Comparative Effectiveness Research (CER) ‒ A Case Study

Background: The Australian healthcare system is complex. Assessing the quality of the care provided in the management of acute coronary syndromes (ACS) is problematic because of disparate systems that constrain an integrated reporting approach. Registry data reported within a comparative effectiveness research (CER) framework establishes the case for clinical process indicators to measure and report hospital performance. Objectives: To aggregate data from The Global Registry of Acute Coronary Events (GRACE) and the Cooperative National Registry of Acute Coronary Care Guideline Adherence and Clinical Events (CONCORDANCE) to describe temporal trends in the management of ACS and associations with in-hospital events, hospital readmission and six month mortality; to develop a composite score of hospital performance quality; to determine associations between adherence to the quality composite score and in-hospital events, hospital readmission and six month mortality and develop a benchmarked stakeholder hospital performance report. Methods: A single case study embedding three units of analysis was used to explore and explain how data reported in a CER framework measures hospital performance in the management of ACS. Analysis: Descriptive analyses of prospectively collected data on the management and outcomes of over 7000 patients admitted to 46 hospitals from 1999 to 2016. Findings: The first Unit of Analysis reports temporal trends in the management of ACS across 11 hospitals in the GRACE registry from 2000 to 2007 which informed the design of the CONCORDANCE registry; The second Unit of Analysis combines both GRACE and CONCORDANCE registries and reports on the management of ST-elevation acute myocardial infarction (STEMI ) from 1999 to 2016 revealing gains in pre-hospital care and fewer in-hospital clinical events, and readmission for urgent revascularisation without a significant reduction in in-hospital or six month mortality. The third Unit of Analysis reports the observed and risk-adjusted association between adherence to the quality composite score and reduced in-hospital events, and increased survival at hospital discharge and at six months post discharge. Conclusion: Case-study analysis of CER in the context of ACS registries provides evidence on adherence to evidence-based care and a quality composite measure of hospital performance in the management of ACS

The underutilisation of dual antiplatelet therapy in acute coronary syndrome

Background Despite guideline recommendation of dual antiplatelet therapy (DAPT) in treating ACS, DAPT is underutilized. Our objective was to determine independent predictors of DAPT non-prescription in ACS and describe pattern of DAPT prescription over time. Methods Patients presenting to 41 Australian hospitals with an ACS diagnosis between 2009 and 2016 were stratified according to discharge prescription with DAPT and single antiplatelet therapy (SAPT) or no antiplatelet therapy. Multiple stepwise logistic regression, accounting for within hospital clustering, was used to determine the independent predictors of DAPT non-prescription, defined as discharge with SAPT alone or no antiplatelet agent. Results 8939 patients survived to discharge with an ACS diagnosis. Of these, 6294 (70.4%) patients were discharged on DAPT, 2154 (24.1%) on SAPT and 491 (5.5%) on no antiplatelet agent. Independent predictors of DAPT non-prescription in the overall cohort were: in-hospital CABG (OR 0.09, 95%CI 0.05–0.14), discharge with warfarin (0.10 (0.07–0.14)), in hospital major bleeding (0.48 (0.34–0.67), diagnosis of unstable angina (0.35, (0.27–0.45)), non-ST-elevation myocardial infarction (0.67 (0.57–0.78)) [both vs. ST-segment elevation myocardial infarction], in hospital atrial arrhythmia (0.72 (0.60–0.86)), history of hypertension (0.83 (0.73–0.94)) and GRACE high risk (0.83 (0.71–0.98)). There was an increase in prescription of DAPT and a shift towards ticagrelor over clopidogrel for ACS from 2013 to 2016 (p\ua

SAFety, Effectiveness of care and Resource use among Australian Hospitals (SAFER Hospitals): a protocol for a population-wide cohort study of outcomes of hospital care

First published on 20 August 2020.INTRODUCTION:Despite global concerns about the safety and quality of health care, population-wide studies of hospital outcomes are uncommon. The SAFety, Effectiveness of care and Resource use among Australian Hospitals (SAFER Hospitals) study seeks to estimate the incidence of serious adverse events, mortality, unplanned rehospitalisations and direct costs following hospital encounters using nationwide data, and to assess the variation and trends in these outcomes. METHODS AND ANALYSIS:SAFER Hospitals is a cohort study with retrospective and prospective components. The retrospective component uses data from 2012 to 2018 on all hospitalised patients age ≥18 years included in each State and Territories' Admitted Patient Collections. These routinely collected datasets record every hospital encounter from all public and most private hospitals using a standardised set of variables including patient demographics, primary and secondary diagnoses, procedures and patient status at discharge. The study outcomes are deaths, adverse events, readmissions and emergency care visits. Hospitalisation data will be linked to subsequent hospitalisations and each region's Emergency Department Data Collections and Death Registries to assess readmissions, emergency care encounters and deaths after discharge. Direct hospital costs associated with adverse outcomes will be estimated using data from the National Cost Data Collection. Variation in these outcomes among hospitals will be assessed adjusting for differences in hospitals' case-mix. The prospective component of the study will evaluate the temporal change in outcomes every 4 years from 2019 until 2030. ETHICS AND DISSEMINATION:Human Research Ethics Committees of the respective Australian states and territories provided ethical approval to conduct this study. A waiver of informed consent was granted for the use of de-identified patient data. Study findings will be disseminated via presentations at conferences and publications in peer-reviewed journals.Isuru Ranasinghe, Sadia Hossain, Anna Ali, Dennis Horton, Robert JT Adams, Bernadette Aliprandi-Costa, Christina Bertilone, Gustavo Carneiro, Martin Gallagher, Steven Guthridge, Billingsley Kaambwa, Sradha Kotwal, Gerry O'Callaghan, Ian A Scott, Renuka Visvanathan, Richard J Woodma

Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand

OBJECTIVE: To evaluate the proportion of patients hospitalised with acute coronary syndrome (ACS) in Australia and New Zealand who received optimal inpatient preventive care and to identify factors associated with preventive care. METHODS: All patients hospitalised bi-nationally with ACS were identified between 14-27 May 2012. Optimal in-hospital preventive care was defined as having received lifestyle advice, referral to rehabilitation, and prescription of secondary prevention pharmacotherapies. Multilevel multivariable logistic regression was used to determine factors associated with receipt of optimal preventive care. RESULTS: For the 2299 ACS survivors, mean (SD) age was 69 (13) years, 46% were referred to rehabilitation, 65% were discharged on sufficient preventive medications, and 27% received optimal preventive care. Diagnosis of ST elevation myocardial infarction (OR: 2.64 [95% CI: 1.88-3.71]; p<0.001) and non-ST elevation myocardial infarction (OR: 1.99 [95% CI: 1.52-2.61]; p<0.001) compared with a diagnosis of unstable angina, having a percutaneous coronary intervention (PCI) (OR: 4.71 [95% CI: 3.67-6.11]; p<0.001) or coronary bypass (OR: 2.10 [95% CI: 1.21-3.60]; p=0.011) during the admission or history of hypertension (OR:1.36 [95% CI: 1.06-1.75]; p=0.017) were associated with greater exposure to preventive care. Age over 70 years (OR:0.53 [95% CI: 0.35-0.79]; p=0.002) or admission to a private hospital (OR:0.59 [95% CI: 0.42-0.84]; p=0.003) were associated with lower exposure to preventive care. CONCLUSIONS: Only one-quarter of ACS patients received optimal secondary prevention in-hospital. Patients with UA, who did not have PCI, were over 70 years or were admitted to a private hospital, were less likely to receive optimal care.Julie Redfern, Karice Hyun, Derek P Chew, Carolyn Astley, Clara Chow, Bernadette Aliprandi-Costa, Tegwen Howell, Bridie Carr, Karen Lintern, Isuru Ranasinghe, Kellie Nallaiah, Fiona Turnbull, Cate Ferry, Chris Hammett, Chris J Ellis, John French, David Brieger, Tom Briff

Trends and predictors of rehospitalisation following an acute coronary syndrome: report from the Australian and New Zealand population of the Global Registry of Acute Coronary Events (GRACE)

BACKGROUND: Readmission following an acute coronary syndrome (ACS) is frequent in our community. Patient specific factors identifying those at risk of readmission are poorly described. METHODS: Data were analysed from 5219 patients with an ACS enrolled in the Australian and New Zealand population of the Global Registry of Acute Coronary Events (GRACE) between 1999 and 2007. Patients who were readmitted for cardiovascular disease within 6 months of discharge were identified; regression analysis was used to predict independent patient factors associated with readmission 1 month and 1-6 months after discharge. RESULTS: 1048 patients (20.1%) were readmitted within 6 months, with a significant proportion (n=434, 41.4%) of readmissions occurring within 30 days of discharge. Readmission within 6 months was associated with a higher incidence of unscheduled cardiac catheterisation (HR 25.64, 95% CI 18.41 to 35.71), unscheduled percutaneous coronary intervention (PCI) (HR 15.78, 95% CI 10.56 to 23.59), stroke (HR 1.92, 95% CI 1.08 to 3.43), and death (HR 2.40, 95% CI 1.66 to 3.49). Recurrent ischemia in hospital and a diagnosis of S-T elevation myocardial infarction during the index admission were associated with the strongest risk of early rehospitalisation, while revascularisation by PCI or coronary artery bypass surgery (CABG) was associated with lowest risk of early readmission. A history of heart failure, prior myocardial infarction or angina was associated with a greater likelihood of later rehospitalisation, whereas revascularisation by CABG was associated with the lowest risk of later rehospitalisation. CONCLUSIONS: Several patient and clinical factors identify patients at higher risk of readmission. Identifying these factors and escalating in-hospital and post-discharge care for these higher risk patients may prevent readmission and improve outcome

Troponin measurements, myocardial infarction diagnoses and outcomes. An analysis of linked data from New South Wales, Australia

Background: Cardiac troponin assays are very widely requested tests, particularly in emergency departments. Thus, many seriously ill patients who may not have heart disease as their primary discharge diagnosis have undergone troponin testing during hospitalisation. Aims: To determine associations between cardiac troponin levels and mortality, including from cardiovascular and non-cardiovascular causes, among patients hospitalised in New South Wales, Australia over a 2-year period. Methods: Over a 2-year period (2006–2008), 172 753 hospitalised patients had a quantitative or qualitative troponin assay performed in New South Wales (Australia). The associations were examined, using data linked to late outcomes, between elevations in levels of troponins T or I and 1-year mortality. Mortality was determined for International Statistical Classification of Diseases 10th Revision diagnostic groups. Results: Of 172 753 patients undergoing troponin testing, 44 357 (25%) had a cardiovascular diagnosis of whom (7% had myocardial infarction) 47 827 (28%) had a probable ischaemic heart disease diagnosis if the 23 873 (14%) of patients coded with ‘chest pain’ were included. In patients with a cardiovascular diagnosis and elevated troponin 3060 (1.8%) died in 12 months in comparison to 6262 (3.6%) in those with a non-cardiovascular disease diagnoses and elevated troponin. The 1-year mortality hazard with respect to a troponin elevation was 2.5 (95% confidence interval 2.3–2.7) and 2.0 (95% confidence interval 1.99–2.01) for those with a cardiovascular and non-cardiovascular diagnosis respectively. Conclusion: In a very large state-wide hospitalised patient cohort, among patients with elevated troponin levels and non-cardiac diagnoses, mortality was higher than in those with cardiovascular diagnoses, including MI

Troponin measurements, myocardial infarction diagnoses and outcomes : an analysis of linked data from New South Wales, Australia

Background: Cardiac troponin assays are very widely requested tests, particularly in emergency departments. Thus, many seriously ill patients who may not have heart disease as their primary discharge diagnosis have undergone troponin testing during hospitalisation. Aims: To determine associations between cardiac troponin levels and mortality, including from cardiovascular and non-cardiovascular causes, among patients hospitalised in New South Wales, Australia over a 2-year period. Methods: Over a 2-year period (2006–2008), 172 753 hospitalised patients had a quantitative or qualitative troponin assay performed in New South Wales (Australia). The associations were examined, using data linked to late outcomes, between elevations in levels of troponins T or I and 1-year mortality. Mortality was determined for International Statistical Classification of Diseases 10th Revision diagnostic groups. Results: Of 172 753 patients undergoing troponin testing, 44 357 (25%) had a cardiovascular diagnosis of whom (7% had myocardial infarction) 47 827 (28%) had a probable ischaemic heart disease diagnosis if the 23 873 (14%) of patients coded with ‘chest pain’ were included. In patients with a cardiovascular diagnosis and elevated troponin 3060 (1.8%) died in 12 months in comparison to 6262 (3.6%) in those with a non-cardiovascular disease diagnoses and elevated troponin. The 1-year mortality hazard with respect to a troponin elevation was 2.5 (95% confidence interval 2.3–2.7) and 2.0 (95% confidence interval 1.99–2.01) for those with a cardiovascular and non-cardiovascular diagnosis respectively. Conclusion: In a very large state-wide hospitalised patient cohort, among patients with elevated troponin levels and non-cardiac diagnoses, mortality was higher than in those with cardiovascular diagnoses, including MI

The contribution of the composite of clinical process indicators as a measure of hospital performance in the management of acute coronary syndromes—insights from the CONCORDANCE registry

Aims: Acute coronary syndrome (ACS) is a costly condition for health service provision yet variation in the delivery of care between hospitals persists. A composite measure of adherence with evidence-based clinical-process indicators (CPIs) could better inform hospital performance reporting and clinical outcomes in the management of ACS. Methods: Data on 7444 ACS patients from 39 Australian hospitals were used to derive a hospital-specific composite quality score by calculating mean adherence to 14 evidence-based CPIs. Using the generalized estimating equation to account for clustering of patients within hospitals and the GRACE risk score to adjust for differences in presenting risk, we evaluated associations between the hospital-specific composite quality score, in-hospital major adverse events, in-hospital mortality and mortality and readmission for ACS at 6 months. Results: Hospitals had a mean adherence of 68.3% (SD 21.7) with the composite quality score. There was significant variation between hospital adherence tertile 1 (79%) and tertile 3 (56%), P, 0.0001. With risk adjustment, there was an association between hospitals with a higher composite quality score and reduced in-hospital adverse events (OR: 0.85, CI: 0.71 - 0.99) and survival at hospital discharge (OR: 0.47; 95% CI: 0.28 - 0.77). There was trending improvement in survival at 6 months (OR 0.48; CI: 0.20 - 1.16) and fewer readmissions to hospital for ACS at 6 months (OR 0.79; CI 0.60 - 1.05). Conclusion: The association between the quality composite score and reduced in-hospital events and survival at hospital discharge supports the utility of reporting CPIs in routine hospital performance reporting on the management of ACS