Health inequalities in terms of myocardial infarction and all-cause mortality: a study with German claims data covering 2006 to 2015

Time trends in income-related disparity in incidence of acute coronary syndrome

BACKGROUND

Higher incidence of acute coronary syndrome (ACS), among those with lower income, has been recognized in the most recent decades. Still, there is a paucity of data on temporal changes. This study aims to investigate 20-year time trends in income-related disparity in the incidence of ACS in Denmark.

METHODS

This Population-based repeated cross-sectional study included all patients with first-time ACS, aged ≥20 years, registered in the Danish National Patient Registry 1998-2017. Aggregated sociodemographic data for the Danish population was accessed from Statistics Denmark. Yearly incidence rates (IR) and incidence rate ratios (IRR), with the highest-income quartile as a reference, were standardized using cell-specific personal equivalent income according to year, sex and age group with 95% confidence intervals. Interaction analysis was executed for differences in IR of ACS between the lowest- and highest-income quartile over time.

RESULTS

A total of 220 070 patients hospitalized with ACS from 1998 to 2017 were identified. The yearly standardized ACS IRs decreased in all income quartiles. However, the IR remained higher in the lowest-income quartile compared to the highest for both men [1998: IRR 1.45 (95% confidence interval, CI 1.39-1.52) and 2017: 1.47 (1.40-1.54)] and women [1998: IRR 1.73 (1.64-1.82) and 2017: 1.76 (1.65-1.88)]. Interaction analysis showed that over the period the difference in IR between the lower- and the highest-income quartile decreased with 1-5 ACS cases per 100 000 person-year.

CONCLUSION

Income-related disparity in the incidence of ACS was present in Denmark between 1998 and 2017. Despite a marked overall decrease in the yearly ACS incidence, the extent of income-related disparity remained unchanged.

Association of socioeconomic status with cardiovascular disease and cardiovascular risk factors: a systematic review and meta-analysis

Aim

Cardiovascular disease (CVD) remains one of the leading causes of mortality worldwide, and several studies have indicated the association between socioeconomic status (SES) with CVD and cardiovascular risk factors (CVRFs). It is necessary to elucidate the association of SES and CVRFs with CVD.

Subject and methods

We searched PubMed, Embase, Web of Science, and the Cochrane Library for publications, using "socioeconomic status," "cardiovascular disease," and corresponding synonyms to obtain literature. The quality of studies was evaluated using the National Institutes of Health Quality Assessment Tool (NIH-QAT). All analyses were performed using Stata V.12.0.

Results

There were 31 eligible studies included in this meta-analysis. All studies presented a low risk of bias via NIH-QAT assessment. As for CVD incidence/mortality, pooled hazard ratios (HR) of low and middle vs. high income were [HR = 1.22 (1.17-1.28); HR = 1.12 (1.09-1.16)] and [HR = 1.37 (1.21-1.56); HR = 1.19 (1.06-1.34)]. The HR of education were [HR = 1.44 (1.28-1.63); HR = 1.2 (1.11-1.3)] and [HR = 1.5 (1.22-1.83); HR = 1.13 (1.05-1.22)]. The HR of deprivation were [HR = 1.28 (1.16-1.41); HR = 1.07 (1.03-1.11)] and [HR = 1.19 (1.11-1.29); HR = 1.1 (1.02-1.17)]. SES was negatively correlated with CVD outcomes. A subgroup analysis of gender and national income level also yielded a negative correlation, and additional details were also obtained.

Conclusions

SES is inversely correlated with CVD outcomes and the prevalence of CVRFs. As for CVD incidence, women may be more sensitive to income and education. In terms of CVD mortality, men may be more sensitive to income and education, and people from low- and middle-income countries are sensitive to income and education.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-023-01825-4.

Widening or narrowing income inequalities in myocardial infarction? Time trends in life years free of myocardial infarction and after incidence

BACKGROUND

Despite substantial improvements in prevention and therapy, myocardial infarction (MI) remains a frequent health event, causing high mortality and serious health impairments. Previous research lacks evidence on how social inequalities in incidence and mortality risks developed over time, and on how these developments affect the lifespan free of MI and after MI in different social subgroups. This study investigates income inequalities in MI-free life years and life years after MI and whether these inequalities widened or narrowed over time.

METHODS

The analyses are based on claims data of a large German health insurance provider insuring approximately 2.8 million individuals in the federal state Lower Saxony. Trends in income inequalities in incidence and mortality were assessed for all subjects aged 60 years and older by comparing the time periods 2006-2008 and 2015-2017 using multistate survival models. Trends in the number of life years free of MI and after MI were calculated separately for income groups by applying multistate life table analyses.

RESULTS

MI incidence and mortality risks decreased over time, but declines were strongest among men and women in the higher-income group. While life years free of MI increased in men and women with higher incomes, no MI-free life years were gained in the low-income group. Among men, life years after MI increased irrespective of income group.

CONCLUSIONS

Income inequalities in the lifespan spent free of MI and after MI widened over time. In particular, men with low incomes are disadvantaged, as life years spent after MI increased, but no life years free of MI were gained.

The frequency and time point of outpatient palliative care integration for people before death: an analysis of health insurance data in Lower Saxony, Germany

Aim

This study aimed to analyse the number of deceased people who received different types of outpatient palliative care, the length of time prior to death that care was initiated, and their palliative care trajectory including the rate of hospital death.

Subject and methods

Data on 35,514 adults insured by the statutory health insurance who died in 2017 in Lower Saxony, Germany, were analysed. The study examined the provision of three different types of outpatient palliative care: general (GPC), intermediate (IPC) and specialised palliative care (SPC). In addition, oncological palliative care services (OS) were considered. Descriptive analyses include frequencies, timing and duration of these services, the number of inpatient hospital stays and hospital deaths.

Results

Prior to death, 31.4% of the deceased received outpatient palliative care: 21.3% GPC, 6.4% GPC with IPC and/or SPC and/or OS; and 3.7% IPC and/or SPC and/or OS, but no GPC. On average, GPC and OS were initiated 9 months and SPC 3 months prior to death. Six percent of the analytic sample received outpatient palliative care more than 2 years before death. Compared to those without outpatient palliative care, patients who received outpatient palliative care had more and longer inpatient hospital stays, but less frequently died in hospital.

Conclusion

Early outpatient palliative care took place in a minor percentage of deceased. Outpatient palliative care starts late before death for most patients, but enables more people not to die in hospital. However, significantly fewer people receive outpatient palliative care relative to current demand estimates. This is particularly true of general outpatient palliative care.

Social inequalities in mild and severe myocardial infarction: how large is the gap in health expectancies?

BACKGROUND

Acute myocardial infarction (MI) remains a frequent health event and a major contributor to long-term impairments globally. So far, research on social inequalities in MI incidence and mortality with respect to MI severity is limited. Furthermore, evidence is lacking on disparities in the length of life affected by MI. This study investigates social inequalities in MI incidence and mortality as well as in life years free of MI and affected by the consequences of mild or severe MI.

METHODS

The study is based on data of a large German statutory health insurance provider covering the years 2008 to 2017 (N = 1,253,083). Income inequalities in MI incidence and mortality risks and in life years with mild or severe MI and without MI were analysed using multistate analyses. The assessment of MI severity is based on diagnosed heart failure causing physical limitations.

RESULTS

During the study period a total of 39,832 mild MI, 22,844 severe MI, 276,582 deaths without MI, 15,120 deaths after mild MI and 16,495 deaths after severe MI occurred. Clear inequalities were found in MI incidence and mortality, which were strongest among men and in severe MI incidence. Moreover, substantial inequalities were found in life years free of MI in both genders to the disadvantage of those with low incomes and increased life years after mild MI in men with higher incomes. Life years after severe MI were similar across income groups.

CONCLUSIONS

Social inequalities in MI incidence and mortality risks led to clear disparities in the length of life free of MI with men with low incomes being most disadvantaged. Our findings stress the importance of primary and secondary prevention focusing especially on socially disadvantaged groups.

The effects of different lookback periods on the sociodemographic structure of the study population and on the estimation of incidence rates: analyses with German claims data

BACKGROUND

Defining incident cases has always been a challenging issue for researchers working with routine data. Lookback periods should enable researchers to identify and exclude recurrent cases and increase the accuracy of the incidence estimation. There are different recommendations for lookback periods depending on a disease entity of up to 10 years. Well-known drawbacks of the application of lookback periods are shorter remaining observation period in the dataset or smaller number of cases. The problem of selectivity of the remaining population after introducing lookback periods has not been considered in the literature until now.

METHODS

The analyses were performed with pseudonymized claims data of a German statutory health insurance fund with annual case numbers of about 2,1 million insured persons. Proportions of study population excluded due to the application of lookback periods are shown according to age, occupational qualification and income. Myocardial infarction and stroke were used to demonstrate changes in incidence rates after applying lookback periods of up to 5 years.

RESULTS

Younger individuals show substantial dropouts after the application of lookback periods. Furthermore, there are selectivities regarding occupational qualification and income, which cannot be handled by age standardization. Due to selective dropouts of younger individuals, crude incidence rates of myocardial infarction and stroke increase after applying lookback periods. Depending on the income group, age-standardized incidence rates changed differentially, leading to a decrease and possible underestimation of the social gradient after applying lookback periods.

CONCLUSIONS

Selectivity analyses regarding age and sociodemographic structure should be performed for the study population after applying lookback periods since the selectivity can affect the outcome especially in health care research. The selectivity effects might occur not only in claims data of one health insurance fund, but also in other longitudinal data with left- or right-censoring not covering the whole population. The effects may also apply to health care systems with a mix of public and private health insurance. A trade-off has to be considered between selectivity effects and eliminating recurrent events for more accuracy in the definition of incidence.