, receiving four or five guideline-recommended medications at discharge, receiving referral to rehabilitation, and experiencing inhospital MACE are shown in Box 7. There was a consistently lower likelihood of receiving guideline-recommended medications among patients originally presenting to non-principal referral hospitals. Patients in private hospitals were significantly more likely to undergo angiography, but not necessarily to receive guideline-recommended medications or rehabilitation referral. There was more variation in the occurrence of inhospital MACE at the health jurisdiction level than between hospital types.

Discussion

Optimising patient outcomes after MI through standardisation of care has emerged as a major near-term goal in the health agenda of Australia and New Zealand.17 Through the most representative assessment of ACS health service resources, clinical care provision and outcomes yet conducted in Australasia, this study provides unique insights into the challenges of providing timely and effective ACS care. These include the complexity of patient comorbidities, which brings the logistical challenges of providing timely invasive management to many patients in regional, remote and outer metropolitan centres into sharp focus.11,12

Translating evidence into practice requires a sophisticated understanding of determinants of care provision at the patient, clinical service and health policy level. Variations in clinical decision making, service availability and health policy represent potential targets for improving translation of the ACS evidence base and outcomes. An integrated approach to health service design is paramount to meeting the needs of our culturally diverse and geographically dispersed communities.

The efficient management of patients presenting with suspected ACS remains challenging. More sensitive markers of myonecrosis, such as high-sensitivity troponin assays, have not simplified this.18 This is demonstrated in our study by the substantial proportion of patients with suspected ACS who had elevated troponin levels, but in whom further investigations confirmed a final diagnosis other than ACS.19,20 Nevertheless, our data demonstrate high rates of inhospital events among such patients, as has been observed by others;21,22 yet the current evidence informing their management is very limited.

Similarly, our data demonstrate the substantial burden of clinical complexity among ACS patients, with relatively high prevalences of comorbidities including prior major bleeding events, cerebrovascular disease, cognitive impairment and concurrent malignancy.23 This complexity underscores the everyday challenges in applying the evidence among patients with typical ACS presentations. Reduced application of evidence-based therapies among patients with increased comorbidities has been found in other studies.24,25 Objective risk stratification that balances the benefits of evidence-based therapies against the risks associated with comorbidities may help narrow the evidence–practice gap for ACS patients with comorbidities.26

Our study highlights the potential for variation in care attributable to jurisdictional and geographical differences. The challenge of providing timely access to invasive management, not only in rural areas but also in the growing outer suburbs of cities, is highlighted by the fact that 26% of all ACS patients in our study required transfer. Attempts to improve consistency and quality of care, such as through clinical guidelines and clinical standards,17 need to consider the significant issues of transfer and coordination of care, particularly outside metropolitan areas, if such initiatives are to be effective and cost-effective.

In combination, these observations call for judicious and validated approaches to the development and implementation of clinical standards and performance measures that take these diagnostic and therapeutic complexities into account.

The broad hospital recruitment approach, consecutive patient enrolment, and high inhospital event rates in our study underscore the importance of representative patient inclusion when evaluating practice and outcomes.27 For the effective integration of clinical guidelines, clinical standards and performance measures into everyday care, the real challenge is to develop mechanisms to acquire and feed back such data on a routine and sustainable basis.28 The SNAPSHOT ACS study was the culmination of significant efforts to engage with national agencies and professional bodies, while implementation depended on the jurisdictional health networks. However, the study also required local hospital commitment to data collection and entry, an enormous unresourced effort that is difficult to quantify but attests to the dedication of health care providers to the quality of ACS care and outcomes. Future attempts to understand the lingering evidence–practice gaps will need to consider such resourcing issues carefully. Nevertheless, this study is unique in its ability to gain insights into the provision of care across multiple levels of decision making. Effectively delivering these insights to key decisionmakers at clinical, health service and health policy levels to enable the design and implementation of fully integrated approaches to ACS care remains the “translational” promise of this initiative.

4 Provision of (A) investigations and revascularisation and (B) guideline-recommended therapies, among patients with a discharge diagnosis of acute coronary syndrome, by enrolling hospital classification*

PCI = percutaneous coronary intervention. CABG = coronary artery grafting. * n refers to number of patients.

5 Inhospital clinical events, by principal diagnosis at time of discharge*

MI = myocardial infarction. CHF = congestive heart failure. MACE = major adverse cardiac events. STEMI/LBBB = ST-segment elevation myocardial infarction/left bundle branch block. NSTEMI = non-STEMI. * All comparisons of outcomes between diagnostic categories are significant (P < 0.001). n refers to number of patients.

6 Inhospital clinical events among (A) all patients and (B) patients with a discharge diagnosis of acute coronary syndrome, by enrolling hospital classification

MI = myocardial infarction. CHF = congestive heart failure. MACE = major adverse cardiac events. * n refers to number of patients.

7 Adjusted odds ratios* for likelihood of (A) provision of angiography, (B) provision of four or five guideline-recommended medications at discharge, (C) referral to cardiac rehabilitation, and (D) inhospital major adverse cardiac events, by hospital classification and health jurisdiction

* Principal referral hospitals and State D are the referent categories for hospital classification and health jurisdiction, respectively. Bars indicate 95% confidence intervals, which have been produced using the floating absolute risk method.16