Are district general hospital patients with unstable angina at a disadvantage?

Objective: To determine whether patients with non-ST elevation acute coronary syndromes requiring coronary angiography and revascularisation have inferior access to these services if admitted to district general hospitals (DGHs) compared with similar patients admitted to a base hospital containing a tertiary cardiac centre. Design: Prospective, consecutive monitoring of all patients with acute coronary syndromes accepted by the tertiary cardiac centre for angiography and revascularisation over a three month period (1 April to 30 June 2002). Participants: All patients accepted for angiography from DGHs and from within the base hospital with a diagnosis of acute coronary syndromes. Setting: Tertiary cardiac facility (Manchester Heart Centre at Manchester Royal Infirmary (MRI)). Main outcome measure: Time waited from referral to angiography and revascularisation. Results: A total of 184 patients with a diagnosis of non-ST elevation acute coronary syndromes underwent angiography with a view to revascularisation. Of these, 89 (48%) were admitted initially to MRI and 95 (52%) were admitted to a feeder DGH. DGH patients waited significantly longer from admission to angiography than MRI patients (median 13 days (25th-75th percentiles 7-19) v 5 days (3-8) respectively; p<0.0005). DGH patients therefore also waited longer from admission to revascularisation (15 days (6-20) v 6 days (3-9) respectively). Once transferred into the Manchester Heart Centre, DGH patients underwent angiography within a median of 1 day (1-2). More DGH patients than those from MRI underwent both coronary artery bypass grafting (21 (22%) v 8 (9%) respectively; p=0.015) and percutaneous coronary intervention (44 (46%) v 32 (36%) respectively; p=NS). Conclusion: Patients admitted to feeder DGHs with non-ST elevation acute coronary syndromes wait significantly longer for access to invasive coronary assessment and revascularisation than similar patients admitted in the hospital that incorporates the tertiary cardiac centre. This inequity of access is determined by postcode rather than clinical priority.