Socioeconomic disparities in outcomes after acute myocardial infarction

The UK National Health Service: delivering equitable treatment across the spectrum of coronary disease

BACKGROUND

Social gradients in cardiovascular mortality across the United Kingdom may reflect differences in incidence, disease severity, or treatment. It is unknown whether a universal healthcare system delivers equitable lifesaving medical therapy for coronary heart disease. We therefore examined secular trends in the use of key medical therapies stratified by socioeconomic circumstances across a broad spectrum of coronary disease presentations, including acute coronary syndromes, secondary prevention, and clinical angina.

METHODS AND RESULTS

This was a cross-sectional observational analysis of nationally representative primary and secondary care data from the United Kingdom. Data on treatments for all myocardial infarction patients in 2003 and 2007 were derived from the Myocardial Ischemia National Audit Project (n=51 755). Data on treatments for patients with chronic angina (n=33 211) or requiring secondary prevention (n=32 976) in 1999 and 2007 were extracted from the General Practice Research Database. Socioeconomic circumstances were defined using a weighted composite of 7 area-level deprivation domains. Treatment estimates were age-standardized. Use of all therapies increased in all patient groups, both men and women. Improvements were most marked in primary care, where use of β-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for secondary prevention and treatment of angina doubled, from ≈30% to >60%. Small age gradients persisted for some therapies. No consistent socioeconomic gradients or sex differences were observed for myocardial infarction and postrevascularization (hard diagnoses). However, some sex inequality was apparent in the treatment of younger women with angina.

CONCLUSIONS

Cardiovascular treatment is generally equitable and independent of socioeconomic circumstances. Future strategies should aim to further increase overall treatment levels and to eradicate remaining age and sex inequalities.

Long-term exposure to air pollution is associated with survival following acute coronary syndrome

Aims

The aim of this study was to determine (i) whether long-term exposure to air pollution was associated with all-cause mortality using the Myocardial Ischaemia National Audit Project (MINAP) data for England and Wales, and (ii) the extent to which exposure to air pollution contributed to socioeconomic inequalities in prognosis.

Methods and results

Records of patients admitted to hospital with acute coronary syndrome (ACS) in MINAP collected under the National Institute for Cardiovascular Outcomes Research were linked to modelled annual average air pollution concentrations for 2004–10. Hazard ratios for mortality starting 28 days after admission were estimated using Cox proportional hazards models. Among the 154 204 patients included in the cohort, the average follow-up was 3.7 years and there were 39 863 deaths. Mortality rates were higher for individuals exposed to higher levels of particles with a diameter of ≤2.5 µm (PM_2.5; PM, particulate matter): the fully adjusted hazard ratio for a 10 µg/m³ increase in PM_2.5 was 1.20 (95% CI 1.04–1.38). No associations were observed for larger particles or oxides of nitrogen. Air pollution explained socioeconomic inequalities in survival to only a small extent.

Conclusion

Mortality from all causes was higher among individuals with greater exposure to PM_2.5 in survivors of hospital admission for ACS in England and Wales. Despite higher exposure to PM_2.5 among those from more deprived areas, such exposure was a minor contribution to the socioeconomic inequalities in prognosis following ACS. Our findings add to the evidence of mortality associated with long-term exposure to fine particles.

Appraising hospital performance by using the JCHAO/CMS quality measures in Southern Italy

Objectives

The main objective of the present study was to estimate the uptake to quality indicators that reflect the current evidence-based recommendations and guidelines.

Methods

A retrospective review of medical records of patients admitted to two hospitals in the South of Italy was conducted. For the purposes of the analysis, a sets of quality indicators has been used from the Joint Commission on Accreditation of Hospital Organizations and Centers for Medicare & Medicaid Services. Four areas of care were selected: acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), and surgical care improvement project (SCIP). Frequency or median was calculated, as appropriate, for each indicator. A composite score was calculated to estimate the overall performance for each area of care.

Results

A total of 1772 medical records were reviewed. The adherence rates showed a wide-ranging variability among the selected indicators. The use of aspirin and angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for AMI, the use of ACEI or ARB for HF, the use of appropriate thromboembolism prophylaxis and appropriate hair removal for surgical patients almost approached optimal adherence. At the other extreme, rates regarding adherence to smoking-cessation counseling in AMI and HF patients, discharge instructions in HF patients, and influenza and pneumococcal vaccination in pneumonia patients were noticeably intangible. Overall, the recommended processes of care among eligible patients were provided in 70% for AMI, in 32.4% for HF, in 46.4% for PN, and in 46% for SCIP.

Conclusions

The results show that there is still substantial work that lies ahead on the way to improve the uptake to evidence-based processes of care. Improvement initiatives should be focused more on domains of healthcare than on specific conditions, especially on the area of preventive care.

Jordanian acute coronary syndrome patients' learning needs: Implications for cardiac rehabilitation and secondary prevention programs

The identification of patients' learning needs is an essential step for nurses in order to facilitate the recovery of acute coronary syndrome survivors. This study aimed to identify and prioritize the actual learning needs of these patients and to explore the differences in learning needs on the basis of sociodemographic and clinical variables. Descriptive comparative design was used, and patients' learning needs data were collected through the Patient Learning Needs Scale. The results showed that patients need a high amount of information after this syndrome. The 10 most needed educational topics belonged to the medications and treatment and activities of daily living categories. Older patients and those from lower socioeconomic backgrounds requested less information than others did. In conclusion, topics perceived by patients as important and sociodemographic variables should be considered in preparing and providing cardiac rehabilitation and secondary prevention programs. Furthermore, these programs should be redesigned considering patients' actual learning needs rather than the expected needs, and they should incorporate medications, treatment and activities of daily living, complications and symptoms, illness-related concerns, and support in the community.

Cardiovascular disease risk among the poor and homeless - what we know so far

Homelessness [and poverty] is rapidly escalating across North America and is associated with dire implications for public health and our health care systems. Both are compelling states of existence affecting all ages, ethnicities and both genders. Homelessness frequently evolves through a complex interaction of factors that are both internal and external to the individual themselves. Once homeless, equitable access to both preventative and remedial health care is lacking and is associated with a higher than average burden of cardiovascular disease [CVD] risk factors, morbidity and mortality and is accompanied by disproportionately high health care costs. The emergence of limited, small scale programs aimed at addressing the unique health and social needs of the homeless is encouraging. However, there has been inadequate commitment at the National, State or Provincial and local levels to implement policies and dedicate funding and resources to the expansion of such “individual level” interventions into comprehensive programs that deliver sustainable, integrated prevention and services, especially with regard to CVD. The long-term solutions that address the links between homelessness and CVD lie in preventing homelessness and reversing the trends in our health care system that create disparities for lower socioeconomic status [SES] and homeless individuals.

Factors associated with life satisfaction in a 6-year follow-up of depressive out-patients

BACKGROUND

The major goal of mental health services is to improve mental health and thus also life satisfaction. However, studies assessing factors associated with life satisfaction during recovery from depression are lacking.

METHODS

A 6-year natural follow-up of 121 depressive out-patients was carried out with questionnaires at baseline, 1/2, 1, 2 and 6 years completed. A structured diagnostic interview was conducted. Throughout the follow-up, clinical status was assessed with several psychometric scales for life satisfaction (LS), depression (BDI, HDRS), hopelessness (HS), functional ability (GAF, SOFAS) and general psychopathology (SCL).

RESULTS

Men and women did not differ in their improvement in life satisfaction. Altogether, 77% of the patients at baseline and 22% at the end were dissatisfied. Life satisfaction on 6-year follow-up was associated with baseline lower interpersonal sensitivity (SCL subscale) and concurrently being loved by someone as well as with baseline and concurrent good self-rated health and wealth. The satisfied were better off in terms of all clinical variables, regardless of the measurement time. Depressive symptoms and hopelessness were the strongest concurrent clinical correlates of LS after 6 years.

CONCLUSIONS

Mental health was strongly related to life satisfaction throughout the follow-up, while most of the non-clinical factors were not. Alleviating depression and interpersonal sensitivity and supporting social networks should be focused on in psychiatric treatment in order to improve life satisfaction among depressive patients.

Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH): design and rationale of a prospective multicenter registry

BACKGROUND

Black patients with myocardial infarction (MI) have worse outcomes than white patients, including higher mortality rates, more angina, and worse quality of life. The Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study was designed to examine whether racial differences in socioeconomic, clinical, genetic, metabolic, biomarker, or treatment characteristics mediate observed disparities in outcomes.

METHODS AND RESULTS

Between April 11, 2005, and December 31, 2008, 31 567 patients with MI were prospectively screened; 6152 had an eligible MI, and 4340 (71%) were enrolled from 24 US centers. Consenting patients had detailed chart abstractions of their medical history and processes of inpatient care, supplemented with a detailed baseline interview. Detailed genetic and metabolic data were obtained at hospital discharge in 2979 (69%) and 3013 patients (69%), respectively. In a subset of patients, blood and urine samples were obtained at 1 month (obtained in 27% of survivors) and blood samples at 6 months (obtained in 19% of survivors). Centralized follow-up interviews sought to quantify patients' postdischarge care and outcomes, with a focus on their health status (symptoms, function, and quality of life). At 1, 6, and 12 months, 23%, 27%, and 24%, respectively, were lost to follow-up. Vital status was available for 99% of patients at 12 months.

CONCLUSIONS

TRIUMPH is a novel MI registry with detailed information on patients' sociodemographic, clinical, treatment, health status, metabolic, and genetic characteristics. The wealth of patient data collected in TRIUMPH will provide unique opportunities to examine factors that may mediate racial differences in mortality and health status after MI and the complex interactions between genetic and environmental determinants of post-MI outcomes.

Predictors of nonadherence to national hospital quality measures for heart failure and pneumonia

BACKGROUND

Understanding factors associated with process measure nonadherence may improve both patient care and future measure design.

METHODS

We analyzed 3401 patients with heart failure and 2186 patients with pneumonia who were eligible for at least 1 National Hospital Quality Measure at an urban tertiary medical center from July 1, 2004, to June 30, 2008. We investigated the association of socioeconomic, demographic, clinical, and care delivery factors with process measure nonadherence, using multivariable analysis.

RESULTS

Demographic and socioeconomic variables were unrelated to heart failure measure adherence. Nonadherence with angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use was more common in patients with renal failure (odds ratio [OR] 2.56; 95% confidence interval [CI], 1.46-4.49), and patients admitted to noncardiac units more often failed the heart failure all-or-none measure (OR 2.22; 95% CI, 1.79-2.75). Patients with pneumonia who were admitted via the emergency department were less likely to fail antibiotic timing (OR 0.41; 95% CI, 0.27-0.63), whereas those with a history of methicillin-resistant Staphylococcus aureus (OR 2.63; 95% CI, 1.31-5.28) or requiring intensive care unit admission (OR 11.4; 95% CI, 6.3-20.8) were more likely to fail the antibiotic selection measure.

CONCLUSION

Demographic and socioeconomic factors were generally unrelated to process measure nonadherence, demonstrating that excellent inpatient care can be delivered even to vulnerable populations. Clinical predictors suggest opportunities for improving both medical record documentation of appropriate exclusions and future measure specifications, especially for complex patients. Care delivery factors substantially affect process adherence.

Prevalence and correlates of smoking cessation pharmacotherapy in hospitalized smokers with acute myocardial infarction

BACKGROUND

Although current performance measures recommend smoking cessation counseling at the time of acute myocardial infarction (AMI), the American College of Cardiology/American Heart Association guidelines recommend pharmacotherapy as well. The aim of this study was to describe the prevalence and correlates of smoking cessation pharmacotherapy in hospitalized patients with AMI.

METHODS

In the 24-center TRIUMPH registry, 4,340 AMI patients underwent detailed interviews; and 1,631 reported smoking within 30 days of admission. Prescription of first-line smoking cessation medications at discharge was assessed by medical record review. All patient-related factors associated with smoking cessation treatment, based on literature review, were included in hierarchical modified log Poisson models.

RESULTS

Only 14% (222/1,631) of AMI patients who smoked were prescribed smoking cessation medication at discharge. After multivariable adjustment for patient characteristics, there was significant variation across sites (range 0%-28%, median rate ratio 1.41, 95% CI 1.23-2.67). Independent factors associated with smoking cessation pharmacotherapy included older age (rate ratio 0.81 per 10-year increment, 95% CI 0.71-0.93), high school graduation (rate ratio 1.37, 95% CI 1.10-1.66), heavy cigarette usage (>20/d) (rate ratio 3.08, 95% CI 2.20-4.12), in-hospital revascularization (rate ratio 1.41, 95% CI 1.0-1.94), and instructions on smoking cessation (rate ratio 2.37, 95% CI 1.40-4.01).

CONCLUSIONS

Smokers surviving an AMI are infrequently prescribed guideline-recommended smoking cessation treatments, and there is considerable variation across hospitals. Older, less educated, and lighter smokers are less likely to receive aggressive smoking cessation treatment. Novel strategies to augment current practice are needed.

Examining the contextual effects of neighborhood on out-of-hospital cardiac arrest and the provision of bystander cardiopulmonary resuscitation

OBJECTIVE

To understand the association between neighborhood and individual characteristics in determining whether or not bystanders perform cardiopulmonary resuscitation (CPR) in cases of out-of-hospital cardiac arrest (OHCA).

METHODS

Between October 1, 2005 to November 30, 2008, 1108 OHCA cases from Fulton County (Atlanta), GA, were eligible for bystander CPR. We conducted multi-level non-linear regression analysis and derived Empirical Bayes estimates for bystander CPR by census tract.

RESULTS

279 (25%) cardiac arrest victims received bystander CPR. Provision of bystander CPR was significantly more common in witnessed events (odds ratio [OR] 1.64; 95% confidence interval [CI] 1.21-2.22, p < 0.001) and those that occurred in public locations (OR 1.67; 95% CI 1.16-2.40, p < 0.001). Other individual-level characteristics were not significantly associated with bystander CPR. Cardiac arrests in the census tracts that rank in the highest income quintile, as compared to the lowest income quintile were much more likely (OR 4.98; 95% CI 1.65-15.04) to receive bystander CPR.

CONCLUSION

Cardiac arrest victims in the highest income census tracts were much more likely to receive bystander CPR than in the lowest income census tracts, even after controlling for individual and arrest characteristics. Low-income neighborhoods may be particularly appropriate targets for community-based CPR training and awareness efforts.

Best practice for prevention and treatment of cardiovascular disease through an equity lens: a review

BACKGROUND

Despite declining rates of cardiovascular disease (CVD) mortality in developed countries, lower socioeconomic groups continue to experience a greater burden of the disease. There are now many evidence-based treatments and prevention strategies for the management of CVD and it is essential that their impact on the more disadvantaged group is understood if socioeconomic inequalities in CVD are to be reduced.

AIMS

To determine whether key interventions for CVD prevention and treatment are effective among lower socioeconomic groups, to describe barriers to their effectiveness and the potential or actual impact of these interventions on the socioeconomic gradient in CVD.

METHODS

Interventions were selected from four stages of the CVD continuum. These included smoking reduction strategies, absolute risk assessment, cardiac rehabilitation, secondary prevention medications, and heart failure self-management programmes. Electronic searches were conducted using terms for each intervention combined with terms for socioeconomic status (SES).

RESULTS

Only limited evidence was found for the effectiveness of the selected interventions among lower SES groups and there was little exploration of socioeconomic-related barriers to their uptake. Some broad themes and key messages were identified. In the majority of findings examined, it was clear that the underlying material, social and environmental factors associated with disadvantage are a significant barrier to the effectiveness of interventions.

CONCLUSION

Opportunities to reduce socioeconomic inequalities occur at all stages of the CVD continuum. Despite this, current treatment and prevention strategies may be contributing to the widening socioeconomic-CVD gradient. Further research into the impact of best-practice interventions for CVD upon lower SES groups is required.

Health span or life span: the role of patient-reported outcomes in informing health policy

OBJECTIVES

Population ageing and the increasing burden of chronic conditions challenge traditional metrics of assessing the efficacy of health care interventions and as a consequence policy and planning. Using chronic heart failure (CHF) as an exemplar this manuscript seeks to describe the importance of patient-reported outcomes to inform policy decisions.

METHODS

The method of an integrative review has been used to identify patient-reported outcomes (PROs) in assessing CHF outcomes. Using the Innovative Care for Chronic Conditions the case for developing a metric to incorporate PROs in policy planning, implementation and evaluation is made.

RESULTS

In spite of the increasing use of PROs in assessing CHF outcomes, their incorporation in the policy domain is limited.

CONCLUSIONS

Effective policy and planning is of health care services is dependent on the impact on the individual and their families. Epidemiological transitions and evolving treatment paradigms challenge traditional metrics of morbidity and mortality underscoring the importance of assessing PROs.

Neighborhood socioeconomic context and long-term survival after myocardial infarction

BACKGROUND

Neighborhood of residence has been suggested to affect cardiovascular risk above and beyond personal socioeconomic status (SES). However, such data are currently lacking for patients with myocardial infarction (MI). We examined all-cause and cardiac mortality according to neighborhood SES in a cohort of MI patients.

METHODS AND RESULTS

Consecutive patients < or =65 years of age discharged from 8 hospitals in central Israel after incident MI in 1992 to 1993 were followed up through 2005. Individual data were obtained at study entry, including education, income, and employment. Neighborhood SES was estimated through a composite census-derived index developed by the Israel Central Bureau of Statistics. During follow-up, 326 deaths occurred in 1179 patients. Patients residing in disadvantaged neighborhoods had higher mortality rates, with 13-year survival estimates of 61%, 74%, and 82% in increasing tertiles (P(trend)<0.001). After adjustment for sociodemographic variables, traditional risk factors, MI severity indexes, and individual SES measures, the hazard ratios for death associated with neighborhood SES were 1.47 (95% confidence interval, 1.05 to 2.06) in the lower and 1.19 (95% confidence interval, 0.86 to 1.63) in the middle tertiles compared with the upper tertile (P(trend)=0.02). The respective hazard ratios were even stronger for cardiac death (1.63; 95% confidence interval, 1.09 to 2.25; and 1.41; 95% confidence interval, 0.96 to 2.07). In the final models, neighborhood context and several individual SES measures were concurrently associated with all-cause and cardiac mortality.

CONCLUSIONS

Neighborhood SES is strongly associated with long-term survival after MI. The association is partly, but not entirely, attributable to individual SES and clinical characteristics. These data support a multidimensional relationship between SES and MI outcome.

Impact of education, income and chronic disease risk factors on mortality of adults: does 'a pauper-rich paradox' exist in Latin American societies?

OBJECTIVES

To test the hypothesis that an inverse association exists between socio-economic position and all-cause mortality in a developing country in Latin America.

STUDY DESIGN

Prospective cohort study carried out in Chile using data from a simple random sample of 920 apparently healthy subjects (weighted population 11,600 aged 30-89 years) followed for 8 years.

METHODS

Education level (0-8 years, 9-12 years and > or = 13 years) and income quartiles were established at the outset of the study, along with behavioural and biological risk factors for chronic diseases: smoking, alcohol use, obesity, diabetes, hypertension, lipids and family history of death by cardiovascular disease. Relative risks of all-cause mortality were estimated using age-adjusted Cox regression models.

RESULTS

During the follow-up period, 46 deaths were observed. Adjusting for age, gender, and behavioural and biological risk factors, the mortality risk for increasing categories of education after controlling for income was 1.0, 0.76 and 0.33 (P for trend<0.01). In contrast, the relative risk for increasing levels of income after controlling for education was 1.0, 0.98, 1.33 and 1.17 (P for trend=0.07).

CONCLUSION

While education level had a protective effect on mortality risk of Chilean adults, income had a slightly unfavourable effect on survival. This finding is described as suggestive of a 'pauper-rich paradox', since the higher income quantiles in this study correspond with the lower income levels in most developed countries. Nevertheless, due to the small number of deaths, additional research is required to assess the validity of these findings.

Impact of peripheral arterial disease on health status: a comparison with chronic heart failure

OBJECTIVE

To further document the experienced burden in patients with peripheral arterial disease (PAD), we compared the health status of patients with PAD and chronic heart failure (CHF). As a secondary aim, we studied clinical and socio-demographic correlates of health status in both conditions.

METHODS

We conducted a cross-sectional observational study in four outpatient clinics in the Southern part of The Netherlands, with subjects consisting of ambulatory (346 PAD and 188 CHF) patients. All patients completed the Short-Form 12 to assess their physical and mental health status. Information about socio-demographic, clinical risk factors, and disease severity indices was obtained from patients' medical records. Propensity methodology was applied to enhance comparability between both medical conditions.

RESULTS

Type of medical condition explained differences in health status (F = 33.1, P < .0001, Effect Size = 0.27). Impaired physical health status was more often reported in PAD patients (48.4%) compared with CHF patients (17.4%, Odds Ratio [OR] = 4.4, 95% Confidence Interval [CI] 2.3-8.8, P < .0001); impaired mental health status was more noted in CHF patients (43.5% vs. 22.0%, OR = 1.7, 95% CI 1.2-2.6, P = .002). In PAD, younger age (P = .002), low education (P = .02), cardiac history (P = .02), diabetes mellitus (P = .03), and a lower ankle brachial index (P = .003) were associated with worse physical health status; younger age (P = .01) and living without partner (P = .01) were associated with lower mental health status scores. In CHF, patients with comorbid diabetes mellitus (P < .001) and females (P = .001) reported worse physical health, whereas no clinical or socio-demographics were associated with mental health status.

CONCLUSIONS

By contrasting PAD patients' health status with another chronic disabling condition, the impact of PAD on patients' physical health status became evident; whereas mental health status was more affected in CHF, patients with PAD reported a greater physical burden as compared with CHF patients. PAD patients who were younger, lower-educated, without a partner or had a cardiac history especially reported a higher disease burden. Clinicians need to be aware of these differences in order to develop tailor-made disease management programs for different groups of cardiovascular patients.

Impact of the community's socioeconomic status on characteristics and outcomes of patients undergoing percutaneous coronary intervention

BACKGROUND

Individual socioeconomic factors have been associated with adverse cardiovascular outcomes. It is however unclear how the socioeconomic status of a community influences the characteristics and outcome of patients treated with percutaneous coronary intervention (PCI).

METHODS

The Israel Central Bureau of Statistics assigns a socioeconomic index (SI) to communities based on demographic, economic and educational parameters. We determined the SI for 1397 consecutive patients who underwent PCI between 4/2004 and 10/2006; patients were divided into low, intermediate or high SI. Baseline and procedural characteristics, adherence to guidelines - recommended medications and major adverse cardiac events (MACE) were compared between groups. Multivariate analysis was used to adjust for baseline and procedural variables.

RESULTS

Patients from low SI communities were younger (59±11, 64±12, 65±11 years for low, middle and high SI groups respectively, P<0.01) and had higher rates of diabetes (P<0.04) and of smoking (P<0.01). A low SI was associated with a lower rate of drug eluting stent implantation (P<0.01), lower adherence to aspirin and clopidogrel therapy, a higher rate of repeat revascularization (P=0.04) and a higher rate of recurrent myocardial infarction. A lower SI was an independent predictor of MACE (H.R 1.52 - 95% CI 1.03-2.25).

CONCLUSION

Among patients undergoing PCI, a low community socioeconomic level is associated with a higher prevalence of cardiovascular risk factors, lower adherence to guidelines recommended therapy and is an independent predictor of MACE during follow up.

Socioeconomic status and the course of quality of life in older patients with coronary heart disease

Background

Previous research suggests that socioeconomic status (SES) might be related to the course of quality of life (QoL) in coronary heart disease (CHD) patients. The authors sought to determine whether there are differences in the course of QoL before and after the incidence of CHD among older persons of differing SES.

Method

Two hundred two CHD patients were followed up longitudinally using a community-based survey. Data on patients’ QoL were collected before the diagnosis and at three follow-up assessments.

Results

High SES patients reported better outcomes at the premorbid assessment with fewer depressive feelings and better physical functioning. In physical functioning, similar results were repeated 6 and 12 months after the diagnosis. Additionally, high SES patients showed better role and social functioning 1 year after CHD. A multivariate analysis of variance revealed differential longitudinal pathways in relation to SES in role, social, and physical functioning.

Conclusion

CHD modulates premorbid differences in depressive feelings. Conversely, high SES leads to better outcomes in all functional domains in the long-term after diagnosis. Postmorbid differences in physical functioning are not directly related to CHD, but rather the reestablishment of a premorbid situation. In contrast, socioeconomic inequalities in social and role functioning are a direct response to the impact of the disease.

From hospital to home: assessing the transitional care needs of vulnerable seniors

PURPOSE

This qualitative study assessed the needs of patients and caregivers during the transition from hospital to home. We specifically identified unmet needs of ethnic minorities, recent immigrants, and seniors with limited English proficiency (LEP). Findings are translated into recommendations for improving services to these groups during health care transitions.

DESIGN AND METHODS

This needs assessment included extensive analysis of qualitative data collected from 20 language-, culture-, and ethnic-specific focus groups with caregivers who recently assisted a senior after a hospital discharge. Findings from these focus groups were supplemented by 5 in-depth, longitudinal case studies of recently hospitalized seniors and their caregivers.

RESULTS

Inadequate information and training at discharge were themes that spanned all groups, despite ethnicity or language. Additional unmet needs were identified for ethnic minorities, those with LEP, and recent immigrants, including lower levels of social support than might be expected, lack of linguistically appropriate information and services, and cultural and financial barriers to using long-term care services.

IMPLICATIONS

As ethnic diversity increases among older Americans, it will become increasingly important to design health care services to meet the needs of diverse groups. Recommendations include assessments of informal care, bilingual information and services, partnerships with community agencies providing culturally competent services, and expansion of home- and community-based services to near-poor seniors.

Factors associated with racial differences in myocardial infarction outcomes

BACKGROUND

Little information is available about factors associated with racial differences across a broad spectrum of post-myocardial infarction outcomes, including patients' symptoms and quality of life.

OBJECTIVE

To determine racial differences in mortality, rehospitalization, angina, and quality of life after myocardial infarction and identify the factors associated with these differences.

DESIGN

Prospective cohort study.

SETTING

10 hospitals in the United States.

PATIENTS

1849 patients who had myocardial infarction, 28% of whom were black.

MEASUREMENTS

Demographic, economic, clinical, psychosocial, and treatment characteristics and outcomes were prospectively collected. Outcomes included time to 2-year all-cause mortality, 1-year rehospitalization, and Seattle Angina Questionnaire-assessed angina and quality of life.

RESULTS

Black patients had higher unadjusted mortality (19.9% vs. 9.3%; P < 0.001) and rehospitalization rates (45.4% vs. 40.4%; P = 0.130), more angina (28.0% vs. 17.8%; P < 0.001), and worse mean quality of life (80.6 [SD, 22.5] vs. 85.9 [SD, 17.2]; P < 0.001). After adjustment for patient characteristics, black patients trended toward greater mortality (hazard ratio, 1.29 [95% CI, 0.92 to 1.81]; P = 0.142), fewer rehospitalizations (hazard ratio, 0.82 [CI, 0.66 to 1.02]; P = 0.071), and higher likelihood of angina at 1 year (odds ratio, 1.41 [CI, 1.03 to 1.94]; P = 0.032) but similar quality of life (mean difference, -0.6 [CI, -3.4 to 2.2]). Adjustment for site of care further attenuated mortality differences (hazard ratio, 1.04 [CI, 0.71 to 1.52]; P = 0.84). Adjustment for treatments had minimal effect on any association.

LIMITATION

Residual confounding and missing data may have introduced bias.

CONCLUSION

Although black patients with myocardial infarction have worse outcomes than white patients, these differences did not persist after adjustment for patient factors and site of care. Further adjustment for treatments received minimally influenced observed differences. Strategies that focus on improving baseline cardiac risk and hospital factors may do more than treatment-focused strategies to attenuate racial differences in myocardial infarction outcomes.

FUNDING

The National Heart, Lung, and Blood Institute Specialized Center of Clinically Oriented Research in Cardiac Dysfunction and Disease, CV Therapeutics, and Cardiovascular Outcomes.

Usefulness of left ventricular diastolic dysfunction as a predictor of one-year rehospitalization in survivors of acute myocardial infarction

Presence of severe left ventricular (LV) diastolic function has been shown to independently predict risk of heart failure or death after acute myocardial infarction (AMI). We aimed to determine whether common echocardiographic parameters and (LV) diastolic function evaluated during AMI hospitalization can predict the risk of rehospitalization, up to 1 year after AMI. One hundred ninety consecutive patients with AMI, who were prospectively enrolled in a longitudinal post-AMI registry, had survived for 1 year, and had a clinically indicated echocardiogram during the index admission, were included in the study. The independent effect of diastolic dysfunction on 1-year all-cause rehospitalization was assessed using multivariable proportional hazards regression. Average age was 62.5 years, 93% were Caucasian, 66% were men, and mean LV ejection fraction was 46%. At 1 year, 78 patients (41%) had been rehospitalized >or=1 time. In multivariable analysis, presence of severe LV diastolic dysfunction was the only echocardiographic variable that predicted increased risk of rehospitalization 1 year after AMI (hazard ration 3.31, 95% confidence interval 1.26 to 8.69). Seventy-eight percent of patients with severe LV diastolic dysfunction (restrictive diastolic physiology) compared with 30% with normal diastolic function (p = 0.0052) and 37% with nonrestrictive physiology during the index admission were rehospitalized. In conclusion, severe LV diastolic dysfunction is the only echocardiographic predictor of rehospitalization in survivors of AMI and routine assessment of diastolic function during AMI hospitalization can provide additional prognostic risk stratification at dismissal.

Influence of socioeconomic status on lifestyle behavior modifications among survivors of acute myocardial infarction

The impact of secondary prevention initiatives on survival in higher-risk socioeconomically disadvantaged patients after acute myocardial infarction (AMI) may depend on behavioral adaptive responsiveness, uptake, and adherence to healthier lifestyles. From December 1999 to February 2003, 1,801 patients in Ontario, Canada were interviewed regarding their lifestyle behaviors at 30 days after their index AMI hospitalization. Data were obtained using self-reported surveys, medical chart abstraction, and administrative data linkage. Multivariate analyses were adjusted for baseline sociodemographic, cardiac risk severity, and co-morbid conditions. Socioeconomically disadvantaged patients had greater cardiac risk severity at baseline than did their wealthier better-educated counterparts. Compared with lower-income patients, patients with higher incomes were less likely to smoke (adjusted odds ratio [OR] for highest vs lowest income tertiles 0.36, 95% confidence interval [CI] 0.21 to 0.63, p <0.001), more likely to participate in exercise (adjusted OR 1.40, 95% CI 1.07 to 1.85, p = 0.02), and more likely to decrease or discontinue alcohol use (adjusted OR 1.64, 95% CI 1.16 to 2.34, p = 0.06). The relation between education and lifestyle behaviors was less pronounced for education than for income. After adjustment for baseline factors, patients who acknowledged participation in regular physical exercise at 1 month had a significantly lower long-term mortality than those who did not. In conclusion, socioeconomically disadvantaged patients were sicker at baseline and less behaviorally responsive to embarking on healthy lifestyle changes after AMI than were those of higher socioeconomic status.

Evolving applications for patient-centered health status measures

Patient-centered health status measures-assessments of patients' symptoms, function, and quality of life-have matured substantially over the past 2 decades. Currently, valid, reliable, and sensitive disease-specific measures are available for quantifying the health status of patients with cardiovascular disease. This article briefly reviews the concept of health status measures, with a focus on their interpretation. It then discusses both the rationale and potential applications of health status measures in clinical care. Health status measures are not surrogate measures of outcome but rather highly meaningful outcomes of care. As such, they have important emerging roles as outcomes in clinical trials, as tools for monitoring patients in routine clinical care, as a mechanism for operationalizing and evaluating disease management programs, and as tools for quality assessment/improvement. Over time, it is expected that health status measures will also have an increasingly important role in patient-centered medical decision making. By becoming aware of the evolving roles of health status measures, clinicians can help to accelerate the realization of the Institute of Medicine's vision for a more transparent, evidence-based, patient-centered healthcare system.

Interaction between income and education in predicting long-term survival after acute myocardial infarction

Background

Population-based data on the impact of socioeconomic status (SES) on long-term survival after myocardial infarction (Ml) are lacking. We evaluated the association of income and education with all-cause mortality and cardiac mortality post-MI and assessed income-by-education interaction.

Design

Prospective cohort study.

Methods

Between February 1992 and February 1993, 1521 consecutive patients aged 65 years or less (19% women) discharged from all hospitals in central Israel after incident acute MI were enrolled and followed up through December 2005. Data on SES indicators, cardiovascular risk factors, MI characteristics and severity, comorbidities, and acute treatment were assessed at baseline.

Results

Low SES, as defined by income and education, was associated with older age, female sex, and higher prevalence of risk factors and comorbidities. Further, low SES patients presented with more severe disease and received fewer cardiac procedures and medications. During follow-up, 427 patients died. Income and education strongly interacted ( P = 0.003). The hazard ratio for death associated with income (below average vs. average/above average) was considerably higher for less educated (≤12 years) patients [2.64, 95% confidence interval (CI): 1.92–3.63] than for more educated (≥12 years) patients (1.53, 95% CI: 1.02–2.29). Adjustment for various prognostic indicators attenuated these estimates, yet excess risk persisted for the less educated group (hazard ratio = 1.58, 95% CI: 1.13–2.21). Similar patterns were noted for cardiac mortality.

Conclusion

Among patients with incident MI, low SES is related to higher risk profile and poorer treatment. Low income is associated with a large increase in mortality risk when accompanied by low education, suggesting a double jeopardy phenomenon.

Health through the urban lens

Cities are now the major sites of human habitation worldwide, a trend that will continue for the foreseeable future, not only in the developed world but in developing countries. Urban residence impacts health and health prospects both positively and negatively through a complex mix of exposures and mechanisms. In addition, cities concentrate population subsets of various demographic, economic, and social characteristics, some with particular health risks and vulnerabilities. Looking at health through the urban lens allows increased understanding of disparate risks and emphasizes the essentiality of collaborative efforts in protecting and enhancing the health of populations, especially those living in cities.

Financial strain predicts recurrent events among women with coronary artery disease

BACKGROUND

Although a number of epidemiological studies have found an association between socioeconomic status (SES) indices such as income and education and coronary morbidity and mortality, few have looked at health consequences arising from actually experiencing financial shortcomings. The objective of the present study was to examine whether financial strain predicts recurrent coronary artery disease (CAD) events among women with established CAD.

METHODS

Two hundred two women (mean age 62+/-9 years) hospitalized for an acute coronary event were followed over a period of 3.5 years. Demographic, socioeconomic, lifestyle-related, psychosocial and biological characteristics were obtained by means of questionnaires and clinical examination. Data on recurrent cardiac events were collected from the Swedish discharge and death registers.

RESULTS

Women experiencing financial strain over the past year had an increased risk for recurrent events, i.e. the combination of all-cause mortality, new acute myocardial infarction and unstable angina pectoris during the follow-up with an unadjusted hazard ratio (HR) of 3.2 (95% CI 1.6-6.6), and a HR of 2.76 (95% CI 1.02-7.50) after controlling for education, household income, age, cohabiting status, inclusion diagnosis and rehabilitation therapy. Adjustment for potential mediators, i.e. psychosocial factors, lipids, diabetes mellitus, smoking, body-mass index, blood pressure, physical activity, alcohol consumption, participation in other cardiac rehabilitation programs did not alter the results significantly.

CONCLUSIONS

Financial strain was a predictor for recurrent events among women with CAD, independently of commonly used SES indicators such as education and household income. Future studies will have to explore the mechanism behind this association.

Neighborhood income and individual education: effect on survival after myocardial infarction

OBJECTIVE

To evaluate the association of neighborhood-level income and individual-level education with post-myocardial infarction (MI) mortality in community patients.

PARTICIPANTS AND METHODS

From November 1, 2002, through May 31, 2006, 705 (mean+/-SD age, 69+/-15 years; 44% women) residents of Olmsted County, MN, who experienced an MI meeting standardized criteria were prospectively enrolled and followed up. The neighborhood's median household income was estimated by census tract data; education was self-reported. Demographic and clinical variables were obtained from the medical records.

RESULTS

Living in a less affluent neighborhood and having a low educational level were both associated with older age and more comorbidity. During follow-up (median, 13 months), 155 patients died. Neighborhood income (hazard ratio [HR], 2.10; 95% confidence interval [CI], 1.42-3.12; for lowest [median, $34,205] vs highest [median, $60,652] tertile) and individual education (HR, 2.21; 95% CI, 1.47-3.32; for <12 vs >12 years) were independently associated with mortality risk. Adjustment for demographics and various post-MI prognostic indicators attenuated these estimates, yet excess risk persisted for low neighborhood income (HR, 1.62; 95% CI, 1.08-2.45). Modeled as a continuous variable, each $10,000 increase in annual income was associated with a 10% reduction in mortality risk (adjusted HR, 0.90; 95% CI, 0.82-0.99).

CONCLUSION

In this geographically defined cohort of patients with MI, low individual education and poor neighborhood income were associated with a worse clinical presentation. Poor neighborhood income was a powerful predictor of mortality even after controlling for a variety of potential confounding factors. These data confirm the socioeconomic disparities in health after MI.

The association between socioeconomic position, use of revascularization procedures and five-year survival after recovery from acute myocardial infarction

Background

Patients living under better socioeconomic circumstances often receive more active treatments after an acute myocardial infarction (AMI) compared to less affluent patients. However, most previous studies were performed in countries with less comprehensive coverage for medical services. In this Swedish nation-wide longitudinal study we wanted to evaluate long-term survival after AMI in relation to socioeconomic position (SEP) and use of revascularization.

Methods

From the Swedish Myocardial Infarction Register we identified all 45 to 84-year-old patients (16,041 women and 30,366 men) alive 28 days after their first AMI during the period 1993 to 1996. We obtained detailed information on the use of revascularization, cumulative household income from the 1975 and 1990 censuses and 5-year survival after the AMI.

Results

Patients with the highest cumulative income (adding the values of the quartile categories of income in 1975 and 1990) underwent a revascularization procedure within one month after their first AMI two to three times as often as patients with the lowest cumulative income and had half the risk of death within five years. The socioeconomic differences in the use of revascularization procedures could not be explained by differences in co-morbidity or type of hospital at first admission. Patients who underwent revascularization showed a similar lowered mortality risk in the different income groups, while there were strong socioeconomic differences in long-term mortality among patients who did not undergo revascularization.

Conclusion

This nationwide Swedish study showed that patients with high income had a better long-term survival after recovery from their AMI compared to patients with low income. Furthermore, even though the use of revascularization procedures is beneficial, low SEP groups receive it less often than high SEP groups.

Influence of patients' socioeconomic status on clinical management decisions: a qualitative study

PURPOSE

Little is known about how patients' socioeconomic status (SES) influences physicians' clinical management decisions, although this information may have important implications for understanding inequities in health care quality. We investigated physician perspectives on how patients' SES influences care.

METHODS

The study consisted of in-depth semistructured interviews with primary care physicians in Connecticut. Investigators coded interviews line by line and refined the coding structure and interview guide based on successive interviews. Recurrent themes emerged through iterative analysis of codes and tagged quotations.

RESULTS

We interviewed 18 physicians from varied practice settings, 6 female, 9 from minority racial backgrounds, and 3 of Hispanic ethnicity. Four themes emerged from our interviews: (1) physicians held conflicting views about the effect of patient SES on clinical management, (2) physicians believed that changes in clinical management based on the patient's SES were made in the patient's interest, (3) physicians varied in the degree to which they thought changes in clinical management influenced patient outcomes, and (4) physicians faced personal and financial strains when caring for patients of low SES.

CONCLUSIONS

Physicians indicated that patient SES did affect their clinical management decisions. As a result, physicians commonly undertook changes to their management plan in an effort to enhance patient outcomes, but they experienced numerous strains when trying to balance what they believed was feasible for the patient with what they perceived as established standards of care.