Ethnic Differences in Coronary Artery Revascularisation in New Zealand: Does the Inverse Care Law Still Apply?

Health Inequalities of STEMI Care Before Implementation of a New Regional Network: A Prefecture-Level Analysis of Social Determinants of Healthcare in Yunnan, China

BACKGROUND

As one of the most serious types of coronary heart disease, ST-elevation myocardial infarction (STEMI) faces huge challenges in the equal management and care of patients due to its life-threatening and time-critical condition. Health inequalities such as sex and age differences in STEMI care have been reported from developed countries. However, limited outcomes have been investigated and the major drivers of inequality are still unclear, especially in under-developed areas. This study aimed to explore the major drivers of health inequalities in STEMI care before implementation of a new regional network in the south-west of China.

METHODS

Prefecture-level data of STEMI patients before the implementation of a regional network were analysed retrospectively. Drivers of inequality were identified from six social determinants of health, namely area of residence, ethnicity, sex, age, education and occupation. Outcomes of STEMI care included timely presentation, reperfusion therapy, timely reperfusion therapy, heart failure, inpatient mortality, length of hospital stay, hospital costs, and various intervals of ischaemic time.

RESULTS

A total of 376 STEMI patients in the research area before implementation of the STEMI network were included. Compared with urban residents, rural patients were significantly less likely to have timely presentation (odds ratio [OR]=0.47, 95% CI: 0.28-0.80, P=.004) and timely reperfusion therapy (OR=0.32, 95% CI: 0.14-0.70, P=.005). Rural residents were less likely to present to hospital promptly than urban residents (HR=0.65, 95% CI=0.52-0.82, P<.001). In the first 3 hours of percutaneous coronary intervention (PCI) reperfusion delay and first 6 hours of total ischaemic time, rural patients had a significantly lower probability to receive prompt PCI (hazard ratio [HR]=0.40, 95% CI: 0.29-0.54, P<.001) and reperfusion therapy (HR=0.37, 95% CI: 0.25-0.56, P<.001) compared to urban patients.

CONCLUSION

Rural residents were a major vulnerable group before implementation of the regional STEMI network. No obvious inequalities in ethnicity, sex, age, education or occupation existed in STEMI care in Chuxiong Prefecture of China.

Very Elderly Patients With Acute Coronary Syndromes Treated With Percutaneous Coronary Intervention

BACKGROUND

The rates of very elderly patients (≥85 years old) undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) are rapidly increasing. They are under-represented in clinical trials, and those who are included may not reflect the real-world population. We aim to review the clinical characteristics of very elderly patients undergoing PCI for ACS and identify factors associated with adverse outcomes.

METHOD

All very elderly patients undergoing PCI for ACS in the Auckland region between January 2014 to December 2016 were included. Baseline clinical and procedural details were obtained, and the primary endpoint was all-cause mortality measured up to a maximum of 4 years. Secondary endpoints include recurrent myocardial infarction, unplanned revascularisation, stroke and major bleeding.

RESULTS

A total of 186 patients were included for analysis (mean age 87.6±2.8 years, 51.6% male). Indications for PCI were ST-elevation myocardial infarction (STEMI) in 74 (39.8%), non-ST elevation myocardial infarction (NSTEMI) in 97 (52.2%) and unstable angina in 15 patients (8.1%). Successful PCI was completed in 180 patients. At a maximal follow-up of 4 years (mean 23.4 mo), the rates of all-cause mortality and recurrent myocardial infarction were 22.0% and 14.0% respectively. The risk of mortality was increased by the presence of diabetes (44.8% vs 17.8%, HR=3.0, 95%CI: 1.6-5.9, p=0.001), STEMI (33.8% vs 13.5%, HR=3.1, 95%CI: 1.6-5.9, p=0.001), and reduced eGFR (every -10 mL/min/1.73m², HR=1.7, 95%CI: 1.3-2.1, p<0.0001). Major bleeding events while on dual antiplatelet therapy as defined by Bleeding Academic Research Consortium score ≥3 occurred in 14 patients (7.5%; 8 on ticagrelor, 6 on clopidogrel).

CONCLUSION

Very elderly patients who undergo PCI for ACS have acceptable survival outcomes. STEMI, diabetes and impaired renal function were predictive of mortality in this elderly cohort.

Māori, Pacific, Aboriginal and Torres Strait Islander Women's Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?

Māori and Pacific women in New Zealand and Aboriginal and Torres Strait Islander women in Australia are recognised as nurturers and leaders within their families and communities. However, women's wellbeing, and that of their communities, are affected by a high burden of cardiovascular disease experienced at a younger age than women from other ethnic groups. There has been little focus on the cardiovascular outcomes and strategies to address heart health inequities among Māori, Pacific, Aboriginal and Torres Strait Islander women. The factors contributing to these inequities are complex and interrelated but include differences in exposure to risk and protective factors, rates of multi-morbidity, and substantial gaps within the health system, which include barriers to culturally responsive, timely and appropriate cardiovascular care. Evidence demonstrates critical treatment gaps across the continuum of risk and disease, including assessment and management of cardiovascular risk in young women and time-critical access to and receipt of acute services. Cardiovascular disease in women impacts not only the individual, but their family and community, and the burden of living with disease limits women's capacity to fulfil their roles and responsibilities which support and sustain families and communities. Our response must draw on the strengths of Māori, Pacific, Aboriginal and Torres Strait Islander women, acknowledge health and wellbeing holistically, address the health and social needs of individuals, families and communities, and recognise that Indigenous women in New Zealand, Australia and across the Pacific must be involved in the design, development and implementation of solutions affecting their own health.

Who is actually asked about their mental health in pregnancy and the postnatal period? Findings from a national survey

BACKGROUND

Pregnancy and the postnatal period is a period of potential vulnerability for women and families. It is UK policy that all women are asked about their mental health and wellbeing early in pregnancy and following the birth to help detect potential problems and prevent serious adverse outcome. However, identification of mental health problems in pregnancy may be less than 50 %. The aim of the study was to find out which women are asked about their mood and mental health during pregnancy and postnatally, and about offer and uptake of treatment.

METHODS

Secondary analysis of a national maternity survey carried out in 2014 which asked about sociodemographic factors, care in pregnancy, childbirth, and the postnatal period with specific questions on emotional and mental health.

RESULTS

The usable response rate to the survey was 47 % (4571 women). Most women recalled being asked about their mental health in pregnancy (82 %) and in the postnatal period (90 %). However, antenatally, Asian and older women were less likely to be asked and to be offered treatment. In the postnatal period, differences were more marked. Non-white women, those living in more deprived areas, and those who had received less education were less likely to be asked about their mental health, to be offered treatment, and to receive support. Women with a trusting relationship with their midwife were more likely to be asked about their mental health.

CONCLUSION

The inequities described in this study suggest that the inverse care law is operating in relation to this aspect of maternity care. Those women most likely to be in need of support and treatment are least likely to be offered it and may be at risk of serious adverse outcomes.

To move or not to move? Exploring the relationship between residential mobility, risk of cardiovascular disease and ethnicity in New Zealand

Residential mobility can have negative impacts on health, with some studies finding that residential mobility can contribute to widening health gradients in the population. However, ethnically differentiated experiences of residential mobility and the relationship with health are neglected in the literature. To examine the relationship between residential mobility, risk of cardiovascular disease (CVD) and ethnicity, we constructed a cohort of 2,077,470 participants aged 30 + resident in New Zealand using encrypted National Health Index (eNHI) numbers linked to individual level routinely recorded data. Using binary logistic regression, we model the risk of CVD for the population stratified by ethnic group according to mover status, baseline deprivation and transitions between deprivation statuses. We show that the relationship between residential mobility and CVD varies between ethnic groups and is strongly influenced by the inter-relationship between residential mobility and deprivation mobility. Whilst residential mobility is an important determinant of CVD, much of the variation between ethnic groups is explained by contrasting deprivation experiences. To reduce inequalities in CVD within New Zealand, policies must focus on residentially mobile Māori, Pacific and South Asian populations who already have a heightened risk of CVD living in more deprived areas.