title: Evidence-based care in a population with chronic kidney disease and acute coronary syndrome. Findings from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE).
abstract: BACKGROUND
  Acute coronary syndrome (ACS) guidelines recommend that patients with chronic kidney disease (CKD) be offered the same therapies as other high-risk ACS patients with normal renal function. Our objective was to describe the gaps in evidence-based care offered to patients with ACS and concomitant CKD.
  
  
  METHODS
  Patients presenting to 41 Australian hospitals with suspected ACS were stratified by presence of CKD (glomerular filtration rate <60 mL/min). Receipt of evidence-based care including, coronary angiography (CA), evidence-based discharge medications (EBMs), and cardiac rehabilitation (CR) referral, were compared between patients with and without CKD. Hospital and clinical factors that predicted receipt of care were determined using multilevel multivariable stepwise logistic regression models.
  
  
  RESULTS
  Of the 4,778 patients admitted with suspected ACS, 1,227 had CKD. On univariate analyses, patients with CKD were less likely to undergo CA (59.1% vs 85.0%, P < .0001) or receive EBM (69.4% vs 78.7%, P < .0001), or were offered CR (49.5% vs 68.0%, P < .0001). After adjusting for patient characteristics and clustering by hospital, CKD remained an independent predictor of not undergoing CA only (odds ratio 0.48, 95% CI 0.37-0.61). Within the CKD cohort, presenting to a hospital with a catheterization laboratory was the strongest predictor of undergoing CA (odds ratio 3.07, 95% CI 1.91-4.93).
  
  
  CONCLUSIONS
  The presence of CKD independently predicts failure to undergo CA but not failure to receive EBM or CR, which is predicted by comorbidities. Among the CKD population, performance of CA is largely determined by admission to a catheterization capable hospital. Targeting these patients through standardization of care across institutions offers opportunities to improve outcomes in this high-risk population.
authors.affiliation: Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia.
authors.forename: Jerrett K
authors.initials: JK
authors.lastname: Lau
authors.affiliation: Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia.
authors.forename: Malcolm O
authors.initials: MO
authors.lastname: Anastasius
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia.
authors.forename: Karice K
authors.initials: KK
authors.lastname: Hyun
authors.affiliation: Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia.
authors.forename: Bilyana
authors.initials: B
authors.lastname: Dabin
authors.affiliation: Sunshine Coast Clinical School, University of Queensland, Nambour General Hospital, Nambour, Australia.
authors.forename: Steven
authors.initials: S
authors.lastname: Coverdale
authors.affiliation: National Heart Foundation of Australia (New South Wales Division), Phillip, Australia.
authors.forename: Cate
authors.initials: C
authors.lastname: Ferry
authors.affiliation: School of Medicine & Pharmacology, Sir Charles Gairdner Hospital Unit. University of Western Australia, Perth, Australia.
authors.forename: Joseph
authors.initials: J
authors.lastname: Hung
authors.affiliation: Department of Cardiology, Monash Medical Centre, Melbourne, Australia.
authors.forename: Paul
authors.initials: P
authors.lastname: Antonis
authors.affiliation: Department of Cardiology, Flinders University, Adelaide, Australia.
authors.forename: Derek P
authors.initials: DP
authors.lastname: Chew
authors.affiliation: Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia.
authors.forename: Bernadette
authors.initials: B
authors.lastname: Aliprandi-Costa
authors.affiliation: Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
authors.forename: Alan
authors.initials: A
authors.lastname: Cass
authors.affiliation: Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia. Electronic address: david.brieger@sydney.edu.au.
authors.forename: David B
authors.initials: DB
authors.lastname: Brieger
mesh_terms: D054058:Acute Coronary Syndrome / Q000453:epidemiology / Q000628:therapy*; D000368:Aged; D001315:Australia / Q000453:epidemiology; D015897:Comorbidity; D019468:Disease Management; D019317:Evidence-Based Medicine / Q000592:standards*; D005260:Female; D005919:Glomerular Filtration Rate; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D012042:Registries; D051436:Renal Insufficiency, Chronic; D012307:Risk Factors