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Waiting times, revascularization modality, and outcomes after acute myocardial infarction at hospitals with and without on-site revascularization facilities in Canada

Alter DA, Tu JV, Austin PC, Naylor CD. J Am Coll Cardiol. 2003; 42(3):410-9.

Objectives — This study was designed to determine whether admission to a Canadian hospital with on-site revascularization (invasive hospital) affected revascularization choice, timing, and outcome compared with community (non-invasive) hospitals.

Background — Health care systems in Canada are characterized by relative restraint in diffusion of tertiary cardiovascular services, with capacity for revascularization procedures concentrated in large regional referral centers.

Methods — We used linked administrative data and a clinical registry to follow-up 15,166 Ontario patients who underwent revascularization within the year after their index acute myocardial infarction (MI). Outcomes included recurrent urgent cardiac hospitalization, hospital bed-days, and death within the same year after the index admission. We adjusted for age, gender, socioeconomic status, illness severity, attending physician specialty, and academic hospital affiliation.

Results — After adjusting for baseline factors, patients admitted to invasive hospitals were more likely to receive angioplasty than bypass surgery (adjusted odds ratio: 1.85; 95% confidence interval: 1.68 to 2.04, p < 0.001). The converse pattern was seen for patients admitted to community hospitals. Median revascularization waiting times were significantly shorter at invasive hospitals (12 vs. 48 days, p < 0.001). Patients admitted to invasive hospitals had fewer cardiac re-admissions (41.5 vs. 68.9 events per 100 patients, p < 0.001) before their first revascularization and consumed fewer hospital bed-days (379 vs. 517 per 100 patients, p < 0.001). There were no differences in outcomes beyond revascularization.

Conclusions — Outcome advantages associated with timely post-MI revascularization highlight the importance of organizing revascularization referral networks and facilitating access to revascularization for patients with acute coronary syndromes admitted to community hospitals in Canada.

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Keywords: Coronary disease/Myocardial infarction Health care services Hospitals