title: Community hospital versus tertiary hospital comparison in the treatment and outcome of patients with acute coronary syndrome: a New Zealand experience.
abstract: OBJECTIVE
  To compare the baseline characteristics, use of evidence-based medications, rate of revascularisation, and mortality of acute coronary syndrome (ACS) patients managed in a community hospital (Invercargill Hospital) without, and a tertiary teaching hospital (Dunedin Hospital) with, catheterisation and an interventional facility.
  
  
  METHODS
  All patients with ACS admitted into Dunedin and Invercargill coronary care units (CCUs) between 2000-2002 inclusive were included in the study.
  
  
  RESULTS
  Major baseline characteristics including age, history of diabetes, heart rate and systolic blood pressure at presentation were not different between the two centres. However, the proportions of patients with ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI) were higher in Invercargill CCU. More Invercargill patients experienced a cardiac arrest or clinical heart failure on hospital arrival. The use of evidence-based medications, coronary angiography (65.5% vs 20.2%, p<0.00001), and revascularisation (46.7% vs 16.4%, p<0.0005) were significantly higher in patients admitted into Dunedin CCU. The in-hospital, 6-months, and 1-year mortality was significantly lower (absolute mortality difference of 4.3%, 9.5%, and 10.0%, p<0.05, respectively) for ACS patients admitted into Dunedin CCU. Using multivariable logistic regression incorporating baseline characteristics, use of evidence-based medicine on arrival and transfer for angiography, the 1-year adjusted hazard ratio 3.02 (95%CI 1.60-5.71) remains significantly higher for patients in Invercargill Hospital.
  
  
  CONCLUSIONS
  There was a disparity in ACS outcome between community and tertiary hospitals in New Zealand. The use of evidence-based medicine in all ACS patients should be encouraged even if revascularisation was not offered.
authors.affiliation: Department of Cardiology, Dunedin School of Medicine, University of Otago, Dunedin Public Hospital, Dunedin.
authors.forename: Eng Wei
authors.initials: EW
authors.lastname: Tang
authors.forename: Cheuk-Kit
authors.initials: CK
authors.lastname: Wong
authors.forename: Peter
authors.initials: P
authors.lastname: Herbison
mesh_terms: D000208:Acute Disease; D000368:Aged; D000789:Angina, Unstable / Q000628:therapy; D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data; D002300:Cardiac Care Facilities / Q000706:statistics & numerical data*; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D003327:Coronary Disease / Q000628:therapy*; D019317:Evidence-Based Medicine / Q000706:statistics & numerical data; D005260:Female; D006764:Hospitals, Community / Q000706:statistics & numerical data*; D006769:Hospitals, General / Q000706:statistics & numerical data*; D006784:Hospitals, Teaching / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000145:classification / Q000628:therapy; D009520:New Zealand; D010043:Outcome and Process Assessment, Health Care; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D016019:Survival Analysis; D013577:Syndrome; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data