Medical care and case fatality from myocardial infarction and coronary death in Newcastle and Perth

Mortality after acute myocardial infarction is lower in metropolitan regions than in non-metropolitan regions

STUDY OBJECTIVES

To compare in-hospital mortality for acute myocardial infarction (AMI) between metropolitan and non-metropolitan hospitals after adjustment for patients' severity; to examine the role of the use of effective cardiac medications in the possible mortality difference between these types of hospital.

DESIGN

Retrospective cohort study.

SETTING

47 acute public hospitals in metropolitan and non-metropolitan areas of New South Wales, Australia, taking part in the Acute Cardiac Care Project based on medical record review.

PATIENTS

1665 patients with principal discharge diagnosis of AMI from February to June 1996.

MAIN RESULTS

There was no difference in crude mortality rate (assessed as seven day mortality) between metropolitan and non-metropolitan hospitals (11.0% compared with 10.7% respectively, p=0.893). After adjustment for severity in a logistic regression model, the odds of death in non-metropolitan hospitals was significantly higher than in metropolitan hospitals (odds ratio = 1. 90; 95% CI 1.21, 3.23). The addition of the use of effective cardiac medications to the model resulted in the difference between hospital type becoming non-significant (odds ratio=1.09; 95% CI 0.57, 2.07).

CONCLUSIONS

In-hospital mortality in non-metropolitan hospitals was higher than that in metropolitan hospitals, after adjustment for patients' severity. This might partly be explained by the difference in use of effective cardiac medications between hospital type.

Excess coronary mortality among Australian men and women living outside the capital city statistical divisions

OBJECTIVES

To compare rates of mortality from coronary heart disease (CHD) between populations living within and outside Australian capital city statistical divisions.

DESIGN AND SETTING

Descriptive epidemiological study based on data for all residents of Australia aged 30-69 years who died between 1986 and 1996 in all States and Territories of Australia.

MAIN OUTCOME MEASURES

Standardised mortality rates from all causes and coronary heart disease as coded by the Australian Bureau of Statistics, and estimated excess deaths in populations living outside capital city statistical divisions.

RESULTS

Between 1986 and 1996, mortality from CHD declined by 46% in men and 51% in women, and accounted for 61% of the decline in mortality from all causes in men and 48% in women. More deaths than expected from acute myocardial infarction resulted in mortality rates from CHD up to 30% higher in men and 21% higher in women living outside the capital city statistical divisions, and accounted for an overall estimated excess of 3835 deaths from CHD in men (32% of excess deaths from all causes), and 1385 deaths from CHD in women (27% of excess deaths from all causes) over the 11-year study period.

CONCLUSIONS

Although there were impressive declines in coronary mortality in all Australian States and Territories from 1986 to 1996, populations living outside capital cities continue to have higher death rates from CHD. These differences in mortality rates indicate a need for further research into factors which may influence mortality rates for CHD in rural and remote areas, and immediate measures to ensure optimal treatment of coronary risk factors and acute coronary events in such populations.

Stated and actual management of acute myocardial infarction among different specialties

OBJECTIVES

To examine the variation in stated management of acute myocardial infarction (AMI) among clinicians of different specialties, and to compare stated with actual practice.

DESIGN

Mail survey using a hypothetical case history, and review of medical records.

SETTING

47 public hospitals in New South Wales.

SUBJECTS

224 cardiologists, general/other physicians and general practitioners (GPs) who manage patients with AMI; 390 patients admitted for AMI between February and June 1996.

OUTCOME MEASURES

Stated and actual use of treatments and investigations for AMI.

RESULTS

Stated use of aspirin, thrombolysis and beta-blockers (95%-100%, 95%-100% and 80%-86%, respectively) was high in all three specialties. Cardiologists were significantly more likely than GPs to state use of heparin (87% v 57%; P < 0.001), ACE inhibitors (84% v 49%; P < 0.001) and echocardiography or gated pool heart scan (79% v 26%; P < 0.001). Stated use of nitrates by cardiologists was significantly lower compared with the other specialties (29% v 50% and 44%; P = 0.027). Actual use of aspirin was high (> 80%) in all specialties. Actual use of thrombolysis was similar to stated use after adjusting for factors such as time to hospital arrival and ST-segment elevation. There were substantial differences between stated and actual use.

CONCLUSIONS

There were differences in practice patterns between and among clinicians of different specialties in NSW, consistent with findings from other countries. The high stated and actual use of aspirin and thrombolysis is encouraging.