eMJA: Multisite, quality-improvement collaboration to optimise cardiac care in Queensland public hospitals

Clive D Hadfield

Gastroenterologist, 30 Megan Street, Cairns, QLD 4870. chadfieldATaustarnet.com.au

To the Editor: In their recent study, Scott and colleagues demonstrated benefit from a program to standardise clinical management of cardiac conditions in Queensland hospitals.1 They found differences in the effect on “low-intensity intervention” hospitals compared with “high-intensity intervention” hospitals. The former were, by and large, district-type hospitals and the latter tertiary hospitals.

The study found that about 50% more patients in the larger hospitals had assessments of left ventricular function. Three times as many patients in the larger hospitals accessed rehabilitation. Nearly three times as many patients in the smaller hospitals were readmitted with a diagnosis of acute coronary syndrome within 30 days, perhaps a surrogate for angiography rates, which were not reported differentially.

It may be that the most urgent intervention required is “high-intensity” funding of district hospitals, so that they can achieve rates of echocardiography, rehabilitation and coronary angiography approaching those of tertiary hospitals. This intervention would need no further justification than that the population served by the district hospitals has paid its share for these treatments. Let us hope that the remaining comparative outcome data are published.

Ian A Scott,* Irene C Darwin,† Kathy H Harvey,‡ Andy B Duke,§ Nicholas D Buckmaster,¶ John Atherton,** Hazel E Harden,†† Michael Ward,‡‡ for the CHI Cardiac Collaborative

* Director of Internal Medicine, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102; † Program Manager, ‡ Project Manager, § Senior Analyst, Collaborative for Healthcare Improvement, Queensland Health; ¶ Director of Medicine, Caboolture Hospital; ** Director of Cardiology, Royal Brisbane Hospital; †† Program Manager, Integrating Strategy and Performance, Queensland Health; ‡‡ Program Director, Queensland Health Skills Development Centre, Royal Brisbane Hospital. ian_scottAThealth.qld.gov.au

In reply: We agree with Hadfield that optimising cardiac care may require extra resources targeted at increasing access of patients in regional Queensland to specific interventions, such as coronary angiography, cardiac rehabilitation and echocardiography, in addition to the quality-improvement strategies used within our collaborative. We contend that both approaches are necessary, and that the magnitude of improvement achieved by either will depend on the intensity with which they are applied. Indeed, the “high-intensity” quality-improvement hospitals in our study were defined on the basis of more funding being made available to undertake quality-improvement activities at those sites.

We concede that some of the differences in quality indicators between “high-intensity” and “low-intensity” quality-improvement hospitals may be attributable to inequities in capital expenditure on service delivery that we did not measure. However, some of the differences may have also arisen from variation in systems for identifying and referring those patients who have most to gain from receiving the care targeted by our collaborative.