Despite Increasing Access to Invasive Cardiac Care, Rural Patients Still at a Disadvantage

In one Canadian province, an increasing number of patients with ACS complicated by cardiogenic shock have access to invasive cardiac care, but those who live farthest away from the catheterization lab are still at an increased risk of dying, a new study shows.

“In Canada, access is not based on a person’s ability to pay,” investigator Jafna L. Cox, MD (Dalhousie University, Halifax, Canada), told TCTMD. “Yet people in the same province, contributing the same to the health system, who are expecting the same healthcare, are having different outcomes just based on where they live.”

In Nova Scotia, invasive cardiac care is only available at one center, the Queen Elizabeth II Health Sciences Centre in Halifax. In a 2006 study, Cox and colleagues reported that only about one-third of patients with ACS complicated by cardiogenic shock had access to invasive cardiac care. Subsequently, the Nova Scotia Guidelines for Acute Coronary Syndromes were published in an attempt to standardize care across the province and improve outcomes.

This study, published in the February 2018 issue of the Canadian Journal of Cardiology, was designed to determine if the guidelines influenced access to care and patient outcomes. Using data from the Cardiovascular Health Nova Scotia registry, the analysis is based on 418 consecutive patients diagnosed with ACS and cardiogenic who were admitted between 2009 and 2013.

Access to invasive cardiac care was available for 73.9% of patients, representing an increase from 58.8% of patients who had access between 1997 and 2002. Among those who had access, which included cardiac catheterization, PCI, or CABG, 111 initially presented to Queen Elizabeth II and 198 were transferred from hospitals without invasive capabilities. Among transferred patients, the median time from first medical contact to catheterization was 29.7 hours.

In-hospital mortality decreased from 60.1% in 1997-2002 to 52.6% in 2009-2013. However, the mortality rate among patients who did not have access to invasive cardiac care was double that of patients who did (83.5% vs. 41.7%; P < 0.0001).

Multivariable adjustment showed that access to cardiac catheterization was an independent predictor of survival. Not surprisingly, patients who lived the farthest from Halifax had the lowest rates of access to invasive care.

Commenting on the study, Timothy D. Henry, MD (Cedars-Sinai Medical Center, Los Angeles, CA), said the increase in access and decrease in mortality for patients with ACS and cardiogenic shock was remarkable.

“It clearly supports that intervention is needed in patients with cardiogenic shock,” Henry said.

Providing More Access

Cox said the researchers could take these results as an opportunity to pat themselves on the back because access has improved or they could acknowledge that despite these increases there is work to be done.

In Canada, there is still a large urban/rural split in many of its provinces, with the majority of the population living in or around urban centers. In a single-payer system, Cox explained, resources must be distributed and the system often puts resources in an urban center to ensure that a large proportion of the population will have access to those services.

“They have to make choices with regard to where to put the healthcare money,” Cox said. “Notwithstanding the fact that there are relatively small distances from Halifax to the extremes of the province, that is sufficient enough of a barrier in terms of getting people in to have interventional cardiac services that have become the norm in other parts of the world.”

Henry agreed that disparities in access between rural and urban areas remain an issue.

“We need to work harder to have access in place, even in the furthest places,” Henry said. “What people should be looking at is state by state, province by province, how are we developing systems of care so that we can cover our entire state or province?”