Variation in coronary angiography rates in Australia: correlations with socio‐demographic, health service and disease burden indices

Chew, Derek P.; MacIsaac, Andrew; Lefkovits, Jeffrey; Harper, Richard W.; Slawomirski, Luke; Braddock, David; Horsfall, Matthew; Ellis, Chris; Brieger, David; Briffa, Tom

doi:10.5694/mja15.01410

Cited by 20 publications

(12 citation statements)

References 31 publications

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“…Previous Australian studies have reported mixed findings regarding socioeconomic variation in the receipt of angiography, ranging from no evidence of an association [ 16 , 21 ], to statistically non-significant findings in the same direction as those observed in our study [ 22 ]. These studies used area- rather than individual-level data and were restricted to public hospital data only, which may have underestimated socioeconomic variation in procedure rates.…”

Section: Discussionsupporting

confidence: 49%

“…Recent findings suggest that these socioeconomic disparities may be disappearing over time as the overall use of coronary procedures has increased [ 16 – 20 ]. However, these studies have relied on area-level measures to assess socioeconomic position [ 13 , 15 , 16 , 21 , 22 ], which generally underestimate variation compared to individual-level measures [ 10 , 23 , 24 ]. Furthermore, many studies use data from public hospitals only, also potentially underestimating variation within the population, and providing no insights into the role of private health care in explaining inequalities in care.…”

Section: Introductionmentioning

confidence: 99%

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Education-related variation in coronary procedure rates and the contribution of private health care in Australia: a prospective cohort study

Hughes

Paige

Welsh

et al. 2020

Int J Equity Health

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Background Contemporary Australian evidence on socioeconomic variation in secondary cardiovascular disease (CVD) care, a possible contributor to inequalities in cardiovascular disease outcomes, is lacking. This study examined the relationship between education, an individual-level indicator of socioeconomic position, and receipt of angiography and revascularisation procedures following incident hospitalisation for acute myocardial infarction (AMI) or angina, and the role of private care in this relationship. Methods Participants aged ≥45 from the New South Wales population-based 45 and Up Study with no history of prior ischaemic heart disease hospitalised for AMI or angina were followed for receipt of angiography or revascularisation within 30 days of hospital admission, ascertained through linked hospital records. Education attainment, measured on baseline survey, was categorised as low (no school certificate/qualifications), intermediate (school certificate/trade/apprenticeship/diploma) and high (university degree). Cox regression estimated the association (hazard ratios [HRs]) between education and coronary procedure receipt, adjusting for demographic and health-related factors, and testing for linear trend. Private health insurance was investigated as a mediating variable. Results Among 4454 patients with AMI, 68.3% received angiography within 30 days of admission (crude rate: 25.8/person-year) and 48.8% received revascularisation (rate: 11.7/person-year); corresponding figures among 4348 angina patients were 59.7% (rate: 17.4/person-year) and 30.8% (rate: 5.3/person-year). Procedure rates decreased with decreasing levels of education. Comparing low to high education, angiography rates were 29% lower among AMI patients (adjusted HR = 0.71, 95% CI: 0.56–0.90) and 40% lower among angina patients (0.60, 0.47–0.76). Patterns were similar for revascularisation among those with angina (0.78, 0.61–0.99) but not AMI (0.93, 0.69–1.25). After adjustment for private health insurance status, the HRs were attenuated and there was little evidence of an association between education and angiography among those admitted for AMI. Conclusions There is a socioeconomic gradient in coronary procedures with the most disadvantaged patients being less likely to receive angiography following hospital admission for AMI or angina, and revascularisation procedures for angina. Unequal access to private health care contributes to these differences. The extent to which the remaining variation is clinically appropriate, or whether angiography is being underused among people with low socioeconomic position or overused among those with higher socioeconomic position, is unclear.

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Section: Discussionsupporting

confidence: 49%

Section: Introductionmentioning

confidence: 99%

Education-related variation in coronary procedure rates and the contribution of private health care in Australia: a prospective cohort study

Hughes

Paige

Welsh

et al. 2020

Int J Equity Health

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“…This is probably due to better enumeration of cardiac procedures with the inclusion of ACT and MBS data in our study, and improved availability of cardiac catheter laboratories in NSW regional areas during our later study period. Other population-based studies have not found a relationship between geographic remoteness and agestandardised rates of coronary angiography across Australia [20]; however, the use of unlinked data in these studies is likely to have affected results.…”

Section: Discussionmentioning

confidence: 86%

Cardiac procedures in ST-segment-elevation myocardial infarction - the influence of age, geography and Aboriginality

Taylor

Nelson

Gale

et al. 2020

BMC Cardiovasc Disord

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Background: Timely restoration of bloodflow acute ST-segment elevation myocardial infarction (STEMI) reduces myocardial damage and improves prognosis. The objective of this study was describe the association of demographic factors with hospitalisation rates for STEMI and time to angiography, Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Graft (CABG) in New South Wales (NSW) and the Australian Capital Territory (ACT), Australia. Methods: This was an observational cohort study using linked population health data. We used linked records of NSW and the ACT hospitalisations and the Australian Government Medicare Benefits Schedule (MBS) for persons aged 35 and over hospitalised with STEMI in the period 1 July 2010 to 30 June 2014. Survival analysis was used to determine the time between STEMI admission and angiography, PCI and CABG, with a competing risk of death without cardiac procedure. Results: Of 13,117 STEMI hospitalisations, 71% were among males; 55% were 65-plus years; 64% lived in major cities, and 2.6% were Aboriginal people. STEMI hospitalisation occurred at a younger age in males than females. Angiography and PCI rates decreased with age: angiography 69% vs 42% and PCI 60% vs 34% on day 0 for ages 35-44 and 75-plus respectively. Lower angiography and PCI rates and higher CABG rates were observed outside major cities. Aboriginal people with STEMI were younger and more likely to live outside a major city. Angiography, PCI and CABG rates were similar for Aboriginal and non-Aboriginal people of the same age and remoteness area. Conclusions: There is a need to improve access to definitive revascularisation for STEMI among appropriately selected older patients and in regional areas. Aboriginal people with STEMI, as a population, are disproportionately affected by access to definitive revascularisation outside major cities. Improving access to timely definitive revascularisation in regional areas may assist in closing the gap in cardiovascular outcomes between Aboriginal and non-Aboriginal people.

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“…Factoring these variations with language barriers can be challenging, as demonstrated by Shafiq et al[32] with patient and physician discordance in symptom reporting. Such factors could even account for variations in observed management and outcomes[33].…”

Section: Evaluation Of Coronary Artery Disease In Multiethnic Communimentioning

confidence: 99%

Risk stratification for coronary artery disease in multi-ethnic populations: Are there broader considerations for cost efficiency?

Iyngkaran

Chan

Liew

et al. 2019

WJM

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Coronary artery disease (CAD) screening and diagnosis are core cardiac specialty services. From symptoms, autopsy correlations supported reductions in coronary blood flow and dynamic epicardial and microcirculatory coronaries artery disease as etiologies. While angina remains a clinical diagnosis, most cases require correlation with a diagnostic modality. At the onset of the evidence building process much research, now factored into guidelines were conducted among population and demographics that were homogenous and often prior to newer technologies being available. Today we see a more diverse multi-ethnic population whose characteristics and risks may not consistently match the populations from which guideline evidence is derived. While it would seem very unlikely that for the majority, scientific arguments against guidelines would differ, however from a translational perspective, there will be populations who differ and importantly there are cost-efficacy questions, e.g ., the most suitable first-line tests or what parameters equate to an adequate test. This article reviews non-invasive diagnosis of CAD within the context of multi-ethnic patient populations.

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Variation in coronary angiography rates in Australia: correlations with socio‐demographic, health service and disease burden indices

Cited by 20 publications

References 31 publications

Education-related variation in coronary procedure rates and the contribution of private health care in Australia: a prospective cohort study

Education-related variation in coronary procedure rates and the contribution of private health care in Australia: a prospective cohort study

Cardiac procedures in ST-segment-elevation myocardial infarction - the influence of age, geography and Aboriginality

Risk stratification for coronary artery disease in multi-ethnic populations: Are there broader considerations for cost efficiency?

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