title: The relationship between the proportion of admitted high risk ACS patients and hospital delivery of evidence based care.
abstract: OBJECTIVE
  Variations in the delivery of evidence based care to high risk patients with Acute Coronary Syndromes (ACS) exist between hospitals. We hypothesised that the relative proportion of admitted high risk patients contributes to variation in care and outcomes.
  
  
  METHODS
  Receipt of evidence based therapies (EBT) according to patient risk was documented in the Australian Co-operative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE). Hospitals were stratified into quartiles (Q) by fraction of high risk patients according to: GRACE Risk Score (GRS), chronic kidney disease (CKD), age, Killip class, and myocardial infarction (MI). For each category, EBT and mortality were compared between hospital groups.
  
  
  RESULTS
  This study included 8390 ACS patients from 39 hospitals. Patients with GRS>130, CKD, and >80years, were less likely to receive EBT at high proportion hospitals (p<0.0001 for all). After adjustment, proportion of patients with CKD negatively predicted coronary angiography (CA) (Q4 vs Q1: OR 0.21, 95%CI 0.10-0.45). Adjusted 6month mortality was greater in CKD and trended greater in >80years in hospitals treating the highest proportions of these patients (Q4 vs Q1 OR 3.80, 95%CI 1.85-7.83, and OR 3.10, 95%CI 0.99-9.70 respectively).
  
  
  CONCLUSIONS
  Elderly ACS patients and those with CKD are less likely to receive EBT at hospitals seeing high proportions of these patients. Failure to provide EBT to these high risk populations may contribute to avoidable mortality in these institutions.
authors.affiliation: Department of Cardiology, Concord Hospital, University of Sydney, Australia. Electronic address: dbrieger@uni.sydney.edu.au.
authors.forename: David
authors.initials: D
authors.lastname: Brieger
authors.affiliation: Anzac Research Institute, University of Sydney, Australia.
authors.forename: Karice
authors.initials: K
authors.lastname: Hyun
authors.affiliation: Flinders Medical Centre, Adelaide, Australia.
authors.forename: Derek
authors.initials: D
authors.lastname: Chew
authors.affiliation: Geelong Hospital, Geelong, Australia.
authors.forename: John
authors.initials: J
authors.lastname: Amerena
authors.affiliation: Austin Hospital, Melbourne, Australia.
authors.forename: Omar
authors.initials: O
authors.lastname: Farouque
authors.affiliation: St Vincent's Hospital, Melbourne, Australia.
authors.forename: Andrew
authors.initials: A
authors.lastname: MacIsaac
authors.affiliation: St Michaels Hospital, Toronto, Canada.
authors.forename: Shaun
authors.initials: S
authors.lastname: Goodman
authors.affiliation: St Michaels Hospital, Toronto, Canada.
authors.forename: Andrew
authors.initials: A
authors.lastname: Yan
authors.affiliation: Sydney Nursing School, University of Sydney, Australia.
authors.forename: Bernadette
authors.initials: B
authors.lastname: Aliprandi Costa
authors.affiliation: Anzac Research Institute, University of Sydney, Australia.
authors.forename: Bilyana
authors.initials: B
authors.lastname: Dabin
authors.affiliation: Department of Cardiology, Concord Hospital, University of Sydney, Australia.
authors.forename: Mario
authors.initials: M
authors.lastname: D'Sousa
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D000368:Aged; D001315:Australia / Q000453:epidemiology; D017023:Coronary Angiography / Q000379:methods / Q000706:statistics & numerical data; D003695:Delivery of Health Care / Q000379:methods / Q000592:standards; D004562:Electrocardiography / Q000379:methods / Q000706:statistics & numerical data; D055416:Evidence-Based Emergency Medicine / Q000458:organization & administration*; D005260:Female; D019983:Guideline Adherence; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D020380:Needs Assessment; D010043:Outcome and Process Assessment, Health Care; D012042:Registries / Q000706:statistics & numerical data; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology; D012307:Risk Factors
keywords: Acute coronary syndromes; Quality of care