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Achterberg JL, Haas MR, Spruit MR. On the evaluation of synthetic longitudinal electronic health records. BMC Med Res Methodol 2024; 24:181. [PMID: 39143466 PMCID: PMC11323671 DOI: 10.1186/s12874-024-02304-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 08/07/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Synthetic Electronic Health Records (EHRs) are becoming increasingly popular as a privacy enhancing technology. However, for longitudinal EHRs specifically, little research has been done into how to properly evaluate synthetically generated samples. In this article, we provide a discussion on existing methods and recommendations when evaluating the quality of synthetic longitudinal EHRs. METHODS We recommend to assess synthetic EHR quality through similarity to real EHRs in low-dimensional projections, accuracy of a classifier discriminating synthetic from real samples, performance of synthetic versus real trained algorithms in clinical tasks, and privacy risk through risk of attribute inference. For each metric we discuss strengths and weaknesses, next to showing how it can be applied on a longitudinal dataset. RESULTS To support the discussion on evaluation metrics, we apply discussed metrics on a dataset of synthetic EHRs generated from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) repository. CONCLUSIONS The discussion on evaluation metrics provide guidance for researchers on how to use and interpret different metrics when evaluating the quality of synthetic longitudinal EHRs.
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Affiliation(s)
- Jim L Achterberg
- Public Health and Primary Care, Health Campus The Hague, Leiden University Medical Center, Albinusdreef 2, Leiden, South-Holland, 2333ZA, Netherlands.
| | - Marcel R Haas
- Public Health and Primary Care, Health Campus The Hague, Leiden University Medical Center, Albinusdreef 2, Leiden, South-Holland, 2333ZA, Netherlands
| | - Marco R Spruit
- Public Health and Primary Care, Health Campus The Hague, Leiden University Medical Center, Albinusdreef 2, Leiden, South-Holland, 2333ZA, Netherlands
- Leiden Institute of Advanced Computer Science, Leiden University, Einsteinweg 55, Leiden, South-Holland, 2333CC, Netherlands
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Hsia RY, Shen YC. Structural Inequities In The Adoption Of Percutaneous Coronary Intervention Services By US Hospitals, 2000-20. Health Aff (Millwood) 2024; 43:1011-1020. [PMID: 38950302 PMCID: PMC11293955 DOI: 10.1377/hlthaff.2023.01649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Percutaneous coronary intervention (PCI) is a procedure that opens blocked arteries and restores blood flow to the heart. Timely access to hospitals offering PCI services can be a matter of life or death for patients experiencing a heart attack; however, hospitals' adoption of PCI services may vary between communities, posing potential barriers to critical care. Our cohort study of US general acute hospitals during the period 2000-20 examined PCI service adoption across communities stratified by race, ethnicity, income, and rurality and further classified as segregated or integrated. Of 5,260 hospitals, 1,621 offered PCI services in 2020 or before, 630 added PCI services between 2001 and 2010, and 225 added PCI services between 2011 and 2020. Hospitals serving Black, racially segregated communities were 48 percent less likely to adopt PCI services compared with hospitals serving non-Black, racially segregated communities, and hospitals serving Hispanic, ethnically segregated communities were 41 percent less likely to do so than those serving non-Hispanic, ethnically segregated communities. Hospitals in high-income, economically integrated communities were 1.8 times more likely to adopt PCI services than those in high-income, economically segregated communities, and rural hospitals were less likely to do so than urban hospitals. Understanding where services are expanding in relation to community need may aid in successful policy interventions.
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Affiliation(s)
- Renee Y Hsia
- Renee Y. Hsia , University of California San Francisco, San Francisco, California
| | - Yu-Chu Shen
- Yu-Chu Shen, Naval Postgraduate School, Monterey, California; and National Bureau of Economic Research, Cambridge, Massachusetts
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Feng X, Qiu F, Zheng L, Zhang Y, Wang Y, Wang M, Xia H, Tang B, Yan C, Liang R. Exposure to volatile organic compounds and mortality in US adults: A population-based prospective cohort study. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 928:172512. [PMID: 38636853 DOI: 10.1016/j.scitotenv.2024.172512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/25/2024] [Accepted: 04/14/2024] [Indexed: 04/20/2024]
Abstract
Volatile organic compounds (VOCs) are ubiquitous in both indoor and outdoor environments. Evidence on the associations of individual and joint VOC exposure with all-cause and cause-specific mortality is limited. Measurements of 15 urinary VOC metabolites were available to estimate exposure to 12 VOCs in the National Health and Nutritional Examination Survey (NHANES) 2005-2006 and 2011-2018. The environment risk score (ERS) was calculated using LASSO regression to reflect joint exposure to VOCs. Follow-up data on death were obtained from the NHANES Public-Use Linked Mortality File through December 31, 2019. Cox proportional hazard models and restricted cubic spline models were applied to evaluate the associations of individual and joint VOC exposures with all-cause and cause-specific mortality. Population attributable fractions were calculated to assess the death burden attributable to VOC exposure. During a median follow-up of 6.17 years, 734 (8.34 %) deaths occurred among 8799 adults. Urinary metabolites of acrolein, acrylonitrile, 1,3-butadiene, and ethylbenzene/styrene were significantly associated with all-cause, cardiovascular disease (CVD), respiratory disease (RD), and cancer mortality in a linear dose-response manner. Linear and robust dose-response relationships were also observed between ERS and all-cause and cause-specific mortality. Each 1-unit increase in ERS was associated with a 33.6 %, 39.1 %, 109.8 %, and 67.8 % increase for all-cause, CVD, RD, and cancer mortality risk, respectively. Moreover, joint exposure to VOCs contributed to 17.95 % of all-cause deaths, 13.49 % of CVD deaths, 35.65 % of RD deaths, and 33.85 % of cancer deaths. Individual and joint exposure to VOCs may enhance the risk of all-cause and cause-specific mortality. Reducing exposure to VOCs may alleviate the all-cause and cause-specific death burden.
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Affiliation(s)
- Xiaobing Feng
- Department of Medical Records Statistics, Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430016, China
| | - Feng Qiu
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Ling Zheng
- Department of Medical Records Statistics, Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430016, China
| | - Yue Zhang
- Department of Medical Records Statistics, Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430016, China
| | - Yuji Wang
- Department of Medical Records Statistics, Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430016, China
| | - Min Wang
- Department of Medical Records Statistics, Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430016, China
| | - Han Xia
- Department of Medical Records Statistics, Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430016, China
| | - Bingrong Tang
- Department of Medical Records Statistics, Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430016, China
| | - Chunxiang Yan
- Department of Medical Records Statistics, Wuhan Children's Hospital (Wuhan Maternal and Child Health Care Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430016, China.
| | - Ruyi Liang
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China.
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Akioyamen LE, Abdel-Qadir H, Han L, Sud M, Mistry N, Alter DA, Atzema CL, Austin PC, Bhatia RS, Booth GL, Dhalla I, Ha ACT, Jackevicius CA, Kapral MK, Krumholz HM, Lee DS, McNaughton CD, Roifman I, Schull MJ, Sivaswamy A, Tu K, Udell JA, Wijeysundera HC, Ko DT. Association of Neighborhood-Level Marginalization With Health Care Use and Clinical Outcomes Following Hospital Discharge in Patients Who Underwent Coronary Catheterization for Acute Myocardial Infarction in a Single-Payer Health Care System. Circ Cardiovasc Qual Outcomes 2023; 16:e010063. [PMID: 38050754 DOI: 10.1161/circoutcomes.123.010063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/06/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Canadian data suggest that patients of lower socioeconomic status with acute myocardial infarction receive less beneficial therapy and have worse clinical outcomes, raising questions regarding care disparities even in universal health care systems. We assessed the contemporary association of marginalization with clinical outcomes and health services use. METHODS Using clinical and administrative databases in Ontario, Canada, we conducted a population-based study of patients aged ≥65 years hospitalized for their first acute myocardial infarction between April 1, 2010 and March 1, 2019. Patients receiving cardiac catheterization and surviving 7 days postdischarge were included. Our primary exposure was neighborhood-level marginalization, a multidimensional socioeconomic status metric. Neighborhoods were categorized by quintile from Q1 (least marginalized) to Q5 (most marginalized). Our primary outcome was all-cause mortality. A proportional hazards regression model with a robust variance estimator was used to quantify the association of marginalization with outcomes, adjusting for risk factors, comorbidities, disease severity, and regional cardiologist supply. RESULTS Among 53 841 patients (median age, 75 years; 39.1% female) from 20 640 neighborhoods, crude 1- and 3-year mortality rates were 7.7% and 17.2%, respectively. Patients in Q5 had no significant difference in 1-year mortality (hazard ratio [HR], 1.08 [95% CI, 0.95-1.22]), but greater mortality over 3 years (HR, 1.13 [95% CI, 1.03-1.22]) compared with Q1. Over 1 year, we observed differences between Q1 and Q5 in visits to primary care physicians (Q1, 96.7%; Q5, 93.7%) and cardiologists (Q1, 82.6%; Q5, 72.6%), as well as diagnostic testing. There were no differences in secondary prevention medications dispensed or medication adherence at 1 year. CONCLUSIONS In older patients with acute myocardial infarction who survived to hospital discharge, those residing in the most marginalized neighborhoods had a greater long-term risk of mortality, less specialist care, and fewer diagnostic tests. Yet, there were no differences across socioeconomic status in prescription medication use and adherence.
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Affiliation(s)
- Leo E Akioyamen
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
| | - Husam Abdel-Qadir
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
- Women's College Hospital, Toronto, ON, Canada (H.A.-Q., J.A.U.)
| | - Lu Han
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
| | - Maneesh Sud
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Nikhil Mistry
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
| | - David A Alter
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Clare L Atzema
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Peter C Austin
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
| | - R Sacha Bhatia
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Gillian L Booth
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada (G.L.B., I.R.,)
| | - Irfan Dhalla
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
| | - Andrew C T Ha
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Cynthia A Jackevicius
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Western University of Health Sciences, Pomona, CA (C.A.J.)
| | - Moira K Kapral
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.)
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Douglas S Lee
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Candace D McNaughton
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Idan Roifman
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada (G.L.B., I.R.,)
| | - Michael J Schull
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Atul Sivaswamy
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
| | - Karen Tu
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Department of Family and Community Medicine, (K.T.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- North York General Hospital, Toronto, ON, Canada (K.T.)
| | - Jacob A Udell
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
- Women's College Hospital, Toronto, ON, Canada (H.A.-Q., J.A.U.)
| | - Harindra C Wijeysundera
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Dennis T Ko
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
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5
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Minhas AMK, Jain V, Li M, Ariss RW, Fudim M, Michos ED, Virani SS, Sperling L, Mehta A. Family income and cardiovascular disease risk in American adults. Sci Rep 2023; 13:279. [PMID: 36609674 PMCID: PMC9822929 DOI: 10.1038/s41598-023-27474-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
Socioeconomic status is an overlooked risk factor for cardiovascular disease (CVD). Low family income is a measure of socioeconomic status and may portend greater CVD risk. Therefore, we assessed the association of family income with cardiovascular risk factor and disease burden in American adults. This retrospective analysis included data from participants aged ≥ 20 years from the National Health and Nutrition Examination Survey (NHANES) cycles between 2005 and 2018. Family income to poverty ratio (PIR) was calculated by dividing family (or individual) income by poverty guidelines specific to the survey year and used as a measure of socioeconomic status. The association of PIR with the presence of cardiovascular risk factors and CVD as well as cardiac mortality and all-cause mortality was examined. We included 35,932 unweighted participants corresponding to 207,073,472 weighted, nationally representative participants. Participants with lower PIR were often female and more likely to belong to race/ethnic minorities (non-Hispanic Black, Mexican American, other Hispanic). In addition, they were less likely to be married/living with a partner, to attain college graduation or higher, or to have health insurance. In adjusted analyses, the prevalence odds of diabetes mellitus, hypertension, coronary artery disease (CAD), congestive heart failure (CHF), and stroke largely decreased in a step-wise manner from highest (≥ 5) to lowest PIR (< 1). In adjusted analysis, we also noted a mostly dose-dependent association of PIR with the risk of all-cause and cardiac mortality during a mean 5.7 and 5.8 years of follow up, respectively. Our study demonstrates a largely dose-dependent association of PIR with hypertension, diabetes mellitus, CHF, CAD and stroke prevalence as well as incident all-cause mortality and cardiac mortality in a nationally representative sample of American adults. Public policy efforts should be directed to alleviate these disparities to help improve cardiovascular outcomes in vulnerable groups with low family income.
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Affiliation(s)
- Abdul Mannan Khan Minhas
- grid.414961.f0000 0004 0426 4740Department of Medicine, Forrest General Hospital, Hattiesburg, MS USA
| | - Vardhmaan Jain
- grid.189967.80000 0001 0941 6502Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA USA
| | - Monica Li
- grid.189967.80000 0001 0941 6502Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Robert W. Ariss
- grid.62560.370000 0004 0378 8294Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Marat Fudim
- grid.189509.c0000000100241216Division of Cardiology, Duke University Medical Center, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Duke Clinical Research Institute, Durham, NC USA
| | - Erin D. Michos
- grid.21107.350000 0001 2171 9311Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Salim S. Virani
- grid.39382.330000 0001 2160 926XMichael E. DeBakey Veterans Affair Medical Center and Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Laurence Sperling
- grid.189967.80000 0001 0941 6502Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA USA
| | - Anurag Mehta
- VCU Health Pauley Heart Center, Virginia Commonwealth University School of Medicine, 1200 East Broad Street, PO Box 980036, Richmond, VA, 23298, USA.
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6
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Kolden MØ, Nymo SH, Øie E. Impact of neighbourhood-level socioeconomic status, traditional coronary risk factors, and ancestry on age at myocardial infarction onset: A population-based register study. BMC Cardiovasc Disord 2022; 22:447. [PMID: 36289452 PMCID: PMC9608887 DOI: 10.1186/s12872-022-02880-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 09/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is consensus that low socioeconomic status (SES) is associated with an increased risk of acute myocardial infarction (AMI), but the extent to which traditional coronary risk factors and other characteristics of low SES mediate this effect remains uncertain. This study examined AMI patients residing in neighbouring city districts with the same local hospital despite having among the most considerable differences in mean SES in Norway. Our purpose was to assess low SES as a coronary risk factor and examine whether traditional coronary risk factors or ancestry mediate this effect. METHODS Six hundred six patients (215 and 391 with a low and high neighbourhood-level SES, respectively) admitted to Diakonhjemmet Hospital with non-ST-elevation myocardial infarction (NSTEMI) between 2014 and 2017, entered analysis. Data from the Norwegian Myocardial Infarction Register were used to identify patient characteristics, and the STATA/SE 15.1 software was used to perform the statistical analyses. RESULTS Patients from socioeconomically disadvantaged city-districts had a 4.9 years earlier onset of AMI (68.99 vs. 73.89 years; p < 0.001) and a higher prevalence of previous AMI, known diabetes, and current smokers (36% vs. 27%, 25% vs. 12%, and 33% vs. 17%, respectively; all p ≤ 0.05). When only comparing patients with a first time AMI, an even greater difference in the age at AMI onset was found (6.1 yrs; p < 0.001). The difference in age at AMI onset remained statistically significant when adjusting for traditional coronary risk factors (3.28 yrs; 95% confidence interval (CI) 1.11-5.44; p = 0.003), but not when adjusting for presumed non-Northwest-European ancestry (1.81 yrs; 95% CI -0.55 to 4.17; p = 0.132). CONCLUSION This study supports earlier research showing an increased risk of AMI in socioeconomically disadvantaged individuals. In our population, presumed non-Northwest-European ancestry could entirely explain the increased risk, whereas traditional coronary risk factors could only partly explain the increased risk.
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Affiliation(s)
| | - Ståle H Nymo
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Erik Øie
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
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7
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Pourfarzi F, Moghadam TZ, Zandian H. Decomposition socio-economic inequality in cardiovascular disease prevalence in adult population: A cohort based cross-sectional study in north-west of Iran. J Prev Med Public Health 2022; 55:297-306. [PMID: 35678004 PMCID: PMC9201090 DOI: 10.3961/jpmph.22.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/29/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Farhad Pourfarzi
- Digestive Disease Research Center, Ardabil University of Medical Sciences, Ardabil,
Iran
| | - Telma Zahirian Moghadam
- Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil,
Iran
| | - Hamed Zandian
- Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil,
Iran
- Department of Community Medicine, School of Medicine, Ardabil University of Medical Sciences, Ardabil,
Iran
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8
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Huded CP, Dalton JE, Kumar A, Krieger NI, Kassis N, Phelan M, Kravitz K, Reed GW, Krishnaswamy A, Kapadia SR, Khot U. Relationship of Neighborhood Deprivation and Outcomes of a Comprehensive ST Elevation Myocardial Infarction Protocol. J Am Heart Assoc 2021; 10:e024540. [PMID: 34779652 PMCID: PMC9075260 DOI: 10.1161/jaha.121.024540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background We evaluated whether a comprehensive ST‐segment–elevation myocardial infarction protocol (CSP) focusing on guideline‐directed medical therapy, transradial percutaneous coronary intervention, and rapid door‐to‐balloon time improves process and outcome metrics in patients with moderate or high socioeconomic deprivation. Methods and Results A total of 1761 patients with ST‐segment–elevation myocardial infarction treated with percutaneous coronary intervention at a single hospital before (January 1, 2011–July 14, 2014) and after (July 15, 2014– July 15, 2019) CSP implementation were included in an observational cohort study. Neighborhood deprivation was assessed by the Area Deprivation Index and was categorized as low (≤50th percentile; 29.0%), moderate (51st –90th percentile; 40.8%), and high (>90th percentile; 30.2%). The primary process outcome was door‐to‐balloon time. Achievement of guideline‐recommend door‐to‐balloon time goals improved in all deprivation groups after CSP implementation (low, 67.8% before CSP versus 88.5% after CSP; moderate, 50.7% before CSP versus 77.6% after CSP; high, 65.5% before CSP versus 85.6% after CSP; all P<0.001). Median door‐to‐balloon time among emergency department/in‐hospital patients was significantly noninferior in higher versus lower deprivation groups after CSP (noninferiority limit=5 minutes; Pnoninferiority high versus moderate = 0.002, high versus low <0.001, moderate versus low = 0.02). In‐hospital mortality, the primary clinical outcome, was significantly lower after CSP in patients with moderate/high deprivation in unadjusted (before CSP 7.0% versus after CSP 3.1%; odds ratio [OR], 0.42 [95% CI, 0.25–0.72]; P=0.002) and risk‐adjusted (OR, 0.42 [95% CI, 0.23–0.77]; P=0.005) models. Conclusions A CSP was associated with improved ST‐segment–elevation myocardial infarction care across all deprivation groups and reduced mortality in those from moderate or high deprivation neighborhoods. Standardized initiatives to reduce care variability may mitigate social determinants of health in time‐sensitive conditions such as ST‐segment–elevation myocardial infarction.
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Affiliation(s)
- Chetan P Huded
- Department of Cardiology Saint Luke's Mid-America Heart Institute Kansas City MO
| | - Jarrod E Dalton
- Department of Quantitative Health Sciences Lerner Research Institute Cleveland Clinic Cleveland OH
| | - Anirudh Kumar
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH.,Center for Healthcare Delivery Innovation Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Nikolas I Krieger
- Department of Quantitative Health Sciences Lerner Research Institute Cleveland Clinic Cleveland OH
| | - Nicholas Kassis
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH.,Center for Healthcare Delivery Innovation Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Michael Phelan
- Department of Emergency Medicine Emergency Services Institute Cleveland Clinic Cleveland OH
| | - Kathleen Kravitz
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Grant W Reed
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Samir R Kapadia
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Umesh Khot
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH.,Center for Healthcare Delivery Innovation Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
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9
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Moledina A, Tang KL. Socioeconomic Status, Mortality, and Access to Cardiac Services After Acute Myocardial Infarction in Canada: A Systematic Review and Meta-analysis. CJC Open 2021; 3:950-964. [PMID: 34401702 PMCID: PMC8347872 DOI: 10.1016/j.cjco.2021.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/01/2021] [Indexed: 12/13/2022] Open
Abstract
Background Low socioeconomic status (SES) is an important prognosticator for those with acute myocardial infarction (AMI), having previously been described to be associated with increased short-term mortality. Whether this effect persists over time, and whether access to cardiac interventions is equitable within Canada’s universal health care system, remains unknown. Methods We conducted a systematic review to determine the associations of SES with mortality and access to a spectrum of interventions including cardiac catheterization, revascularization, and cardiac rehabilitation. Electronic databases (EMBASE and MEDLINE) were searched in March 2019 and December 2019. Original studies from Canada examining associations between SES and any of the above outcomes in AMI patients were included. Meta-analyses were conducted using random effects models. Results Nineteen studies were included, 11 of which could be meta-analyzed. Low SES was associated with a 48% and 34% increase in short-term and intermediate-term mortality, respectively. There was a trend toward increased long-term mortality more than 1-year post-event (pooled odds ratio [OR] 1.34 [95% confidence interval {CI} 0.95-1.88]). Low SES was also associated with lower rates of cardiac catheterization (pooled OR 0.80 [95% CI 0.65-0.99]) and revascularization (pooled OR 0.76 [95% CI 0.63-0.90]) post-AMI. Studies on cardiac rehabilitation showed reduced access and participation in low-SES groups. Conclusions Low SES is associated with not only increased mortality post-AMI, but also reduced access to cardiac interventions that have demonstrated benefits for mortality and morbidity. Interventions that improve access to catheterization, revascularization, and cardiac rehabilitation for low-SES populations are needed if true equitable care in Canada is desired.
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Affiliation(s)
- Aliza Moledina
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Karen L Tang
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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10
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Li Y, Babazono A, Ohmori T, Jamal A, Yoshida S, Kim SA, Fujita T, Liu N. Health Inequality Among Older Adults with Percutaneous Coronary Intervention and Universal Health Coverage in Japan. Popul Health Manag 2021; 25:23-30. [PMID: 34076535 DOI: 10.1089/pop.2021.0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
This study aimed to comprehensively evaluate whether income affects long-term health outcomes for older patients who underwent percutaneous coronary intervention (PCI) provided by a universal health coverage system. Data were from the Latter Stage Elderly Healthcare Insurance database in Fukuoka Prefecture, Japan. A total of 5625 individuals aged ≥65 years who underwent PCI in 2014-2016 were included. Cox proportional hazards models were used to assess the association between income status and the incidence of health outcomes. With a median follow-up of 1095 days, 554 acute myocardial infarction (AMI) cases, 1075 stroke cases, 1690 repeat revascularization cases, and 1094 deaths were observed. Risk of all-cause mortality decreased significantly with increasing income level in both unadjusted and adjusted Cox regression models. Patients in the low-income level had a significantly higher rate of AMI (log-rank P = 0.003), stroke (log-rank P = 0.039), and all-cause mortality (log-rank P = 0.001) compared with patients in the high-income level. Observed rates for repeat revascularization also were high in the first year after PCI. In the Japanese universal health setting, low-income patients had a comparatively higher mortality risk after PCI. Poor long-term outcomes might be attributed to patients' baseline characteristics rather than treatment processes.
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Affiliation(s)
- Yunfei Li
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akira Babazono
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takashi Ohmori
- Department of Transitional and Palliative Care, Iizuka Hospital, Iizuka, Japan
| | - Aziz Jamal
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Health Administration Program, Faculty of Business and Management, Universiti Teknologi MARA, Selangor, Malaysia
| | - Shinichiro Yoshida
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Sung-A Kim
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takako Fujita
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ning Liu
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Kitakyushu, Japan
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11
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Malki N, Hägg S, Tiikkaja S, Koupil I, Sparén P, Ploner A. Short-term and long-term case-fatality rates for myocardial infarction and ischaemic stroke by socioeconomic position and sex: a population-based cohort study in Sweden, 1990-1994 and 2005-2009. BMJ Open 2019; 9:e026192. [PMID: 31278093 PMCID: PMC6615790 DOI: 10.1136/bmjopen-2018-026192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Case-fatality rates (CFRs) for myocardial infarction (MI) and ischaemic stroke (IS) have decreased over time due to better prevention, medication and hospital care. It is unclear whether these improvements have been equally distributed according to socioeconomic position (SEP) and sex. The aim of this study is to analyse differences in short-term and long-term CFR for MI and IS by SEP and sex between the periods 1990-1994 to 2005-2009 for the entire Swedish population. DESIGN Population-based cohort study based on Swedish national registers. METHODS We used logistic regression and flexible parametric models to estimate short-term CFR (death before reaching the hospital or on the disease event day) and long-term CFR (1 year case-fatality conditional on surviving short-term) across five distinct SEP groups, as well as CFR differences (CFRDs) between SEP groups for both MI and IS from 1990-1994 to 2005-2009. : Result S: Overall short-term CFR for both MI and IS decreased between study periods. For MI, differences in short-term and long-term CFR between the least and most favourable SEP group were generally stable, except in long-term CFR among women; intermediate SEP groups mostly managed to catch up with the most favourable SEP group. For IS, short-term CFRD generally decreased compared with the most favourable group; but long-term CFRD were mostly stable, except for an increase for older subjects. CONCLUSION Despite a general decline in CFR for MI and IS across all SEP groups and both sexes as well as some reductions in CFRD, we found persistent and even increasing CFRD among the least advantaged SEP groups, older patients and women. We speculate that targeted prevention rather than treatment strategies have the potential to reduce these inequalities.
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Affiliation(s)
- Ninoa Malki
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Sara Hägg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Sanna Tiikkaja
- Centre of Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Public Health and Caring Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Ilona Koupil
- Centre for Health Equity Studies, Stockholm University/Karolinska Institutet, Stockholm, Sweden
| | - Pär Sparén
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Alexander Ploner
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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12
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Steele L, Palmer J, Lloyd A, Fotheringham J, Iqbal J, Grech ED. Impact of socioeconomic status on survival following ST-elevation myocardial infarction in a universal healthcare system. Int J Cardiol 2019; 276:26-30. [DOI: 10.1016/j.ijcard.2018.11.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/02/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
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13
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Couper K, Kimani PK, Gale CP, Quinn T, Squire IB, Marshall A, Black JJM, Cooke MW, Ewings B, Long J, Perkins GD. Variation in outcome of hospitalised patients with out-of-hospital cardiac arrest from acute coronary syndrome: a cohort study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background
Each year, approximately 30,000 people have an out-of-hospital cardiac arrest (OHCA) that is treated by UK ambulance services. Across all cases of OHCA, survival to hospital discharge is less than 10%. Acute coronary syndrome (ACS) is a common cause of OHCA.
Objectives
To explore factors that influence survival in patients who initially survive an OHCA attributable to ACS.
Data source
Data collected by the Myocardial Ischaemia National Audit Project (MINAP) between 2003 and 2015.
Participants
Adult patients who had a first OHCA attributable to ACS and who were successfully resuscitated and admitted to hospital.
Main outcome measures
Hospital mortality, neurological outcome at hospital discharge, and time to all-cause mortality.
Methods
We undertook a cohort study using data from the MINAP registry. MINAP is a national audit that collects data on patients admitted to English, Welsh and Northern Irish hospitals with myocardial ischaemia. From the data set, we identified patients who had an OHCA. We used imputation to address data missingness across the data set. We analysed data using multilevel logistic regression to identify modifiable and non-modifiable factors that affect outcome.
Results
Between 2003 and 2015, 1,127,140 patient cases were included in the MINAP data set. Of these, 17,604 OHCA cases met the study inclusion criteria. Overall hospital survival was 71.3%. Across hospitals with at least 60 cases, hospital survival ranged from 34% to 89% (median 71.4%, interquartile range 60.7–76.9%). Modelling, which adjusted for patient and treatment characteristics, could account for only 36.1% of this variability. For the primary outcome, the key modifiable factors associated with reduced mortality were reperfusion treatment [primary percutaneous coronary intervention (pPCI) or thrombolysis] and admission under a cardiologist. Admission to a high-volume cardiac arrest hospital did not influence survival. Sensitivity analyses showed that reperfusion was associated with reduced mortality among patients with a ST elevation myocardial infarction (STEMI), but there was no evidence of a reduction in mortality in patients who did not present with a STEMI.
Limitations
This was an observational study, such that unmeasured confounders may have influenced study findings. Differences in case identification processes at hospitals may contribute to an ascertainment bias.
Conclusions
In OHCA patients who have had a cardiac arrest attributable to ACS, there is evidence of variability in survival between hospitals, which cannot be fully explained by variables captured in the MINAP data set. Our findings provide some support for the current practice of transferring resuscitated patients with a STEMI to a hospital that can deliver pPCI. In contrast, it may be reasonable to transfer patients without a STEMI to the nearest appropriate hospital.
Future work
There is a need for clinical trials to examine the clinical effectiveness and cost-effectiveness of invasive reperfusion strategies in resuscitated OHCA patients of cardiac cause who have not had a STEMI.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Keith Couper
- Warwick Medical School, University of Warwick, Coventry, UK
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Peter K Kimani
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- York Teaching Hospital NHS Foundation Trust, York, UK
| | - Tom Quinn
- Faculty of Health, Social Care and Education, Kingston University, London and St George’s, University of London, London, UK
| | - Iain B Squire
- University of Leicester and Leicester NIHR Cardiovascular Research Unit, Glenfield Hospital, Leicester, UK
| | | | - John JM Black
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK
| | | | | | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Heart of England NHS Foundation Trust, Birmingham, UK
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14
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Gaalema DE, Elliott RJ, Morford ZH, Higgins ST, Ades PA. Effect of Socioeconomic Status on Propensity to Change Risk Behaviors Following Myocardial Infarction: Implications for Healthy Lifestyle Medicine. Prog Cardiovasc Dis 2017; 60:159-168. [PMID: 28063785 PMCID: PMC5498261 DOI: 10.1016/j.pcad.2017.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/02/2017] [Indexed: 01/04/2023]
Abstract
Failure to change risk behaviors following myocardial infarction (MI) increases the likelihood of recurrent MI and death. Lower-socioeconomic status (SES) patients are more likely to engage in high-risk behaviors prior to MI. Less well known is whether propensity to change risk behaviors after MI also varies inversely with SES. We performed a systematized literature review addressing changes in risk behaviors following MI as a function of SES. 2160 abstracts were reviewed and 44 met eligibility criteria. Behaviors included smoking cessation, cardiac rehabilitation (CR), medication adherence, diet, and physical activity (PA). For each behavior, lower-SES patients were less likely to change after MI. Overall, lower-SES patients were 2 to 4 times less likely to make needed behavior changes (OR's 0.25-0.56). Lower-SES populations are less successful at changing risk behaviors post-MI. Increasing their participation in CR/secondary prevention programs, which address multiple risk behaviors, including increasing PA and exercise, should be a priority of healthy lifestyle medicine (HLM).
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Affiliation(s)
- Diann E Gaalema
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT; Department of Psychiatry, University of Vermont, Burlington, VT; Department of Psychological Science, University of Vermont, Burlington, VT.
| | - Rebecca J Elliott
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT; Department of Psychiatry, University of Vermont, Burlington, VT
| | - Zachary H Morford
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT; Department of Psychiatry, University of Vermont, Burlington, VT; Department of Psychological Science, University of Vermont, Burlington, VT
| | - Stephen T Higgins
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT; Department of Psychiatry, University of Vermont, Burlington, VT; Department of Psychological Science, University of Vermont, Burlington, VT
| | - Philip A Ades
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT; Department of Medicine, Division of Cardiology, University of Vermont Medical Center, Burlington, VT
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15
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Schröder SL, Richter M, Schröder J, Frantz S, Fink A. Socioeconomic inequalities in access to treatment for coronary heart disease: A systematic review. Int J Cardiol 2016; 219:70-8. [PMID: 27288969 DOI: 10.1016/j.ijcard.2016.05.066] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 05/12/2016] [Indexed: 11/28/2022]
Abstract
Strong socioeconomic inequalities exist in cardiovascular mortality and morbidity. The current review aims to synthesize the current evidence on the association between socioeconomic status (SES) and access to treatment of coronary heart disease (CHD). We examined quantitative studies analyzing the relationship between SES and access to CHD treatment that were published between 1996 and 2015. Our data sources included Medline and Web of Science. Our search yielded a total of 2066 records, 57 of which met our inclusion criteria. Low SES was found to be associated with low access to coronary procedures and secondary prevention. Access to coronary procedures, especially coronary angiography, was mainly related to SES to the disadvantage of patients with low SES. However, access to drug treatment and cardiac rehabilitation was only associated with SES in about half of the studies. The association between SES and access to treatment for CHD was stronger when SES was measured based on individual-level compared to area level, and stronger for individuals living in countries without universal health coverage. Socioeconomic inequalities exist in access to CHD treatment, and universal health coverage shows only a minor effect on this relationship. Inequalities diminish along the treatment pathway for CHD from diagnostic procedures to secondary prevention. We therefore conclude that CHD might be underdiagnosed in patients with low SES. Our results indicate that there is an urgent need to improve access to CHD treatment, especially by increasing the supply of diagnostic angiographies, to reduce inequalities across different healthcare systems.
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Affiliation(s)
- Sara L Schröder
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Germany.
| | - Matthias Richter
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Germany
| | - Jochen Schröder
- Department of Internal Medicine III (Cardiology and Angiology), Martin Luther University Halle-Wittenberg, Germany
| | - Stefan Frantz
- Department of Internal Medicine III (Cardiology and Angiology), Martin Luther University Halle-Wittenberg, Germany
| | - Astrid Fink
- Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Germany
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16
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Fabreau GE, Leung AA, Southern DA, James MT, Knudtson ML, Ghali WA, Ayanian JZ. Area Median Income and Metropolitan Versus Nonmetropolitan Location of Care for Acute Coronary Syndromes: A Complex Interaction of Social Determinants. J Am Heart Assoc 2016; 5:JAHA.115.002447. [PMID: 26908400 PMCID: PMC4802481 DOI: 10.1161/jaha.115.002447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Metropolitan versus nonmetropolitan status and area median income may independently affect care for and outcomes of acute coronary syndromes. We sought to determine whether location of care modifies the association among area income, receipt of cardiac catheterization, and mortality following an acute coronary syndrome in a universal health care system. Methods and Results We studied a cohort of 14 012 acute coronary syndrome patients admitted to cardiology services between April 18, 2004, and December 31, 2011, in southern Alberta, Canada. We used multivariable logistic regression to determine the odds of cardiac catheterization within 1 day and 7 days of admission and the odds of 30‐day and 1‐year mortality according to area median household income quintile for patients presenting at metropolitan and nonmetropolitan hospitals. In models adjusting for area income, patients who presented at nonmetropolitan facilities had lower adjusted odds of receiving cardiac catheterization within 1 day of admission (odds ratio 0.22, 95% CI 0.11–0.46, P<0.001). Among nonmetropolitan patients, when examined by socioeconomic status, each incremental decrease in income quintile was associated with 10% lower adjusted odds of receiving cardiac catheterization within 7 days (P<0.001) and 24% higher adjusted odds of 30‐day mortality (P=0.008) but no significant difference for 1‐year mortality (P=0.12). There were no differences in adjusted mortality among metropolitan patients. Conclusion Within a universal health care system, the association among area income and receipt of cardiac catheterization and 30‐day mortality differed depending on the location of initial medical care for acute coronary syndromes. Care protocols are required to improve access to care and outcomes in patients from low‐income nonmetropolitan communities.
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Affiliation(s)
- Gabriel E Fabreau
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA O'Brien Institute for Public Health, University of Calgary, Alberta, Canada Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Alexander A Leung
- O'Brien Institute for Public Health, University of Calgary, Alberta, Canada
| | | | - Matthew T James
- O'Brien Institute for Public Health, University of Calgary, Alberta, Canada
| | | | - William A Ghali
- O'Brien Institute for Public Health, University of Calgary, Alberta, Canada
| | - John Z Ayanian
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA Department of Health Care Policy, Harvard Medical School, Boston, MA Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
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17
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Savu A, Schopflocher D, Scholnick B, Kaul P. The intersection of health and wealth: association between personal bankruptcy and myocardial infarction rates in Canada. BMC Public Health 2016; 16:31. [PMID: 26762139 PMCID: PMC4711153 DOI: 10.1186/s12889-016-2705-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 01/09/2016] [Indexed: 11/28/2022] Open
Abstract
Background We examined the association between personal bankruptcy filing and acute myocardial infarction (AMI) rates in Canada. Methods Between 2002 and 2009, aggregate and yearly bankruptcy and AMI rates were estimated for 1,155 forward sortation areas of Canada. Scatter plot and correlations were used to assess the association of the aggregate rates. Cross-lagged structural equation models were used to explore the longitudinal relationship between bankruptcy and AMI after adjustment for socio-economic factors. Results A cross-lagged structural equation model estimated that on average, an increase of 100 in bankruptcy filing count is associated with an increase of 1.5 (p = 0.02) in AMI count in the following year, and an increase of 100 in AMI count is associated with an increase of 7 (p < 0.01) in bankruptcy filing count. Conclusions We found that regions with higher rates of AMI corresponded to those with higher levels of economic and financial stress, as indicated by personal bankruptcy rate, and vice-versa.
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Affiliation(s)
- Anamaria Savu
- Canadian Vigour Center, University of Alberta, Edmonton, AB, T6G 2E1, Canada
| | | | - Barry Scholnick
- Alberta School of Business, University of Alberta, Edmonton, AB, T6G 2R6, Canada
| | - Padma Kaul
- Canadian Vigour Center, University of Alberta, Edmonton, AB, T6G 2E1, Canada.
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18
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Lewis MW, Khodneva Y, Redmond N, Durant RW, Judd SE, Wilkinson LL, Howard VJ, Safford MM. The impact of the combination of income and education on the incidence of coronary heart disease in the prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study. BMC Public Health 2015; 15:1312. [PMID: 26715537 PMCID: PMC4696109 DOI: 10.1186/s12889-015-2630-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/16/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We investigated the association between income-education groups and incident coronary heart disease (CHD) in a national prospective cohort study. METHODS The REasons for Geographic And Racial Differences in Stroke study recruited 30,239 black and white community-dwelling adults between 2003 and 2007 and collected participant-reported and in-home physiologic variables at baseline, with expert adjudicated CHD endpoints during follow-up. Mutually exclusive income-education groups were: low income (annual household income <$35,000)/low education (< high school), low income/high education, high income/low education, and high income/high education. Cox models estimated hazard ratios (HR) for incident CHD for each exposure group, examining differences by age group. RESULTS At baseline, 24,461 participants free of CHD experienced 809 incident CHD events through December 31, 2011 (median follow-up 6.0 years; interquartile range 4.5-7.3 years). Those with low income/low education had the highest incidence of CHD (10.1 [95% CI 8.4-12.1]/1000 person-years). After full adjustment, those with low income/low education had higher risk of incident CHD (HR 1.42 [95% CI: 1.14-1.76]) than those with high income/high education, but findings varied by age. Among those aged <65 years, compared with those reporting high income/high education, risk of incident CHD was significantly higher for those reporting low income/low education and low income/high education (adjusted HR 2.07 [95% CI 1.42-3.01] and 1.69 [95% CI 1.30-2.20], respectively). Those aged ≥ 65 years, risk of incident CHD was similar across income-education groups after full adjustment. CONCLUSION For younger individuals, low income, regardless of education, was associated with higher risk of CHD, but not observed for ≥ 65 years. Findings suggest that for younger participants, education attainment may not overcome the disadvantage conferred by low income in terms of CHD risk, whereas among those ≥ 65 years, the independent effects of income and education are less pronounced.
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Affiliation(s)
- Marquita W Lewis
- Department of Human Studies, School of Education, College of Arts and Sciences, University of Alabama at Birmingham, 901 13th Street South, Birmingham, AL, 35294-1250, USA. .,Department of Medicine, School of Medicine, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL, 35294-4410, USA.
| | - Yulia Khodneva
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL, 35294-4410, USA.
| | - Nicole Redmond
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL, 35294-4410, USA.
| | - Raegan W Durant
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL, 35294-4410, USA.
| | - Suzanne E Judd
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, 1665 University Boulevard, Birmingham, AL, 35294-0022, USA.
| | - Larrell L Wilkinson
- Department of Human Studies, School of Education, College of Arts and Sciences, University of Alabama at Birmingham, 901 13th Street South, Birmingham, AL, 35294-1250, USA.
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1665 University Boulevard, Birmingham, AL, 35294-0022, USA.
| | - Monika M Safford
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL, 35294-4410, USA.
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19
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Bucholz EM, Ma S, Normand SLT, Krumholz HM. Race, Socioeconomic Status, and Life Expectancy After Acute Myocardial Infarction. Circulation 2015; 132:1338-46. [PMID: 26369354 PMCID: PMC5097251 DOI: 10.1161/circulationaha.115.017009] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 07/21/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous studies have been unable to disentangle the negative associations of black race and low socioeconomic status (SES) with long-term outcomes of patients after acute myocardial infarction (AMI). Such information could assist in efforts to address both racial and socioeconomic disparities. METHODS AND RESULTS We used data from the Cooperative Cardiovascular Project, a prospective cohort study of Medicare beneficiaries hospitalized with AMI with 17 years of follow-up, to evaluate the relationship between race, area-level SES (measured by zip code-level median household income), and life expectancy after AMI. Life expectancy was estimated by using Cox proportional hazards regression with extrapolation using exponential models. Of the 141 095 patients with AMI, 6.3% were black and 6.8% resided in low-SES areas; 26% of black patients lived in low-SES areas in comparison with 5.7% of white patients. Post-myocardial infarction life expectancy estimates were shorter for black patients than for white patients across all socioeconomic levels in patients ≤ 75 years of age. After adjustment for patient and treatment characteristics, the association between race and life expectancy persisted but was attenuated. Younger black patients (<68 years) had shorter life expectancies than white patients, whereas older black patients had longer life expectancies. The largest white-black gap in life expectancy occurred in patients residing in high- and medium-SES areas (P=0.02 interaction). CONCLUSIONS Black and white patients residing in low-SES areas have similar life expectancies after AMI, which are lower than those living in higher-SES areas. Racial disparities were most prominent among patients living in high-SES areas.
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Affiliation(s)
- Emily M Bucholz
- From Yale School of Medicine, New Haven, CT (E.M.B.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.M.B.); Department of Biostatistics, Yale School of Public Health, New Haven, CT (S.M.); Department of Biostatistics, Harvard School of Public Health, and Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.T.N.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven CT (H.M.K.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Robert Wood Johnson Clinical Scholars Program, Department of Medicine (H.M.K.); and the Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Shuangge Ma
- From Yale School of Medicine, New Haven, CT (E.M.B.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.M.B.); Department of Biostatistics, Yale School of Public Health, New Haven, CT (S.M.); Department of Biostatistics, Harvard School of Public Health, and Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.T.N.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven CT (H.M.K.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Robert Wood Johnson Clinical Scholars Program, Department of Medicine (H.M.K.); and the Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Sharon-Lise T Normand
- From Yale School of Medicine, New Haven, CT (E.M.B.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.M.B.); Department of Biostatistics, Yale School of Public Health, New Haven, CT (S.M.); Department of Biostatistics, Harvard School of Public Health, and Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.T.N.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven CT (H.M.K.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Robert Wood Johnson Clinical Scholars Program, Department of Medicine (H.M.K.); and the Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Harlan M Krumholz
- From Yale School of Medicine, New Haven, CT (E.M.B.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.M.B.); Department of Biostatistics, Yale School of Public Health, New Haven, CT (S.M.); Department of Biostatistics, Harvard School of Public Health, and Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.T.N.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven CT (H.M.K.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Robert Wood Johnson Clinical Scholars Program, Department of Medicine (H.M.K.); and the Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine, New Haven, CT (H.M.K.).
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20
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Thorne K, Williams JG, Akbari A, Roberts SE. The impact of social deprivation on mortality following acute myocardial infarction, stroke or subarachnoid haemorrhage: a record linkage study. BMC Cardiovasc Disord 2015; 15:71. [PMID: 26187051 PMCID: PMC4506594 DOI: 10.1186/s12872-015-0045-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 06/01/2015] [Indexed: 12/20/2022] Open
Abstract
Background The impact of social deprivation on mortality following acute myocardial infarction (AMI), stroke and subarachnoid haemorrhage (SAH) is unclear. Our objectives were, firstly, to determine, for each condition, whether there was higher mortality following admission according to social deprivation and secondly, to determine how any higher mortality for deprived groups may be correlated with factors including patient demographics, timing of admission and hospital size. Methods Routinely collected, linked hospital inpatient, mortality and primary care data were analysed for patients admitted as an emergency to hospitals in Wales between 2004 and 2011 with AMI (n = 30,663), stroke (37,888) and SAH (1753). Logistic regression with Bonferroni correction was used to examine, firstly, any significant increases in mortality with social deprivation quintile and, secondly, the influence of patient demographics, timing of admission and hospital characteristics on any higher mortality among the most socially deprived groups. Results Mortality was 14.3 % at 30 days for AMI, 21.4 % for stroke and 35.6 % for SAH. Social deprivation was significantly associated with higher mortality for AMI (25 %; 95 % CI = 12 %, 40 %) higher for quintile V compared with I), stroke (24 %; 14 %, 34 %), and non-significantly for SAH (32 %; −7 %, 87 %). The higher mortality at 30 days with increased social deprivation varied significantly according to patient age for AMI patients and time period for SAH. It was also highest for both AMI and stroke patients, although not significantly for female patients, for admissions on weekdays and during autumn months. Conclusions We have demonstrated a positive association between social deprivation and higher mortality following emergency admissions for both AMI and stroke. The study findings also suggest that the influence of patient demographics, timing of admission and hospital size on social inequalities in mortality are quite similar for AMI and stroke. Electronic supplementary material The online version of this article (doi:10.1186/s12872-015-0045-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kymberley Thorne
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, UK.
| | - John G Williams
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, UK.
| | - Ashley Akbari
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, UK.
| | - Stephen E Roberts
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, UK.
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21
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Vassileva CM, Boley T, Standard J, Markwell S, Hazelrigg S. Relationship between Patient Income Level and Mitral Valve Repair Utilization. Heart Surg Forum 2015; 16:E89-95. [DOI: 10.1532/hsf98.20121105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
<p><b>Background:</b> The superiority of mitral valve (MV) repair is well established with respect to long-term survival, preservation of ventricular function, and valve-related complications. The relationship between patient income level and the selection of MV procedure (repair versus replacement) has not been studied.</p><p><b>Methods:</b> The 2005 to 2007 Nationwide Inpatient Sample database was searched for patients ? 30 years old with MV repair or replacement; patients with ischemic and congenital MV disease were excluded. Patients were stratified into quartiles according to income level (quartile 1, lowest; quartile 4, highest). We used univariate and multivariate models to compare patients with respect to baseline characteristics, selection of MV procedure, and hospital mortality.</p><p><b>Results:</b> The preoperative profiles of the income quartiles differed significantly, with more risk factors occurring in the lower income quartiles. Unadjusted hospital mortality decreased with increasing income quartile. The percentage of patients receiving MV repair increased with increasing income (35.6%, 39.6%, 48.2%, and 55.8% for quartiles 1, 2, 3, and 4, respectively; <i>P</i> = .0001). Following adjustment for age, race, sex, urban residency, admission status, primary payer, Charlson comorbidity index, and hospital location and teaching status, the income quartiles had similar hospital death rates, whereas the highly significant relationship between valve repair and income level persisted (<i>P</i> = .0008).</p><p><b>Conclusions:</b> Significant disparity exists among patients in the different income quartiles with respect to the likelihood of receiving MV repair. MV repair is performed less frequently in patients with lower incomes, even after adjustment for differences in baseline characteristics. The higher unadjusted mortality rate for less affluent patients appears mostly related to their worse preoperative profiles.</p>
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22
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Bhayana R, Vermeulen MJ, Li Q, Hellings CR, Berdahl C, Schull MJ. Socioeconomic status and the use of computed tomography in the emergency department. CAN J EMERG MED 2015; 16:288-95. [PMID: 25060082 DOI: 10.2310/8000.2013.131102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACT
Background:
Low socioeconomic status (SES) is associated with adverse health outcomes. Possible explanations include differences in health status, access to health care, and care provided by clinicians. We sought to determine whether SES is associated with computed tomography (CT) use in the emergency department (ED).
Methods:
A retrospective cohort study of all Ontario ED patients (April 1, 2009, to March 31, 2010) using administrative databases was conducted, and patients were stratified into SES quintiles based on median neighbourhood income. Using multivariate logistical regression, CT scan use within SES quintiles was compared for all patients and subgroups based on chief complaints: headache, abdominal pain, and complex abdominal pain (age ≥ 65 years, high acuity, and admittance to hospital).
Results:
We analyzed 4,551,101 patient visits, of which 52% were female. Overall, 8.2% underwent CT scanning. In adjusted analyses, the lowest SES patients were less likely to undergo CT scanning overall and in all clinical subgroups, except for complex abdominal pain. Compared to the lowest SES quintile, the adjusted odds ratios of CT scanning in the highest SES quintile were 1.08 (95% CI 1.07–1.09), 1.28 (95%CI 1.22–1.34), and 1.24 (95% CI 1.21–1.27) for all patients, headache pain patients, and abdominal pain patients, respectively. For patients presenting with complex abdominal pain, no significant difference in CT use was observed.
Conclusion:
Lowest SES ED patients were less likely to receive CT scans overall and in headache and abdominal pain subgroups. No difference was seen among complex abdominal pain patients, suggesting that as clinical indications for the test become more clearcut, use across SES quintiles differs less.
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23
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van Loo HM, van den Heuvel ER, Schoevers RA, Anselmino M, Carney RM, Denollet J, Doyle F, Freedland KE, Grace SL, Hosseini SH, Parakh K, Pilote L, Rafanelli C, Roest AM, Sato H, Steeds RP, Kessler RC, de Jonge P. Sex dependent risk factors for mortality after myocardial infarction: individual patient data meta-analysis. BMC Med 2014; 12:242. [PMID: 25515680 PMCID: PMC4292997 DOI: 10.1186/s12916-014-0242-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 11/21/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Although a number of risk factors are known to predict mortality within the first years after myocardial infarction, little is known about interactions between risk factors, whereas these could contribute to accurate differentiation of patients with higher and lower risk for mortality. This study explored the effect of interactions of risk factors on all-cause mortality in patients with myocardial infarction based on individual patient data meta-analysis. METHODS Prospective data for 10,512 patients hospitalized for myocardial infarction were derived from 16 observational studies (MINDMAPS). Baseline measures included a broad set of risk factors for mortality such as age, sex, heart failure, diabetes, depression, and smoking. All two-way and three-way interactions of these risk factors were included in Lasso regression analyses to predict time-to-event related all-cause mortality. The effect of selected interactions was investigated with multilevel Cox regression models. RESULTS Lasso regression selected five two-way interactions, of which four included sex. The addition of these interactions to multilevel Cox models suggested differential risk patterns for males and females. Younger women (age<50) had a higher risk for all-cause mortality than men in the same age group (HR 0.7 vs. 0.4), while men had a higher risk than women if they had depression (HR 1.4 vs. 1.1) or a low left ventricular ejection fraction (HR 1.7 vs. 1.3). Predictive accuracy of the Cox model was better for men than for women (area under the curves: 0.770 vs. 0.754). CONCLUSIONS Interactions of well-known risk factors for all-cause mortality after myocardial infarction suggested important sex differences. This study gives rise to a further exploration of prediction models to improve risk assessment for men and women after myocardial infarction.
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Affiliation(s)
- Hanna M van Loo
- Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Department of Psychiatry, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Edwin R van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Den Dolech 2, 5612 AZ, Eindhoven, The Netherlands.
| | - Robert A Schoevers
- Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Department of Psychiatry, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Matteo Anselmino
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, C.so A.M. Dogliotti, 14, 10126, Turin, Italy.
| | - Robert M Carney
- Department of Psychiatry, Washington University School of Medicine, 4320 Forest Park Avenue, St. Louis, Missouri, 63108, USA.
| | - Johan Denollet
- CoRPS-Center of Research on Psychology in Somatic diseases, Tilburg University, Warandelaan 2, 5000 LE, Tilburg, The Netherlands.
| | - Frank Doyle
- Division of Population Health Sciences (Psychology), Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland.
| | - Kenneth E Freedland
- Department of Psychiatry, Washington University School of Medicine, 4320 Forest Park Avenue, St. Louis, Missouri, 63108, USA.
| | - Sherry L Grace
- Faculty of Health, York University and University Health Network, 368 Norman Bethune, 4700 Keele Street, Toronto, M3J 1P3, Canada.
| | - Seyed H Hosseini
- Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Psychosomatic department, Imam hospital, Sari, Iran.
| | - Kapil Parakh
- John Hopkins School of Medicine, John Hopkins Bloomberg School of Public Health, John Hoplins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, Maryland, 21224, USA.
| | - Louise Pilote
- Division of General Internal Medicine, McGill University, McGill University Health Centre, 687 Pine Avenue West, V Building, V2.17, Montreal, H3A 1A1, Canada.
| | - Chiara Rafanelli
- Department of Psychology, University of Bologna, Viale Berti Pichat 5, 40127, Bologna, Italy.
| | - Annelieke M Roest
- Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Department of Psychiatry, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Hiroshi Sato
- School of Human Welfare Studies, Kwansei Gakuin University, 1-1-155, Uegahara, Nishinomiya, Hyogo, 662-8501, Japan.
| | - Richard P Steeds
- Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH, West Midlands, UK.
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, Massachusetts, 02115, USA.
| | - Peter de Jonge
- Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Department of Psychiatry, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO box 30.001, 9700 RB, Groningen, The Netherlands.
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Reduction in myocardial infarction incidence: focus on socioeconomic disparities. Int J Cardiol 2014; 174:773-4. [PMID: 24794958 DOI: 10.1016/j.ijcard.2014.04.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 04/04/2014] [Indexed: 11/24/2022]
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Fabreau GE, Leung AA, Southern DA, Knudtson ML, McWilliams JM, Ayanian JZ, Ghali WA. Sex, socioeconomic status, access to cardiac catheterization, and outcomes for acute coronary syndromes in the context of universal healthcare coverage. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2014; 7:540-9. [PMID: 24895450 DOI: 10.1161/circoutcomes.114.001021] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sex and neighborhood socioeconomic status (nSES) may independently affect the care and outcomes of acute coronary syndrome, partly through barriers in timely access to cardiac catheterization. We sought to determine whether sex modifies the association between nSES and the receipt of cardiac catheterization and mortality after an acute coronary syndrome in a universal healthcare system. METHODS AND RESULTS We studied 14 012 patients with acute coronary syndrome admitted to cardiology services between April 18, 2004, and December 31, 2011, in Southern Alberta, Canada. We used multivariable logistic regression to compare the odds of cardiac catheterization within 2 and 30 days of admission and the odds of 30-day and 1-year mortality for men and women by quintile of neighborhood median household income. Significant relationships between nSES and the receipt of cardiac catheterization and mortality after acute coronary syndrome were detected for women but not men. When examined by nSES, each incremental decrease in neighborhood income quintile for women was associated with a 6% lower odds of receiving cardiac catheterization within 30 days (P=0.01) and a 14% higher odds of 30-day mortality (P=0.03). For men, each decrease in neighborhood income quintile was associated with a 2% lower odds of receiving catheterization within 30 days (P=0.10) and a 5% higher odds of 30-day mortality (P=0.36). CONCLUSIONS Associations between nSES and receipt of cardiac catheterization and 30-day mortality were noted for women but not men in a universal healthcare system. Care protocols designed to improve equity of access to care and outcomes are required, especially for low-income women.
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Affiliation(s)
- Gabriel E Fabreau
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.).
| | - Alexander A Leung
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
| | - Danielle A Southern
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
| | - Merrill L Knudtson
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
| | - J Michael McWilliams
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
| | - John Z Ayanian
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
| | - William A Ghali
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
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Kim JH, Jeong MH, Park IH, Choi JS, Rhee JA, Lee DH, Park SH, Kim IS, Jeong HC, Cho JY, Jang SY, Lee KH, Park KH, Sim DS, Kim KH, Hong YJ, Park HW, Kim JH, Ahn Y, Cho JG, Park JC. The association of socioeconomic status with three-year clinical outcomes in patients with acute myocardial infarction who underwent percutaneous coronary intervention. J Korean Med Sci 2014; 29:536-43. [PMID: 24753701 PMCID: PMC3991797 DOI: 10.3346/jkms.2014.29.4.536] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 02/03/2014] [Indexed: 11/20/2022] Open
Abstract
The aim of this study was to evaluate whether the clinical outcomes were associated with socioeconomic status (SES) in patients with acute myocardial infarction (AMI) who underwent percutaneous coronary intervention (PCI). The author analyzed 2,358 patients (64.9 ± 12.3 yr old, 71.5% male) hospitalized with AMI between November 2005 and June 2010. SES was measured by the self-reported education (years of schooling), the residential address (social deprivation index), and the national health insurance status (medical aid beneficiaries). Sequential multivariable modeling assessed the relationship of SES factors with 3-yr major adverse cardiovascular events (MACEs) and mortality after the adjustment for demographic and clinical factors. During the 3-yr follow-up, 630 (26.7%) MACEs and 322 (13.7%) all-cause deaths occurred in 2,358 patients. In multivariate Cox proportional hazards regression modeling, the only lower education of SES variables was associated with MACEs (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.04-1.91) and mortality (HR, 1.93; 95% CI, 1.16-3.20) in the patients with AMI who underwent PCI. The study results indicate that the lower education is a significant associated factor to increased poor clinical outcomes in patients with AMI who underwent PCI.
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Affiliation(s)
- Jeong Hun Kim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
- Department of Public Health, Chonnam National University Medical School, Gwangju, Korea
| | - Myung Ho Jeong
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
- Department of Public Health, Chonnam National University Medical School, Gwangju, Korea
| | - In Hyae Park
- Department of Public Health, Chonnam National University Medical School, Gwangju, Korea
| | - Jin Soo Choi
- Department of Public Health, Chonnam National University Medical School, Gwangju, Korea
| | - Jung Ae Rhee
- Department of Public Health, Chonnam National University Medical School, Gwangju, Korea
| | - Doo Hwan Lee
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Soo Hwan Park
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - In Soo Kim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Hae Chang Jeong
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jae Yeong Cho
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Soo Young Jang
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Ki hong Lee
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Keun-Ho Park
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Doo Sun Sim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Kye Hun Kim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Hyung Wook Park
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Ju Han Kim
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jeong Gwan Cho
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
| | - Jong Chun Park
- The Heart Center of Chonnam National University Hospital, Gwangju, Korea
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Kirchberger I, Meisinger C, Golüke H, Heier M, Kuch B, Peters A, Quinones PA, von Scheidt W, Mielck A. Long-term survival among older patients with myocardial infarction differs by educational level: results from the MONICA/KORA myocardial infarction registry. Int J Equity Health 2014; 13:19. [PMID: 24552463 PMCID: PMC3940020 DOI: 10.1186/1475-9276-13-19] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 02/07/2014] [Indexed: 11/10/2022] Open
Abstract
Background Socioeconomic disparities in survival after acute myocardial infarction (AMI) have been found in many countries. However, population-based results from Germany are lacking so far. Thus, the objective of this study was to examine the association between educational status and long-term mortality in a population-based sample of people with AMI. Methods The sample consisted of 2,575 men and 844 women, aged 28–74 years, hospitalized with a first-time AMI between 1 January 2000 and 31 December 2008, recruited from a population-based AMI registry. Patients were followed up until December 2011. Data on education, risk factors and co-morbidities were collected by individual interviews; data on clinical characteristics and AMI treatment by chart review. Cox proportional hazards models were used to assess the relationship between educational status and long-term mortality. Results During follow-up, 19.1% of the patients with poor education died compared with 13.1% with higher education. After adjustment for covariates, no effect of education on mortality was found for the total sample and for patients aged below 65 years. In older people, however, low education level was significantly associated with increased mortality (hazard ratio (HR) 1.44, 95% confidence interval (CI) 1.05–1.98, p = 0.023). Stratified analyses showed that women older than 64 years with poor education were significantly more likely to die than women in the same age group with higher education (HR 1.57, 95% CI 1.02–2.41, p = 0.039). Conclusions Elderly, poorly educated patients with AMI, and particularly women, have poorer long-term survival than their better educated peers. Further research is required to illuminate the reasons for this finding.
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Affiliation(s)
- Inge Kirchberger
- Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Stenglinstr, 2, Augsburg D-86156, Germany.
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Wang JY, Wang CY, Juang SY, Huang KY, Chou P, Chen CW, Lee CC. Low socioeconomic status increases short-term mortality of acute myocardial infarction despite universal health coverage. Int J Cardiol 2014; 172:82-7. [PMID: 24444479 DOI: 10.1016/j.ijcard.2013.12.082] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 12/16/2013] [Accepted: 12/20/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND This nationwide population-based study investigated the relationship between individual and neighborhood socioeconomic status (SES) and mortality rates for acute myocardial infarction (AMI) in Taiwan. METHODS A population-based follow-up study included 23,568 patients diagnosed with AMI from 2004 to 2008. Each patient was monitored for 2 years, or until their death, whichever came first. The individual income-related insurance payment amount was used as a proxy measure of patient's individual SES. Neighborhood SES was defined by household income, and neighborhoods were grouped as advantaged or disadvantaged. The Cox proportional hazards model was used to compare the mortality rates between the different SES groups after adjusting for possible confounding risk factors. RESULTS After adjusting for potential confounding factors, AMI patients with low individual SES had an increased risk of death than those with high individual SES who resided in advantaged neighborhoods. In contrast, the cumulative readmission rate from major adverse cardiovascular events did not differ significantly between the different individual and neighborhood SES groups. AMI patients with low individual SES had a lower rate of diagnostic angiography and subsequent percutaneous coronary intervention (P<0.001). The presence of congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, pneumonia, septicemia, and shock revealed an incremental increase with worse SES (P<0.001). CONCLUSIONS The findings indicate that AMI patients with low individual SES have the greatest risk of short-term mortality despite being under a universal health-care system. Public health strategies and welfare policies must continue to focus on this vulnerable group.
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Affiliation(s)
- Jen-Yu Wang
- Department of Internal Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Shiun-Yang Juang
- Department of Medical Research, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Kuang-Yung Huang
- School of Medicine, Tzu Chi University, Hualian, Taiwan; Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Pesus Chou
- Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Wei Chen
- School of Medicine, Tzu Chi University, Hualian, Taiwan; Division of Cardiology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.
| | - Ching-Chih Lee
- School of Medicine, Tzu Chi University, Hualian, Taiwan; Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Taiwan; Department of Otolaryngology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; Department of Education, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; Center for Clinical Epidemiology and Biostatistics, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.
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Venermo M, Manderbacka K, Ikonen T, Keskimäki I, Winell K, Sund R. Amputations and socioeconomic position among persons with diabetes mellitus, a population-based register study. BMJ Open 2013; 3:e002395. [PMID: 23572197 PMCID: PMC3641442 DOI: 10.1136/bmjopen-2012-002395] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 02/18/2013] [Accepted: 02/22/2013] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Low socioeconomic position is a known health risk. Our study aims to evaluate the association between socioeconomic position (SEP) and lower limb amputations among persons with diabetes mellitus. DESIGN Population-based register study. SETTING Finland, nationwide individual-level data. PARTICIPANTS All persons in Finland with any record of diabetes in the national health and population registers from 1991 to 2007 (FinDM II database). METHODS Three outcome indicators were measured: the incidence of first major amputation, the ratio of first minor/major amputations and the 2-year survival with preserved leg after the first minor amputation. SEP was measured using income fifths. The data were analysed using Poisson and Cox regression as well as age-standardised ratios. RESULTS The risk ratio of the first major amputation in the lowest SEP group was 2.16 (95% CI 1.95 to 2.38) times higher than the risk in the highest SEP group (p<0.001). The incidence of first major amputation decreased by more than 50% in all SEP groups from 1993 to 2007, but there was a stronger relative decrease in the highest compared with the lowest SEP group (p=0.0053). Likewise, a clear gradient was detected in the ratio of first minor/major amputations: the higher the SEP group, the higher the ratio. After the first minor amputation, the 2-year and 10-year amputation-free survival rates were 55.8% and 9.3% in the lowest and 78.9% and 32.3% in the highest SEP group, respectively. CONCLUSIONS According to all indicators used, lower SEP was associated with worse outcomes in the population with diabetes. Greater attention should be paid to prevention of diabetes complications, adherence to treatment guidelines and access to the established pathways for early expert assessment when diabetic complications arise, with a special attention to patients from lower SEP groups.
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Affiliation(s)
- Maarit Venermo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Kristiina Manderbacka
- Service System Research Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Tuija Ikonen
- Technologies and Practices Assessment Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Ilmo Keskimäki
- Division of Health and Social Services, National Institute for Health and Welfare, Helsinki, Finland
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Klas Winell
- Division of Health and Social Services, National Institute for Health and Welfare, Helsinki, Finland
| | - Reijo Sund
- Service System Research Unit, National Institute for Health and Welfare, Helsinki, Finland
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Tonne C, Wilkinson P. Long-term exposure to air pollution is associated with survival following acute coronary syndrome. Eur Heart J 2013; 34:1306-11. [PMID: 23423735 PMCID: PMC3640199 DOI: 10.1093/eurheartj/ehs480] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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 (PM2.5; PM, particulate matter): the fully adjusted hazard ratio for a 10 µg/m3 increase in PM2.5 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 PM2.5 in survivors of hospital admission for ACS in England and Wales. Despite higher exposure to PM2.5 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.
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Affiliation(s)
- Cathryn Tonne
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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Jones CA, Perera A, Chow M, Ho I, Nguyen J, Davachi S. Cardiovascular disease risk among the poor and homeless - what we know so far. Curr Cardiol Rev 2011; 5:69-77. [PMID: 20066152 PMCID: PMC2803292 DOI: 10.2174/157340309787048086] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 08/26/2008] [Accepted: 08/26/2008] [Indexed: 11/22/2022] Open
Abstract
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.
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Shahian DM, Nordberg P, Meyer GS, Mort E, Atamian S, Liu X, Karson AS, Zheng H. Predictors of nonadherence to national hospital quality measures for heart failure and pneumonia. Am J Med 2011; 124:636-46. [PMID: 21683830 DOI: 10.1016/j.amjmed.2011.03.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 03/08/2011] [Accepted: 03/08/2011] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- David M Shahian
- Massachusetts General Hospital, Center for Quality and Safety, Department of Surgery, Harvard Medical School, Boston, 02114, USA.
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Donyavi T, Naieni KH, Nedjat S, Vahdaninia M, Najafi M, Montazeri A. Socioeconomic status and mortality after acute myocardial infarction: a study from Iran. Int J Equity Health 2011; 10:9. [PMID: 21299888 PMCID: PMC3042926 DOI: 10.1186/1475-9276-10-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 02/07/2011] [Indexed: 11/28/2022] Open
Abstract
Background Studies have shown an inverse relationship between socioeconomic status (SES) and mortality due to coronary heart disease (CHD). Little is known about this association in Iran. This study aimed to investigate whether mortality after myocardial infarction (MI) varies by SES. Methods In a retrospective study, 1283 MI patients who hospitalized in Tehran Heart Center from March 2005 to March 2006 were followed up in March 2008. Demographic, clinical and SES data were collected from case records and by telephone interviews. Multiple logistic regression analysis was performed to estimate the predictive effect of socioeconomic factors on outcome. Results In all 664 patients were studied. Of these, 500 patients were alive and 164 were dead due to MI (64 died at hospital and 100 died at home). The results of regression analysis showed that in addition to treatment (OR = 9.52, 95%CI 4.84-18.7), having diabetes (OR = 1.78, 95% CI 1.12-2.81) or hyperlipidemia (OR = 1.82, 95% CI 1.14-2.90), socioeconomic variables including living area in square per person (lowest level vs. upper level OR = 4.92, 95% CI 2.11-11.4), unemployment (OR = 3.50, 95% CI 1.50-8.13) and education (OR for illiterate patients = 2.51, 95% CI 1.00-6.31) were the most significant contributing factors to increased mortality after MI. Conclusion Although the findings should be interpreted with caution, the study results indicated that socioeconomic variables were significant contributing factors to increased mortality after myocardial infarction. The underlying role of socioeconomic status on increased mortality after MI deserves further investigation.
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Affiliation(s)
- Tahereh Donyavi
- Department of Mental Health, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran.
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Socioeconomic Disparities in Infant Mortality After Nonaccidental Trauma: A Multicenter Study. ACTA ACUST UNITED AC 2010; 69:20-5. [DOI: 10.1097/ta.0b013e3181bbd7c3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gerber Y, Benyamini Y, Goldbourt U, Drory Y. Neighborhood socioeconomic context and long-term survival after myocardial infarction. Circulation 2010; 121:375-83. [PMID: 20065165 DOI: 10.1161/circulationaha.109.882555] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Yariv Gerber
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, 69978, Israel.
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Korda RJ, Clements MS, Kelman CW. Universal health care no guarantee of equity: comparison of socioeconomic inequalities in the receipt of coronary procedures in patients with acute myocardial infarction and angina. BMC Public Health 2009; 9:460. [PMID: 20003401 PMCID: PMC2807435 DOI: 10.1186/1471-2458-9-460] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 12/14/2009] [Indexed: 11/10/2022] Open
Abstract
Background In Australia there is a socioeconomic gradient in morbidity and mortality favouring socioeconomically advantaged people, much of which is accounted for by ischaemic heart disease. This study examines if Australia's universal health care system, with its mixed public/private funding and delivery model, may actually perpetuate this inequity. We do this by quantifying and comparing socioeconomic inequalities in the receipt of coronary procedures in patients with acute myocardial infarction (AMI) and patients with angina. Methods Using linked hospital and mortality data, we followed patients admitted to Western Australian hospitals with a first admission for AMI (n = 5539) or angina (n = 7401) in 2001-2003. An outcome event was the receipt, within a year, of a coronary procedure—angiography, angioplasty and/or coronary artery bypass surgery (CABG). Socioeconomic status was assigned to each individual using an area-based measure, the SEIFA Index of Disadvantage. Multivariable proportional hazards regression was used to model the association between socioeconomic status and procedure rates, allowing for censoring and adjustment of multiple covariates. Mediating models examined the effect of private health insurance. Results In the AMI patient cohort, socioeconomic gradients were not evident except that disadvantaged women were more likely than advantaged women to undergo CABG. In contrast, in the angina patient group there were clear socioeconomic gradients for all procedures, favouring more advantaged patients. Compared with patients in the most disadvantaged quintile of socioeconomic status, patients in the least disadvantaged quintile were 11% (1-21%) more likely to receive angiography, 52% (29-80%) more likely to undergo angioplasty and 30% (3-55%) more likely to undergo CABG. Private health insurance explained some of the socioeconomic variation in rates. Conclusions Australia's universal health care system does not guarantee equity in the receipt of high technology health care for patients with ischaemic heart disease. While such a system might ensure equity for patients with AMI, where guidelines for treatment are relatively well established, this is not the case for angina patients, where health care may be less urgent and more discretionary.
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Affiliation(s)
- Rosemary J Korda
- Australian Centre for Economic Research on Health, The Australian National University, Canberra ACT 0200, Australia.
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Foraker RE, Rose KM, McGinn AP, Suchindran CM, Goff DC, Whitsel EA, Wood JL, Rosamond WD. Neighborhood income, health insurance, and prehospital delay for myocardial infarction: the atherosclerosis risk in communities study. ACTA ACUST UNITED AC 2008; 168:1874-9. [PMID: 18809814 DOI: 10.1001/archinte.168.17.1874] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Outcomes following an acute myocardial infarction (AMI) are generally more favorable if prehospital delay time is minimized. METHODS We examined the association of neighborhood household income (nINC) and health insurance status with prehospital delay among a weighted sample of 9700 men and women with a validated, definite, or probable AMI in the Atherosclerosis Risk in Communities (ARIC) community surveillance study (1993-2002). Weighted multinomial regression with generalized estimation equations was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) and to account for the clustering of patients within census tracts. RESULTS Low nINC was associated with a higher odds of long vs short delay (OR, 1.46; 95% CI, 1.09-1.96) and medium vs short delay (OR, 1.43; 95% CI, 1.12-1.81) compared with high nINC in a model including age, sex, race, diabetes, hypertension, presence of chest pain, arrival at the hospital via emergency medical service, distance from residence to hospital, study community, and year of AMI event. Meanwhile, compared with patients with prepaid insurance or prepaid plus Medicare, patients with Medicaid were more likely to have a long vs short delay (OR, 1.87; 95% CI, 1.10-3.19) and a medium vs short delay (OR, 1.76; 95% CI, 1.13-2.74). CONCLUSIONS Both low nINC and being a Medicaid recipient are associated with longer prehospital delay. Reducing socioeconomic and insurance disparities in prehospital delay is critical because excess delay time may hinder effective care for AMI.
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Affiliation(s)
- Randi E Foraker
- Department of Epidemiology, University of North Carolina at Chapel Hill, 137 E Franklin St, Ste 306, Chapel Hill, NC 27514, USA.
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Interaction between income and education in predicting long-term survival after acute myocardial infarction. ACTA ACUST UNITED AC 2008; 15:526-32. [DOI: 10.1097/hjr.0b013e328304feac] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Rosvall M, Gerward S, Engström G, Hedblad B. Income and short-term case fatality after myocardial infarction in the whole middle-aged population of Malmö, Sweden. Eur J Public Health 2008; 18:533-8. [PMID: 18621776 DOI: 10.1093/eurpub/ckn059] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There are no previous studies investigating when and where those who die pre-hospitally after an AMI paid their last visit to medical care. METHODS AND RESULTS Incidence of AMI, pre-hospital and 28-day case fatality rates were monitored over 13 years of follow-up, in relation to sex-specific quartiles of annual income in all inhabitants aged 40-64 years in Malmö, Sweden. Both incidence and short-term case fatality were inversely related to income. In all, 60-70% of all deaths within 28 days after the AMI were pre-hospital deaths. As compared with the lowest income group, the highest income group had lower odds of pre-hospital death with an age- and time-to-event-adjusted odds ratio of 0.5 (95% CI 0.4-0.8) for men and 0.3 (95% CI 0.1-0.6) for women. On the other hand, while 72% of those in the lowest two income groups had paid a visit to the medical services during the three months before death, only 59% had done so in the two highest income groups (P < 0.05). CONCLUSIONS Poor socioeconomic circumstances increase the risk of pre-hospital death after an AMI. Of the pre-hospital deaths, the proportion who had visited the medical services during the 3 months preceding their AMI was higher among those from lower income groups. However, many of those suffering a pre-hospital death had visited clinics that normally do not treat coronary symptoms. If more patients were identified at an earlier stage this might increase the number of patients reaching hospital alive.
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Affiliation(s)
- Maria Rosvall
- Department of Clinical Sciences, Social Epidemiology, Lund University, Malmö University Hospital, Malmö, Sweden.
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Gerber Y, Weston SA, Killian JM, Therneau TM, Jacobsen SJ, Roger VL. Neighborhood income and individual education: effect on survival after myocardial infarction. Mayo Clin Proc 2008; 83:663-9. [PMID: 18533083 PMCID: PMC2650487 DOI: 10.4065/83.6.663] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Yariv Gerber
- Department of Health Sciences Research, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Rosvall M, Chaix B, Lynch J, Lindström M, Merlo J. The association between socioeconomic position, use of revascularization procedures and five-year survival after recovery from acute myocardial infarction. BMC Public Health 2008; 8:44. [PMID: 18241335 PMCID: PMC2275258 DOI: 10.1186/1471-2458-8-44] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Accepted: 02/01/2008] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Maria Rosvall
- Social Epidemiology, Department of Clinical Sciences, Malmö University Hospital, Lund University, Malmö, Sweden.
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Abstract
Cardiovascular disease is the leading cause of death worldwide, with a projected increase in incidence in developed and developing countries. This paper will review the literature on the role of poverty and socioeconomic deprivation in cardiovascular disease and outline ways to tackle poverty. The literature acknowledges the individual risk factors for cardiovascular disease, but highlights the negative effects of neighborhood deprivation on the incidence of cardiovascular disease and its mortality rates. The studies show that equitable access to health care is not evident and those in less affluent neighborhoods have greater disease incidence and increased mortality and morbidity rates, particularly for angina, myocardial infarction, and heart failure. The approach to reducing disease rates needs to be conducted from an individual level to the societal level and needs to prevent and treat heart disease (particularly in deprived neighborhoods). Nurses and health professionals must drive health policy so that progress can be achieved in reducing the disease rates.
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Affiliation(s)
- Geraldine Lee
- Preventative Cardiology, Baker Heart Research Institute, Melbourne, Australia.
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Krumholz HM, Masoudi FA. The year in epidemiology, health services research, and outcomes research. J Am Coll Cardiol 2007; 50:2254-62. [PMID: 18061075 DOI: 10.1016/j.jacc.2007.08.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 08/27/2007] [Accepted: 08/27/2007] [Indexed: 12/31/2022]
Affiliation(s)
- Harlan M Krumholz
- Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine, New Haven, Connecticut 06520-8088, USA.
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