Hospital discharge rates for suspected acute coronary syndromes between 1990 and 2000: population based analysis
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.38111.650741.F7 (Published 10 June 2004) Cite this as: BMJ 2004;328:1413
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In their recent population based analysis, (1) Murphy and colleagues
reported a marked increase in morbidity rates for suspected acute coronary
syndromes, between 1990 and 2000.
However, we need to eliminate all reasonable doubt that the trend
represents an actual rise and is not simply the result of empowerment of
the population, enabled to recognize symptoms and better enforce their
rights. For example, among “new-fashioned” elderly, this factor may
contribute to the reported rise in morbidity which, in the case in point,
may not be due solely to the ageing population process. To this end it
would be helpful to know the morbidity rate trends in Scotland by urban
and rural areas. Traditionally, utilization rates were in fact lower than
in urban areas for partly cultural reasons. (2,3)
References
1. Murphy NF, MacIntyre K, Capewell S, Stewart S, Pell J, Chalmers J,
et al. Hospital discharge rates for suspected acute coronary syndromes
between 1990 and 2000: population based analysis. BMJ 2004;328: 1413-4.
2. Sheikh K, Bullock C. Urban-rural differences in the quality of care for
medicare patients with acute myocardial infarction. Arch Intern Med
2001;161(5): 737-43.
3. Mariotto A. Urban-rural differences in the quality of care for Medicare
patients with acute myocardial infarction. Arch Intern Med 2001;161: 2386-
7.
Competing interests:
None declared
Competing interests: No competing interests
I am writing in response to the recent article by Dr Murphy and
colleagues (1). The authors have shown some interesting trends in hospital
discharge rates from 1990 to 2000 by age; a decline in discharge rates for
acute myocardial infarction and rising trends for chest pain and angina. I
agree with the authors that these trends press the need for expansion of
coronary services. The rise in chest pain rates needs careful evaluation
as this might represent a trend in queue jumping in the overcrowded
hospitals. A recent study in 2 urban cardiac referral centers in Canada
has reported a 5% false negative rate for emergency room clinical
assessment regarding acute coronary syndrome (2). Therefore, in view of
the seriousness of this symptom and high associated costs of thorough
cardiac evaluation, there is a need for improvement in the clinical
assessment tools.
1. Murphy N, MacIntyre K, Capewell S, Stewart S, Pell J, Chalmers J,
et al. Hospital discharge rates for suspected acute coronary syndromes
between 1990 and 2000: population based analysis. BMJ 2004;328:1413-1414.
2. Christenson J, Innes G, McKnight D, Boychuk B, Grafstein E,
Thompson C, et al. Safety and efficiency of emergency department
assessment of chest discomfort. CMAJ 2004; 170: 1803-1807
Competing interests:
None declared
Competing interests: No competing interests
Hospital discharge rates for acute coronary heart disease 1997-2002 in a health board region in Ireland: evidence of a shift in the pattern of presentation of the disease to acute hospitals.
Dear Editor,
In their recent population based analysis, Murphy and colleagues1
reported that although hospital discharge rates for acute myocardial
infarction were falling, there were increases in the hospital discharge
rates for acute coronary syndromes, chest pain and angina. A recent
population based analysis on hospital discharges from acute hospitals for
years 1997-2002, among residents from a health board region (population c.
350,000) in Ireland, showed that similarly to the authors’ findings, the
age standardised hospital discharge rate for acute myocardial infarction
(ICD-9 410) decreased by 26.9% from a rate of 200.1 per 100,000 population
in 1996 to 146.2 per 100,000 population in 2002 (Figure 1).
However, contrary to the authors’ findings, this study showed that
the age standardised hospital discharge rate for acute coronary syndromes
(ICD-9, 411), decreased by 50.2% from 155.9 per 100,000 population in 1997
to 77.6 per 100,000 population in 2002. The age standardised hospital
discharge rate for angina (ICD-9, 413) also decreased by 92.8% from 37.6
per 100,000 population in 1997 to 2.7 per 100,000 population in 2002. The
age standardised hospital discharge rate for chest pain (ICD-9, 786.5)
also decreased by 33% from 138.6 per 100,000 population in 1997 to 92.9
per 100,000 population in 2002 (Figure 1). Similarly to the authors, we
analysed discharges coded only in the principal position and in the case
of acute myocardial infarctions, we limited the analysis to “initial
episode of care” events. We also limited the analysis to emergency
admissions only (excluding routine elective admissions). We calculated
rates using annual census estimates for 1997-2002 and we used the 2002
census data as our standard population in the calculation of the age
standardised rates. We believe, therefore that the study methodology is
comparable even though our study is on more recent data (1997-2002) and is
on a smaller population.
Our findings shows that there has been a decrease in the hospital
discharge rate for all forms of acute coronary heart disease (for eg,
acute myocardial infarction, acute coronary syndromes, angina and chest
pain). We therefore believe that this study is showing a real decrease in
the number of patients requiring hospital admission with an acute form of
coronary heart disease and not due to re-classification or re-coding. This
decrease in the acute forms of coronary heart disease is possibly due to
improved lifestyle factors (for eg, current smoking rates in Ireland
reduced from 31% 2 in 1998 to 27% in 2002 3 ) improved primary care
provision (for eg, the use of evidence based medications such as statins
has increased four fold in Ireland4 after publication of the Scandinavian
Simvastatin Survival Study (4S) in 1994). These positive changes are
leading to a reduction in admissions to acute hospitals for acute coronary
heart disease in our population. Contrary to the study by Murphy et al1,
we believe the resource implications of our findings suggest that there
may be less need for resources in acute coronary services and perhaps a
greater need for resources to treat chronic coronary conditions in the
future.
REFERENCES:
1. Murphy NF, MacIntyre K, Capewell S, Stewart J, Pell J, Chalmers
J, Redpath A, Frame S, Boyd J, McMurray JJ. (2004). Hospital discharge
rates for suspected acute coronary syndromes between 1990-2000: population
based analysis. BMJ, 328: 1413-1414.
2. Centre for Health Promotion Studies. The National Health and
Lifestyle Surveys (SLÁN and HBSC). Galway: Centre for Health Promotion
Studies, National University of Ireland Galway, 1999.
3. Centre for Health Promotion Studies. The National Health and
Lifestyle Surveys (SLÁN and HBSC). Galway: Centre for Health Promotion
Studies, National University of Ireland Galway, 2003.
4. Feely J, McGettigan P, Kelly A. (2000). Growth in use of statins
after trials is not targeted to most appropriate patients. Clin.
Pharmacol. Thera. Apr; 67(4): 438-441.
Anne O’Farrell, Research Officer, Department of Public Health, NEHB,
Navan Co. Meath, Ireland. Email: ann.o’farrell@nehb.ie
Declan Bedford, Specialist in Public Health, Departmen of Public Health,
NEHB, Navan Co. Meath, Ireland.
Fenton Howell, Director in Public Health, Department of Public Health,
NEHB, Navan, Co. Meath Ireland.
Competing interests:
None declared
Competing interests: No competing interests