Ischaemic heart disease and Australian immigrants: the influence of ethnicity and language skills on treatment and use of health services

Admission rates for ischaemic heart disease (IHD), and the use of invasive cardiovascular procedures, separation mode and length of stay (LOS) were compared between Australians from non-English speaking background (NESB; n=8627) and English speaking background (ESB; n=13162) aged 20 years and over admitted to Victorian urban public hospitals. The study covered the period from 1993 to 1998. It was found that, compared with their ESB counterparts, the incidence of admission for acute myocardial infarction was significantly higher for NESB men and women before and after controlling for confounding factors. The age-adjusted ratios for NESB women compared with their ESB counterparts ranged from 1.23 to 1.89 for cardiac catheterisation, from 0.23 to 0.27 for percutaneous transluminal coronary angioplasty (PTCA), and from 1.04 to 1.80 for coronary artery bypass grafting (CABG). Procedure rates were comparable in men for cardiac catheterisation and CABG but higher for PTA rates in NESB men (OR: 1.29, 95%CI: 1.11-1.50) than their ESB counterparts. Both NESB men (Beta=0.04, 95%CI: 0.01-0.07) and women (Beta=0.03, 95%CI: 0.02-0.08) experienced significantly longer hospital stays than their ESB counterparts. These findings indicate there may be systematic differences in patients' treatment and service utilisation in Victorian public hospitals. The extent to which physicians' bias and patients' choice could explain these differences requires further investigation.

In the public interest: autonomy and resistance to methods of standardising nurses' advice and practices from a health call centre in Perth, Western Australia

The history of nursing is replete with examples of nurses battling for autonomy over their education, knowledge and work practices. The latest battleground is HealthDirect, Australia's first medial call centre, where nurses are required to meet externally imposed clinical standards while satisfying legal and financial obligations. These objectives are arguably achieved when nurses assess callers' health problems via computerised algorithms that determine an appropriate plan of action. That way, nurses' subjective responses to callers are ruled out. To ensure nurses comply with the standard processes, calls are monitored randomly and surreptitiously in formal and informal ways. This paper explores how nurses respond to standard procedures and surveillance, in order to argue that nurses' input partially drives reform processes. Nurses continue to seek autonomy over the advice they give and how their work is evaluated but are constrained by structural power relations.

Towards a Safer Culture: clinical pathways in acute coronary syndromes and stroke

Towards a Safer Culture (TASC) aims to provide a safer culture in hospital departments by introducing clinical pathways for the management of patients with acute coronary syndromes or stroke. Specific clinical pathways have been implemented for patients with different levels of risk to guide the most appropriate evidence-based medical care for each patient. Pathways facilitate continuity of care across different clinical departments by identifying gaps in care, and clarifying tasks and responsibilities. A multidisciplinary and interdepartmental approach to managing patients is seen as an effective way of effecting change. A system for "point-of-care" data acquisition, a centralised database and web-based reporting enable benchmarking for participating hospitals. A comprehensive range of educational/training strategies is used to facilitate multidisciplinary teamwork and promote clinical leadership. Phase 1 of TASC was successfully piloted at four hospitals in New South Wales, Victoria and Queensland. TASC is currently being rolled out to 29 hospitals in NSW and three hospitals in Western Australia.

Impact of a chest-pain guideline on clinical decision-making

OBJECTIVE

To evaluate the impact of a chest-pain guideline on clinical decision-making and medium-term outcomes of patients presenting to a hospital emergency department (ED) with non-traumatic chest pain.

DESIGN

Before-and-after guideline implementation study.

SETTING

Bankstown-Lidcombe Hospital, Sydney, NSW (454-bed metropolitan teaching hospital), in the six-month periods before and after guideline implementation in February 2001.

PARTICIPANTS

Patients presenting to the ED with non-traumatic chest pain who had chest-pain assessment forms completed by ED doctors, comprising 422/768 (54.9%) of those presenting before and 461/691 (66.7%) after guideline implementation.

MAIN OUTCOME MEASURES

Appropriateness of admission/discharge decisions compared with decision of senior cardiologist based on guideline; death, recurrent chest pain, ED re-presentation and hospital readmission in the ensuing three months.

RESULTS

After guideline implementation, appropriate admission/discharge decisions increased significantly from 180/265 (68%) to 261/324 (81%) (difference, 13%; 95% CI, 6%-20%). The largest increase was for patients at moderate risk of death or acute myocardial infarction within six months, from 39/96 (38%) to 57/103 (55%) (difference, 18%; 95% CI, 4%-31%). Increases were seen for both junior doctors (interns and resident medical officers) (18%; 95% CI, 7%-30%) and senior doctors (11%; 95% CI, 2%-19%). Logistic regression showed that implementation of the guideline, seniority of assessing doctor and patient history of coronary disease were independent predictors of appropriate decisions. There was a significant decline in re-presentations to ED with recurrent chest pain in patients previously presenting with cardiac or possibly cardiac pain, from 46/201 (23%) before implementation to 32/247 (13%) after (difference, 210%; 95% CI, 217% to 23%).

CONCLUSIONS

The chest-pain guideline resulted in a significant improvement in clinical decision-making in the ED and reduced re-presentations with cardiac/possibly cardiac chest pain.

Review article: the burden of illness of non-cardiac chest pain

BACKGROUND

Non-cardiac chest pain is a common condition affecting approximately one-quarter of the population during their lifetime, but the long-term economic costs of non-cardiac chest pain are poorly defined.

METHODS

A MEDLINE and Current Contents search was performed from 1991 to 2002 using specific keywords. All major articles on the subject of non-cardiac chest pain in this period were reviewed and their reference lists searched.

RESULTS

Limited studies suggest that the majority of those with non-cardiac chest pain do not consult a doctor regarding their symptoms; the drivers of health care seeking are not known. The impact on the quality of life in consulters can be severe, with as many as 36% reporting much lower quality of life levels. The diagnosis of non-cardiac chest pain can be difficult due to the heterogeneous nature of the condition, with significant overlap of gastro-oesophageal reflux disease, chest wall syndromes and psychiatric disease, which may drive up the costs of management. The prognosis appears to be good, but there are conflicting results in long-term studies.

CONCLUSIONS

The costs of non-cardiac chest pain to the health care system are likely to be large and represent a significant proportion of each Western country's health care budget. Further studies are required to determine methods of reducing health care costs.

Ninety-minute accelerated critical pathway for chest pain evaluation

Rapid, efficient, and accurate evaluation of chest pain patients in the emergency department optimizes patient care from public health, economic, and liability perspectives. To evaluate the performance of an accelerated critical pathway for patients with suspected coronary ischemia that utilizes clinical history, electrocardiographic findings, and triple cardiac marker testing (cardiac troponin I [cTnI], myoglobin, and creatine kinase-MB [CK-MB]), we performed an observational study of a chest pain critical pathway in the setting of a large Emergency Department at the Veterans Affairs Medical Center in 1,285 consecutive patients with signs and symptoms of cardiac ischemia. The accelerated critical pathway for chest pain evaluation was analyzed for: (1) accuracy in triaging of patients within 90 minutes of presentation, (2) sensitivity, specificity, positive predictive value, and negative predictive value of cTnI, myoglobin, and CK-MB in diagnosing acute myocardial infarction (MI) within 90 minutes, and (3) impact on Coronary Care Unit (CCU) admissions. All MIs were diagnosed within 90 minutes of presentation (sensitivity 100%, specificity 94%, positive predictive value 47%, negative predictive value 100%). CCU admissions decreased by 40%. Ninety percent of patients with negative cardiac markers and a negative electrocardiogram at 90 minutes were discharged home with 1 patient returning with an MI (0.2%) within the next 30 days. Thus, a simple, inexpensive, yet aggressive critical pathway that utilizes high-risk features from clinical history, electrocardiographic changes, and rapid point-of-care testing of 3 cardiac markers allows for accurate triaging of chest pain patients within 90 minutes of presenting to the emergency department.