Does a 'direct' transfer protocol reduce time to coronary angiography for patients with non-ST-elevation acute coronary syndromes? A prospective observational study

Readmission and processes of care across weekend and weekday hospitalisation for acute myocardial infarction, heart failure or stroke: an observational study of the National Readmission Database

OBJECTIVES

Variation in hospital resource allocations across weekdays and weekends have led to studies of the 'weekend effect' for ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), heart failure (HF) and stroke. However, few studies have explored the 'weekend effect' on unplanned readmission. We aimed to investigate 30-day unplanned readmissions and processes of care across weekend and weekday hospitalisations for STEMI, NSTEMI, HF and stroke.

DESIGN

We grouped hospitalisations for STEMI, NSTEMI, HF or stroke into weekday or weekend admissions. Multivariable adjusted ORs for binary outcomes across weekend versus weekday (reference) groups were estimated using logistic regression.

SETTING

We included all non-elective hospitalisations for STEMI, NSTEMI, HF or stroke, which were recorded in the US Nationwide Readmissions Database between 2010 and 2014.

PARTICIPANTS

The analysis sample included 659 906 hospitalisations for STEMI, 1 420 600 hospitalisations for NSTEMI, 3 027 699 hospitalisations for HF, and 2 574 168 hospitalisations for stroke.

MAIN OUTCOME MEASURES

The primary outcome was unplanned 30-day readmission. As secondary outcomes, we considered length of stay and the following processes of care: coronary angiography, primary percutaneous coronary intervention, coronary artery bypass graft, thrombolysis, brain scan/imaging, thrombectomy, echocardiography and cardiac resynchronisation therapy/implantable cardioverter-defibrillator.

RESULTS

Unplanned 30-day readmission rates were 11.0%, 15.1%, 23.0% and 10.9% for STEMI, NSTEMI, HF and stroke, respectively. Weekend hospitalisations for HF were associated with a statistically significant but modest increase in 30-day readmissions (OR of 1.045, 95% CI 1.033 to 1.058). Weekend hospitalisation for STEMI, NSTEMI or stroke was not associated with increased risk of 30-day readmission.

CONCLUSION

There was no clinically meaningful evidence against the supposition that weekend and weekday hospitalisations have the same 30-day unplanned readmissions. Thirty-day readmission rates were high, especially for HF, which has implications for service provision. Strategies to reduce readmission rates should be explored, regardless of day of hospitalisation.

International comparison of acute myocardial infarction care and outcomes using quality indicators

Objective

To compare temporal changes in European Society of Cardiology (ESC) acute myocardial infarction (AMI) quality indicator (QI) attainment in the UK and Israel.

Methods

Data cross-walking using information from the Myocardial Ischaemia National Audit Project and the Acute Coronary Syndrome in Israel Survey for matching 2-month periods in 2006, 2010 and 2013 was used to compare country-specific attainment of 14 ESC AMI QIs.

Results

Patients in the UK (n=17 068) compared with Israel (n=5647) were older, more likely to be women, and had less diabetes, dyslipidaemia and heart failure. Baseline ischaemic risk was lower in Israel than the UK (Global Registry of Acute Coronary Events (GRACE) risk, 110.5 vs 121.0). Overall, rates of coronary angiography (87.6% vs 64.8%) and percutaneous coronary intervention (70.3% vs 41.0%) were higher in Israel compared with the UK. Composite QI performance increased more in the UK (1.0%–86.0%) than Israel (70.2%–78.0%). Mortality rates at 30 days declined in each country, with lower rates in Israel in 2013 (4.2% vs 7.6%). Composite QI adherence adjusted for GRACE risk score was inversely associated with 30-day mortality (OR 0.95; CI 0.95 to 0.97, p<0.001).

Conclusions

International comparisons of guideline recommended AMI care and outcomes can be quantified using the ESC AMI QIs. International implementation of the ESC AMI QIs may reveal country-specific opportunities for improved healthcare delivery.

Effect of weekend admission on process of care and clinical outcomes for the management of acute coronary syndromes: a retrospective analysis of three UK centres

OBJECTIVES

The effect of weekend versus weekday admission following acute coronary syndrome (ACS) on process of care and mortality remains controversial. This study aimed to investigate the 'weekend-effect' on outcomes using a multicentre dataset of patients with ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction/unstable angina (NSTEMI/UA).

DESIGN

This retrospective observational study used propensity score (PS) stratification to adjust estimates of weekend effect for observed confounding. Logistic regression was used to estimate odds ratios (ORs) for binary outcomes and time-to-event endpoints were modelled using Cox proportional hazards to estimate hazard ratios (HRs).

SETTING

Three tertiary cardiac centres in England and Wales that contribute to the Myocardial Ischaemia National Audit Project.

PARTICIPANTS

Between January 2010 and March 2016, 17 705 admissions met the study inclusion criteria, 4327 of which were at a weekend.

PRIMARY AND SECONDARY OUTCOMES

Associations were studied between weekend admissions and the following primary outcome measures: in-hospital mortality, 30-day mortality and long-term survival; secondary outcomes included several processes of care indicators, such as time to coronary angiography.

RESULTS

After PS stratification adjustment, mortality outcomes were similar between weekend and weekday admission across patients with STEMI and NSTEMI/UA. Weekend admissions were less likely to be discharged within 1 day (HR 0.72, 95% CI 0.66 to 0.78), but after 4 days the length of stay was similar (HR 0.97, 95% CI 0.90 to 1.04). Fewer patients with NSTEMI/UA received angiography between 0 and 24 hours at a weekend (HR 0.71, 95% CI 0.65 to 0.77). Weekend patients with STEMI were less likely to undergo an angiogram within 1 hour, but there was no significant difference after this time point.

CONCLUSION

Patients with ACS had similar mortality and processes of care when admitted on a weekend compared with a weekday. There was evidence of a delay to angiography for patients with NSTEMI/UA admitted at the weekend.

Reducing time to angiography and hospital stay for patients with high-risk non-ST-elevation acute coronary syndrome: retrospective analysis of a paramedic-activated direct access pathway

OBJECTIVE

To assess whether a novel 'direct access pathway' (DAP) for the management of high-risk non-ST-elevation acute coronary syndromes (NSTEACS) is safe, results in 'shorter time to intervention and shorter admission times'. This pathway was developed locally to enable London Ambulance Service to rapidly transfer suspected high-risk NSTEACS from the community to our regional heart attack centre for consideration of early angiography.

METHODS

This is a retrospective case-control analysis of 289 patients comparing patients with high-risk NSTEACS admitted via DAP with age-matched controls from the standard pan-London high-risk ACS pathway (PLP) and the conventional pathway (CP). The primary end point of the study was time from admission to coronary angiography/intervention. Secondary end point was total length of hospital stay.

RESULTS

Over a period of 43 months, 101 patients were admitted by DAP, 109 matched patients by PLP and 79 matched patients through CP. Median times from admission to coronary angiography for DAP, PLP and CP were 2.8 (1.5-9), 16.6 (6-50) and 60 (33-116) hours, respectively (p<0.001). Median length of hospital stay for DAP and PLP was similar at 3.0 (2.0-5.0) days in comparison to 5 (3-7) days for CP (p<0.001).

CONCLUSIONS

DAP resulted in a significant reduction in time to angiography for patients with high-risk NSTEACS when compared to existing pathways.

Management of high-risk non-ST elevation myocardial infarction in the UK: need for alternative models of care to reduce length of stay and admission to angiography times

The roll out of the primary percutaneous coronary intervention pathway as the default treatment for patients with ST elevation myocardial infarction (STEMI) across the NHS has led to a paradigm shift in the model of care resulting in a significant improvement in mortality. In comparison, a similar care plan does not exist for non-ST elevation acute coronary syndrome (NSTE-ACS) despite the fact that patients presenting with high-risk non-STEMI carry a similar if not higher mortality at six months in comparison to STEMI. In this article we focus on the contemporary management of NSTE-ACS in the NHS and also look at some of the dedicated pathways already developed and implemented successfully in expediting treatment and decreasing hospital stay without compromising the safety of patients.