Regional to tertiary inter-hospital transfer versus in-house percutaneous coronary intervention in acute coronary syndrome

Abstract

RationaleTo address the inaccessibility of interventional cardiac services in North Queensland a new cardiac catheterisation laboratory (CCL) was established in Mackay Base Hospital (MBH) in February 2014.ObjectiveTo determine whether the provision of in-house angiography and/or percutaneous coronary intervention (PCI) 1) minimises treatment delays 2) further reduces the risk of mortality, recurrent myocardial infarction (MI) and recurrent ischaemia 3) improves patient satisfaction and 4) minimises cost expenditure compared with inter-hospital transfer for patients with acute coronary syndrome (ACS).MethodsWe compared ACS patients who were transferred to tertiary centres from July 2012 to June 2013 with those who received in-house angiography and/or PCI from February 2015 to January 2016. The primary outcome was the composite of all-cause mortality, recurrent myocardial infarction (MI) or recurrent ischaemia at six months. Pre-specified secondary outcomes were the composite of all-cause mortality, recurrent MI or recurrent ischaemia at one month, a summated patient satisfaction score and the proportional cost savings generated between 2015 and 2016.ResultsWe included consecutive samples of 203 patients from July 2012 to June 2013 and 229 patients from February 2015 to January 2016. There was a reduction in the median time to treatment of 3.2 days and a reduction in the median length of stay of four days amongst all ACS patients receiving in-house angiography and/or PCI. The primary outcome occurred in 14 (6.9%) patients in the 2012 to 2013 group, as compared with 18 (7.9%) patients in the 2015 to 2016 group (OR = 0.71, 95% CI 0.24–2.1, P = 0.54). The secondary outcome at one month occurred in four (2.0%) patients in the 2012 to 2013 group, as compared with three (1.3%) patients in the 2015 to 2016 group (OR = 1.2, 95% CI 0.11–13.1, P = 0.87). There was a statistically significant improvement in the summated patient satisfaction score amongst patients who received in-house angiography and/or PCI (U = 1918, P <0.05 two tailed). A calculation of estimated cost savings showed a reduction in proportional cost of $14 481 (51%) per ACS patient receiving in house angiography and/or PCI between 2015 and 2016.ConclusionThis study suggests that the provision of regional in-house angiography and/or PCI for the treatment of ACS minimises delays to invasive treatment by 3.2 days, minimises the median length of stay by four days, significantly improves patient satisfaction and reduces proportional treatment costs by $14 481 (51%) per patient. Currently, however, it appears that that in-house treatment does not further reduce the risk of mortality, recurrent MI and recurrent ischaemia at one and six months.

Advanced skills for general surgeons and carving out a niche: Endoscopic retrograde cholangiopancreatography in regional Australia

“…Given a gastroenterology department with ERCP capability is a distant luxury in many rural and regional Australian hospitals, this study exemplifies the value of a single general surgeon paragon in a rural hospital trained in this complex endoscopic procedure. For the 191 patients who underwent ERCP locally, they were saved the displacement of long‐distance travel to a tertiary hospital 386 km away while the hospital and health service saved upwards of $580 000 6 . With an average age of 61, many of these patients were not only older and comorbid but often unwell with 24.61% of patients requiring emergency surgery that may not have been amendable to transfer.…”

“…Much like other skillsets like trauma or urology that are so often well regarded in the armamentarium of the rural general surgeon, ERCP presents an opportunity for health services to invest in post‐fellowship training of general surgeons to service rural communities by avoiding transfers, managing conditions locally and expansion of training of registrars. Other studies in our institution have investigated the significant cost savings of local care over an inter‐hospital transfer, with the aeromedical retrieval process alone being over $3500 per patient 6 . We sought to study the performance of ERCP in this single rural institution, comparing it with recognized performance indicators to demonstrate safety and efficacy in the hands of a general surgeon, and to propose a case for further investment in this technique in rural Queensland.…”

“…Other studies in our institution have investigated the significant cost savings of local care over an inter-hospital transfer, with the aeromedical retrieval process alone being over $3500 per patient. 6 We sought to study the performance of ERCP in this single rural institution, comparing it with recognized performance indicators to demonstrate safety and efficacy in the hands of a general surgeon, and to propose a case for further investment in this technique in rural Queensland.…”

Myocardial ischemia/reperfusion injury: Mechanisms of injury and implications for management (Review)

“…The first two forms are reversible while the others are irreversible ( 11 ). Clinically, percutaneous coronary intervention (PCI) ( 12 ), antiplatelet ( 13 ) and anticoagulant ( 14 ) therapy are primarily used for patients exposed to the latter two types of injury to maintain coronary artery patency. During myocardial reperfusion, timely and effective restoration of blood flow cannot effectively prevent MIRI.…”

YQHX Alleviates H/R-Induced Cardiomyocyte Apoptosis by Downregulating miR-1

“…Acute myocardial infarction (AMI) has emerged as one of the major diseases endangering human health and life [ 1 ]. In clinical practice, AMI is mainly treated by percutaneous coronary intervention or drug thrombolysis; however, upon rapid restoration of coronary blood supply, myocardial ischemia-reperfusion injury (MIRI) is inevitable [ 2 – 4 ]. Cardiomyocyte apoptosis is the main pathological basis of MIRI.…”