title: Impact of a regionalised clinical cardiac support network on mortality among rural patients with myocardial infarction.
abstract: 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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors: Country Health, Adelaide, SA, Australia. Derek.Chew@flinders.edu.au.
authors: Philip A
authors: PA
authors: Tideman
authors: Country Health, Adelaide, SA, Australia.
authors: Rosy
authors: R
authors: Tirimacco
authors: Rural Doctors Workforce Agency, Adelaide, SA, Australia.
authors: David P
authors: DP
authors: Senior
authors: Royal Flying Doctor Service, Adelaide, SA, Australia.
authors: John J
authors: JJ
authors: Setchell
authors: Cardiology, Lyell McEwin and Modbury Hospitals, Adelaide, SA, Australia.
authors: Luan T
authors: LT
authors: Huynh
authors: SA Health, Adelaide, SA, Australia.
authors: Rosanna
authors: R
authors: Tavella
authors: Southern Adelaide Local Health Network, Flinders Medical Centre, Adelaide, SA, Australia.
authors: Philip E G
authors: PE
authors: Aylward
authors: Southern Adelaide Local Health Network, Flinders Medical Centre, Adelaide, SA, Australia.
authors: Derek P B
authors: DP
authors: Chew
mesh_terms: D002300:Cardiac Care Facilities / Q000458:organization & administration*; D015897:Comorbidity; D017023:Coronary Angiography; D006297:Health Services Accessibility; D006780:Hospitals, Rural; D006801:Humans; D007902:Length of Stay; D009203:Myocardial Infarction / Q000453:epidemiology / Q000401:mortality*; D010360:Patient Transfer; D011320:Primary Health Care / Q000458:organization & administration; D018570:Risk Assessment; D019035:Rural Health Services; D012424:Rural Population / Q000706:statistics & numerical data*; D013021:South Australia / Q000453:epidemiology