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Impact of a regionalised clinical cardiac support network on mortality among rural patients with myocardial infarction

Philip A Tideman, Rosy Tirimacco, David P Senior, John J Setchell, Luan T Huynh, Rosanna Tavella, Philip E G Aylward and Derek P B Chew
Med J Aust 2014; 200 (3): 157-160. || doi: 10.5694/mja13.10645

Summary

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.

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  • Philip A Tideman1
  • Rosy Tirimacco1
  • David P Senior2
  • John J Setchell3
  • Luan T Huynh4
  • Rosanna Tavella5
  • Philip E G Aylward6
  • Derek P B Chew6

  • 1 Country Health, Adelaide, SA.
  • 2 Rural Doctors Workforce Agency, Adelaide, SA.
  • 3 Royal Flying Doctor Service, Adelaide, SA.
  • 4 Cardiology, Lyell McEwin and Modbury Hospitals, Adelaide, SA.
  • 5 SA Health, Adelaide, SA.
  • 6 Southern Adelaide Local Health Network, Flinders Medical Centre, Adelaide, SA.


Acknowledgements: 

We sincerely thank all the South Australian rural doctors and nurses who have embraced this model of care, cardiologists who have supported the network, Country Health South Australia who provided operational funding, the Australian Health Ministers’ Advisory Council for initial funding to set up the network, and all ICCNet scientific and administrative staff.

Competing interests:

Philip Tideman has received speaker fees from Roche Diagnostics Australia. Philip Aylward has received consultancy fees from AstraZeneca Australia, Boehringer Ingelheim Australia, Pfizer Australia, Sanofi Aventis Australia and Eli Lilly Australia; grants from AstraZeneca Australia, Eli Lilly Australia, Bayer, Johnson and Johnson Medical and Merck Australia; lecture fees from AstraZeneca Australia, Boehringer Ingelheim Australia, Eli Lilly Australia; and travel assistance from AstraZeneca Australia and Boehringer Ingelheim Australia. Derek Chew has received consultancy fees from Abbott Vascular; lecture fees from AstraZeneca Global; and payment for education programs from Heart.org.

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