Flinders University, Adelaide, SA
St Vincent's Hospital, Melbourne, VIC.
Med J Aust. 2016 Aug 1;205(3):114-20. doi: 10.5694/mja15.01410.
Variation in the provision of coronary angiography is associated with health care inefficiency and inequity. We explored geographic, socio-economic, health service and disease indicators associated with variation in angiography rates across Australia.
Australian census and National Health Survey data were used to determine socio-economic, health workforce and service indicators. Hospital separations and coronary deaths during 2011 were identified in the National Hospital Morbidity and Mortality databases. All 61 Medicare Locals responsible for primary care were included, and age- and sex-standardised rates of acute coronary syndrome (ACS) incidence, coronary angiography, revascularisation and mortality were tested for correlations, and adjusted by Bayesian regression.
There were 3.7-fold and 2.3-fold differences between individual Medicare Locals in the lowest and highest ACS and coronary artery disease mortality rates respectively, whereas angiography rates varied 5.3-fold. ACS and death rates within Medicare Locals were correlated (partial correlation coefficient [CC], 0.52; P < 0.001). There was modest correlation between ACS and angiography rates (CC, 0.31; P = 0.018). The proportion of patients undergoing angiography who proceeded to revascularisation was inversely correlated with the total angiogram rate (CC, -0.71; P < 0.001). Socio-economic disadvantage and remoteness were correlated with disease burden, ACS incidence and mortality, but not with angiography rate. In the adjusted analysis, the strongest association with local angiography rates was with admissions to private hospitals (71 additional angiograms [95% CI, 47-93] for every 1000 admissions).
Variation in rates of coronary angiography, not related to clinical need, occurs across Australia. A greater focus on clinical care standards and better distribution of health services will be required if these variations are to be attenuated.
冠状动脉造影术的提供情况存在差异，与医疗保健效率低下和不公平有关。我们探讨了与澳大利亚各地血管造影率差异相关的地理、社会经济、卫生服务和疾病指标。
使用澳大利亚人口普查和国家健康调查数据确定社会经济、卫生人力和服务指标。在国家医院发病率和死亡率数据库中确定了 2011 年的住院分离和冠状动脉死亡。包括负责初级保健的所有 61 个医疗保险地区，对急性冠状动脉综合征 (ACS) 发病率、冠状动脉造影、血运重建和死亡率的年龄和性别标准化率进行相关性检验，并通过贝叶斯回归进行调整。
个别医疗保险地区的 ACS 和冠心病死亡率最低和最高之间的差异分别为 3.7 倍和 2.3 倍，而血管造影率差异为 5.3 倍。医疗保险地区内的 ACS 和死亡率呈正相关（部分相关系数 [CC]，0.52；P < 0.001）。ACS 和血管造影率之间存在适度相关性（CC，0.31；P = 0.018）。接受血管造影的患者进行血运重建的比例与总血管造影率呈负相关（CC，-0.71；P < 0.001）。社会经济劣势和偏远地区与疾病负担、ACS 发病率和死亡率相关，但与血管造影率无关。在调整分析中，与当地血管造影率最强相关的是私人医院的住院人数（每 1000 名住院患者增加 71 次血管造影 [95%CI，47-93]）。
澳大利亚各地的冠状动脉造影术率存在差异，与临床需求无关。如果要减轻这些差异，就需要更加关注临床护理标准和更好地分配卫生服务。
