Inequalities in socio-economic status and invasive procedures for coronary heart disease: a comparison between the USA and the UK

Insurance Types and All-Cause Mortality in Korean Cancer Patients: A Nationwide Population-Based Cohort Study

BACKGROUND

Economic deprivation is expected to influence cancer mortality due to its impact on screening and treatment options, as well as healthy lifestyle. However, the relationship between insurance type, premiums, and mortality rates remains unclear. This study investigated the relationship between insurance type and mortality in patients with newly diagnosed cancer using data from the Korean National Health Insurance Database.

METHODS

this retrospective cohort study included 111,941 cancer patients diagnosed between 1 January 2007 and 31 December 2008, with a median follow-up period of 13.41 years. The insurance types were categorized as regional and workplace subscribers and income-based insurance premiums were divided into tertiles (T1, T2, and T3).

RESULTS

Cox proportional hazards regression analysis adjusted for age, lifestyle factors, health metrics, and comorbidities showed workplace subscribers (n = 76,944) had a lower all-cause mortality hazard ratio (HR) (95% confidence interval [CI]: 0.940 [0.919-0.961]) compared to regional subscribers (n = 34,997). Higher income tertiles (T2, T3) were associated with lower mortality compared to the T1 group, notably in male regional and workplace subscribers, and female regional subscribers.

CONCLUSION

The study identified that insurance types and premiums significantly influence mortality in cancer patients, highlighting the necessity for individualized insurance policies for cancer patients.

Understanding the association between county-level unemployment and health stratified by education and income in the southwestern United States

Past research on the relationship between unemployment rates and population health has produced mixed findings. The relationship can be influenced by the kinds of health outcomes observed, time frame, level of geographic aggregation, and other factors. Given these mixed findings, there is a need to add to our knowledge about how unemployment rates and population health are related. There is limited research that examines the association of unemployment rates with both physical and mental health, while simultaneously stratifying populations by income and education levels. Using survey-based self-reported data, this first population-based study examined the association between unemployment rates and physically and mentally unhealthy days in the southwestern United States, by county-level stratification of income (high and low) as well as education (high and low), from 2015 to 2019. After controlling for covariates, associations were modelled using negative binomial regression, with autocorrelative residuals, and were reported as rate ratios (RR). Overall, we found that a 1% rise in unemployment rates was significantly associated with an increase in physically unhealthy days [adjusted RR 1.007; 95% CI, 1.004-1.011, P < 0.001] and mentally unhealthy days [RR 1.006; 95% CI, 1.003-1.009, P  < 0.001]. Upon stratification, a significant risk was found among the high education and high income category [RR 1.035; 95% CI, 1.021-1.049, P  < 0.001], as well as for the high education and low income category [RR 1.026; 95% CI, 1.013-1.040, P  < 0.001]. A better understanding of how unemployment is associated with the health of communities with different education and income levels could help reduce the burden on society through tailored interventions and social policies not only in the United States, but also in other developed nations.

The Influence of Socioeconomic Status on the Prognosis and Profile of Patients Admitted for Acute Heart Failure during COVID-19 Pandemic: Overestimated Aspects or a Multifaceted Hydra of Cardiovascular Risk Factors?

Background: Heart failure (HF) is a complex clinical syndrome that represents a great burden on public health systems due to its increased prevalence, disability and mortality rates. There are multiple triggers that can induce or aggravate a preexisting HF, socioeconomic status (SES) emerging as one of the most common modifiable risk factors. Our study aimed to analyze the influence of certain SES indicators on the outcome, clinical aspects and laboratory parameters of patients with HF in North-Eastern Romania, as well as their relationship with other traditional cardiovascular risk factors. Methods: We conducted a prospective, single-center study comprising 120 consecutively enrolled patients admitted for acute HF. The evaluation of individual SES was based upon a standard questionnaire and evidence from official documents. Results: the patients’ age ranged between 18 and 94 years; Out of 120 patients, 49 (40.8%) were women and 71 (59.2%) were men, residing in rural 59 (49.2%) or urban 61 (50.8%) areas. 14.2% were university graduates, while 15.8% had only attended primary school. The majority of the patients are or were employed in the service sector (54.5%), followed by industry (29.2%) and agriculture (20%). The mean monthly income was 306.1 ± 177.4 euro, while the mean hospitalization cost was 2471.8 ± 2073.8 euro per patient. The individual income level was positively correlated with urban area of residence, adequate household sanitation facilities and healthcare access, and negatively associated with advanced age and previous hospitalizations due to HF. However, the individual financial situation was also positively correlated with the increased prevalence of certain cardiovascular risk factors, such as arterial hypertension, anemia or obesity, but not with total cholesterol or male gender. Concerning the direct impact of a poor economic status upon prognosis in the setting of acute HF, our results showed no statistically significant differences concerning the in-hospital or at 1-month follow-up mortality rates. Rather than inducing a direct impact on the short-term outcome, these findings concerning SES indicators are meant to enhance the implementation of policies aimed to provide adequate healthcare for people from all social layers, with a primary focus on modifiable cardiovascular risk factors.

Socioeconomic Status, Mortality, and Access to Cardiac Services After Acute Myocardial Infarction in Canada: A Systematic Review and Meta-analysis

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.

Low socio-economic status associated with increased risk of dengue haemorrhagic fever in Taiwanese patients with dengue fever: a population-based cohort study

BACKGROUND

Evidence indicates that socio-economic status (SES) may affect health outcomes in patients with chronic diseases. However, little is known about the impact of SES on the prognosis of acute dengue. This nationwide cohort study determined the risk of dengue haemorrhagic fever (DHF) in Taiwanese dengue fever patients from 2000 to 2014.

METHODS

From 1 January 2000, we identified adult dengue cases reported in the Taiwan Centers for Disease Control Notifiable Diseases Surveillance System Database. Dengue cases were defined as positive virus isolation, nucleic acid amplification tests or serological tests. Associations between SES and incident DHF were estimated using a Cox proportional hazards model.

RESULTS

Of 27 750 dengue patients, 985 (3.5%) had incident DHF during the follow-up period, including 442 (4.8%) and 543 (2.9%) with low and high SES, respectively. After adjusting for age, sex, history of dengue fever and comorbidities, low SES was significantly associated with an increased risk of incident DHF (adjusted hazard ratio [AHR] 1.61 [95% confidence interval {CI} 1.42 to 1.83]). Rural-dwelling dengue patients had a higher likelihood of DHF complication than their urban counterparts (AHR 2.18 [95% CI 1.90 to 2.51]).

CONCLUSIONS

This study suggests low SES is an independent risk factor for DHF. Future dengue control programs should particularly target dengue patients with low SES for improved outcomes.

Poverty and Targeted Immunotherapy: Survival in Children's Oncology Group Clinical Trials for High-Risk Neuroblastoma

BACKGROUND

Whether social determinants of health are associated with survival in the context of pediatric oncology-targeted immunotherapy trials is not known. We examined the association between poverty and event-free survival (EFS) and overall survival (OS) for children with high-risk neuroblastoma treated in targeted immunotherapy trials.

METHODS

We conducted a retrospective cohort study of 371 children with high-risk neuroblastoma treated with GD2-targeted immunotherapy in the Children's Oncology Group trial ANBL0032 or ANBL0931 at a Pediatric Health Information System center from 2005 to 2014. Neighborhood poverty exposure was characterized a priori as living in a zip code with a median household income within the lowest quartile for the cohort. Household poverty exposure was characterized a priori as sole coverage by public insurance. Post hoc analyses examined the joint effect of neighborhood and household poverty using a common reference. All statistical tests were 2-sided.

RESULTS

In multivariable Cox regressions adjusted for disease and treatment factors, household poverty-exposed children experienced statistically significantly inferior EFS (hazard ratio [HR] = 1.90, 95% confidence interval [CI] = 1.28 to 2.82, P = .001) and OS (HR = 2.79, 95% CI = 1.63 to 4.79, P < .001) compared with unexposed children. Neighborhood poverty was not independently associated with EFS or OS. In post hoc analyses exploring the joint effect of neighborhood and household poverty, children with dual-poverty exposure (neighborhood poverty and household poverty) experienced statistically significantly inferior EFS (HR = 2.21, 95% CI = 1.48 to 3.30, P < .001) and OS (HR = 3.70, 95% CI = 2.08 to 6.59, P < .001) compared with the unexposed group.

CONCLUSIONS

Poverty is independently associated with increased risk of relapse and death among neuroblastoma patients treated with targeted immunotherapy. Incorporation of social and environmental factors in future trials as health-care delivery intervention targets may increase the benefit of targeted therapies.

Education-related variation in coronary procedure rates and the contribution of private health care in Australia: a prospective cohort study

Background

Contemporary Australian evidence on socioeconomic variation in secondary cardiovascular disease (CVD) care, a possible contributor to inequalities in cardiovascular disease outcomes, is lacking. This study examined the relationship between education, an individual-level indicator of socioeconomic position, and receipt of angiography and revascularisation procedures following incident hospitalisation for acute myocardial infarction (AMI) or angina, and the role of private care in this relationship.

Methods

Participants aged ≥45 from the New South Wales population-based 45 and Up Study with no history of prior ischaemic heart disease hospitalised for AMI or angina were followed for receipt of angiography or revascularisation within 30 days of hospital admission, ascertained through linked hospital records. Education attainment, measured on baseline survey, was categorised as low (no school certificate/qualifications), intermediate (school certificate/trade/apprenticeship/diploma) and high (university degree). Cox regression estimated the association (hazard ratios [HRs]) between education and coronary procedure receipt, adjusting for demographic and health-related factors, and testing for linear trend. Private health insurance was investigated as a mediating variable.

Results

Among 4454 patients with AMI, 68.3% received angiography within 30 days of admission (crude rate: 25.8/person-year) and 48.8% received revascularisation (rate: 11.7/person-year); corresponding figures among 4348 angina patients were 59.7% (rate: 17.4/person-year) and 30.8% (rate: 5.3/person-year). Procedure rates decreased with decreasing levels of education. Comparing low to high education, angiography rates were 29% lower among AMI patients (adjusted HR = 0.71, 95% CI: 0.56–0.90) and 40% lower among angina patients (0.60, 0.47–0.76). Patterns were similar for revascularisation among those with angina (0.78, 0.61–0.99) but not AMI (0.93, 0.69–1.25). After adjustment for private health insurance status, the HRs were attenuated and there was little evidence of an association between education and angiography among those admitted for AMI.

Conclusions

There is a socioeconomic gradient in coronary procedures with the most disadvantaged patients being less likely to receive angiography following hospital admission for AMI or angina, and revascularisation procedures for angina. Unequal access to private health care contributes to these differences. The extent to which the remaining variation is clinically appropriate, or whether angiography is being underused among people with low socioeconomic position or overused among those with higher socioeconomic position, is unclear.

Socioeconomic gradients in admission to coronary or intensive care units among Australians presenting with non-traumatic chest pain in emergency departments

BACKGROUND

Socioeconomic inequalities in cardiovascular morbidity have been previously reported showing direct associations between socioeconomic disadvantage and worse health outcomes. However, disagreement remains regarding the strength of the direct associations. The main objective of this panel design was to inspect socioeconomic gradients in admission to a coronary care unit (CCU) or an intensive care unit (ICU) among adult patients presenting with non-traumatic chest pain in three acute-care public hospitals in Victoria, Australia, during 2009-2013.

METHODS

Consecutive adults aged 18 or over presenting with chest pain in three emergency departments (ED) in Victoria, Australia during the five-year study period were eligible to participate. A relative index of inequality of socioeconomic status (SES) was estimated based on residential postcode socioeconomic index for areas (SEIFA) disadvantage scores. Admission to specialised care units over repeated presentations was modelled using a multivariable Generalized Estimating Equations approach that accounted for various socio-demographic and clinical variables.

RESULTS

Non-traumatic chest pain accounted for 10% of all presentations in the emergency departments (ED). A total of 53,177 individuals presented during the study period, with 22.5% presenting more than once. Of all patients, 17,579 (33.1%) were hospitalised over time, of whom 8584 (48.8%) were treated in a specialised care unit. Female sex was independently associated with fewer admissions to CCU / ICU, whereas, a dose-response effect of socioeconomic disadvantage and admission to CCU / ICU was found, with risk of admission increasing incrementally as SES declined. Patients coming from the lowest SES locations were 27% more likely to be admitted to these units compared with those coming from the least disadvantaged locations, p <  0.001. Men were significantly more likely to be admitted to such units than similarly affected and aged women among those diagnosed with angina pectoris, arrhythmia, myocardial infarction, heart failure, chest pain, and general signs and symptoms.

CONCLUSIONS

This study is the first to report socioeconomic gradients in admission to CCU / ICU in patients presenting with chest pain showing a dose-response effect. Our findings suggest increased cardiovascular morbidity as socioeconomic disadvantage increases.

Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature

There is a general understanding that socioeconomically disadvantaged people are also disadvantaged with respect to their access to NHS care. Insofar as considerable NHS funding has been targeted at deprived areas, it is important to better understand whether and why socioeconomic variations in access and utilisation exist. Exploring this question with reference to cardiovascular care, our aims were to synthesise and evaluate evidence relating to access to and/or use of English NHS services around (i) different points on the care pathway (i.e. presentation, primary management and specialist management) and (ii) different dimensions of inequality (socioeconomic, age- and gender-related, ethnic or geographical). Restricting our search period from 2004 to 2016, we were concerned to examine whether, compared to earlier research, there has been a change in the focus of research examining inequalities in cardiac care and whether the pro-rich bias reported in the late 1990s and early 2000s still applies today. We conducted a scoping study drawing on Arksey & O'Malley's framework. A total of 174 studies were included in the review and appraised for methodological quality. Although, in the past decade, there has been a shift in research focus away from gender and age inequalities in access/use and towards socioeconomic status and ethnicity, evidence that deprived people are less likely to access and use cardiovascular care is very contradictory. Patterns of use appear to vary by ethnicity; South Asian populations enjoying higher access, black populations lower. By contrast, female gender and older age are consistently associated with inequity in cardiovascular care. The degree of geographical variation in access/use is also striking. Finally, evidence of inequality increases with stage on the care pathway, which may indicate that barriers to access arise from the way in which health professionals are adjudicating health needs rather than a failure to seek help in the first place.

How Socioeconomic Status Affects Patient Perceptions of Health Care: A Qualitative Study

Introduction: Clinician perceptions of patients with low socioeconomic status (SES) have been shown to affect clinical decision making and health care delivery in this group. However, it is unknown how and if low SES patients perceive clinician bias might affect their health care. Methods: In-depth interviews with 80 enrollees in a state Medicaid program were analyzed to identify recurrent themes in their perceptions of care. Results: Most subjects perceived that their SES affected their health care. Common themes included treatment provided, access to care, and patient-provider interaction. Discussion: This study highlights complex perceptions patients have around how SES affects their health care. These results offer opportunities to reduce health care disparities through better understanding of their impact on the individual patient-provider relationship. This work may inform interventions that promote health equity via a multifaceted approach, which targets both providers and the health care system as a whole.

Socioeconomic inequalities in access to treatment for coronary heart disease: A systematic review

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.

Socioeconomic status and survival from ventricular fibrillation out-of-hospital cardiac arrest

PURPOSE

Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the United States. How individual-level socioeconomic status (SES) influences survival is uncertain.

METHODS

The investigation is a retrospective cohort study of adults who suffered OHCA and presented with a shockable rhythm in a metropolitan county from January 1, 1999-December 31, 2005. Individual-level measures of SES were obtained from vital records and surveys. SES measures included education and occupation. We used multivariable logistic regression to assess the independent association between SES measures and survival to hospital discharge.

RESULTS

Of the 1390 eligible OHCA patients, 374 (27%) survived to hospital discharge. Compared to those with less than high school diploma, the multivariable-adjusted odds ratio of survival was 1.36 (95% confidence interval [CI], 0.87-2.14) for high school graduates, 1.54 (95% CI, 0.95-2.48) for those with some college, and 1.96 (95% CI, 1.17-3.27) for those with college degrees (test for trend across the categories P < .001). We did not observe an independent association between occupation and survival.

CONCLUSIONS

Higher education was associated with greater survival after OHCA. This relationship was not explained by key demographic or clinical characteristics. A better understanding of the mechanism by which individual-level SES characteristics influence prognosis may provide opportunities to improve survival.

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Background

A strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.

Objectives

To generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.

Design

Cross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).

Results

The utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.

Conclusions

We found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

How socioeconomic inequalities impact pathways of care for coronary artery disease among elderly patients: study protocol for a qualitative longitudinal study

INTRODUCTION

Several studies have identified that socioeconomic inequalities in coronary artery disease (CAD) morbidity and mortality lead to a disadvantage in patients with low socioeconomic status (SES). International studies have shown that socioeconomic inequalities also exist in terms of access, utilisation and quality of cardiac care. The aim of this qualitative study is to provide information on the impact of socioeconomic inequalities on the pathway of care for CAD, and to establish which factors lead to socioeconomic inequality of care to form and expand existing scientific theories.

METHODS AND ANALYSIS

A longitudinal qualitative study with 48 patients with CAD, aged 60-80 years, is being conducted. Patients have been recruited consecutively at the University Hospital in Halle/Saale, Germany, and will be followed for a period of 6 months. Patients are interviewed two times face-to-face using semistructured interviews. Data are transcribed and analysed based on grounded theory.

ETHICS AND DISSEMINATION

Only participants who have been informed and who have signed a declaration of consent have been included in the study. The study complies rigorously with data protection legislation. Approval of the Ethical Review Committee at the Martin-Luther University Halle-Wittenberg, Germany was obtained. The results of the study will be presented at several congresses, and will be published in high-quality peer-reviewed international journals.

TRIAL REGISTRATION NUMBER

This study has been registered with the German Clinical Trials Register and assigned DRKS00007839.

Stage A Heart Failure Is Not Adequately Recognized in US Adults: Analysis of the National Health and Nutrition Examination Surveys, 2007-2010

BACKGROUND

Stage A heart failure (HF) is defined as people without HF symptoms or structural heart disease, but with predisposing conditions for HF. This classification is used to identify high risk patients to prevent progression to symptomatic HF. While guidelines exist for managing HF risk factors, achievement of treatment goals in the United States (US) population is unknown.

METHODS

We examined all adults with Stage A HF (≥20 years, N =4,470) in the National Health and Nutrition Examination Surveys (NHANES) 2007-2010, a nationally representative sample. Stage A HF was defined by coronary heart disease (CHD), hypertension, diabetes mellitus, or chronic kidney disease. We evaluated whether nationally accepted guidelines for risk factor control were achieved in Stage A patients, including sodium intake, body mass index, hemoglobin A1c (HbA1c), cholesterol, and blood pressure (BP). Pharmacologic interventions and socioeconomic factors associated with guideline compliance were also assessed.

RESULTS

Over 75 million people, or 1 in 3 US adults, have Stage A HF. The mean age of the Stage A population was 56.9 years and 51.5% were women. Seventy-two percent consume ≥2g sodium/day and 49.2% are obese. Of those with CHD, 58.6% were on a statin and 51.8% were on a beta-blocker. In people with diabetes, 43.6% had HbA1c ≥7%, with Mexican Americans more likely to have HbA1c ≥7% . Of those with hypertension, 30.8% had a systolic BP ≥140 or diastolic BP ≥90 mm Hg. Having health insurance was associated with controlled blood pressure, both in those with hypertension and diabetes. In CHD patients, income ≥$20,000/year and health insurance were inversely associated with LDL ≥100mg/dL with prevalence ratio (PR) of 0.58 (P=0.03) and 0.56 (P=0.03), respectively.

CONCLUSIONS

One-third of the US adult population has Stage A HF. Prevention efforts should focus on those with poorly controlled comorbid disease.

Mental health effects of climate change

We all know that 2014 has been declared as the hottest year globally by the Meteorological department of United States of America. Climate change is a global challenge which is likely to affect the mankind in substantial ways. Not only climate change is expected to affect physical health, it is also likely to affect mental health. Increasing ambient temperatures is likely to increase rates of aggression and violent suicides, while prolonged droughts due to climate change can lead to more number of farmer suicides. Droughts otherwise can lead to impaired mental health and stress. Increased frequency of disasters with climate change can lead to posttraumatic stress disorder, adjustment disorder, and depression. Changes in climate and global warming may require population to migrate, which can lead to acculturation stress. It can also lead to increased rates of physical illnesses, which secondarily would be associated with psychological distress. The possible effects of mitigation measures on mental health are also discussed. The paper concludes with a discussion of what can and should be done to tackle the expected mental health issues consequent to climate change.

Primary payer status is associated with mortality and resource utilization for coronary artery bypass grafting

BACKGROUND

Medicaid and uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes after coronary artery bypass grafting (CABG) in the United States is dependent on primary payer status.

METHODS AND RESULTS

From 2003 to 2007, 1,250,619 isolated CABG operations were evaluated using the Nationwide Inpatient Sample (NIS) database. Patients were stratified by primary payer status: Medicare, Medicaid, uninsured, and private insurance. Hierarchical multiple regression models were applied to assess the effect of primary payer status on postoperative outcomes. Unadjusted mortality for Medicare (3.3%), Medicaid (2.4%), and uninsured (1.9%) patients were higher compared with private insurance patients (1.1%, P<0.001). Unadjusted length of stay was longest for Medicaid patients (10.9 ± 0.04 days) and shortest for private insurance patients (8.0 ± 0.01 days, P<0.001). Medicaid patients accrued the highest unadjusted total costs ($113 380 ± 386, P<0.001). Importantly, after controlling for patient risk factors, income, hospital features, and operative volume, Medicaid (odds ratio, 1.82; P<0.001) and uninsured (odds ratio, 1.62; P<0.001) payer status independently conferred the highest adjusted odds of in-hospital mortality. In addition, Medicaid payer status was associated with the longest adjusted length of stay and highest adjusted total costs (P<0.001).

CONCLUSIONS

Medicaid and uninsured payer status confers increased risk adjusted in-hospital mortality for patients undergoing coronary artery bypass grafting operations. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors. Possible explanations include delays in access to care or disparate differences in health maintenance.

Community care in England: reducing socioeconomic inequalities in heart failure

BACKGROUND

Socioeconomic deprivation is associated with increased heart failure (HF) incidence, hospitalization rates, and mortality. However, whether the delivery of survival-enhancing medical therapy is equitable remains uncertain. We examined secular trends in the uptake of key medical therapies (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, spironolactone) stratified by socioeconomic circumstances in patients with HF. Secondary analyses examined trends in HF incidence, prevalence, and survival.

METHODS AND RESULTS

This study was a cross-sectional observational analysis of nationally representative primary care data from England. Treatments for patients with HF in 1999 and 2007 (n=13 330) were extracted from the General Practice Research Database. Socioeconomic circumstances were defined with the Index of Multiple Deprivation 2007, a weighted composite of 7 area-level deprivation domains. Treatment uptake estimates were age standardized. The incidence and prevalence of HF decreased year to year. Although clear socioeconomic gradients in both the incidence and prevalence of HF were apparent, the absolute difference between most and least deprived reduced over time. Uptake of therapies improved over time in both men and women. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker uptake increased from 46% to 64%, β-blocker uptake from 12% to 41%, and spironolactone uptake from 3% to 20%. Modest age and sex inequalities were apparent. However, no consistent socioeconomic gradients were observed in either treatment or case fatality.

CONCLUSIONS

Socioeconomic gradients in the incidence and prevalence of HF are reducing. Treatment is generally equitable and independent of socioeconomic circumstances. Most important, no significant inequality in outcomes was apparent. Future strategies should continue to address inequalities in the underlying causes of HF and to increase overall treatment levels further.

The relation between socioeconomic status and short-term mortality after acute myocardial infarction persists in the elderly: results from a nationwide study

We assessed whether the previously observed relationship between socioeconomic status (SES) and short-term mortality (pre-hospital mortality and 28-day case-fatality) after a first acute myocardial infarction (AMI) in persons <75 years, are also observed in the elderly (i.e. ≥75 years), and whether these relationships vary by sex. A nationwide register based cohort study was conducted. Between January 1st 1998 and December 31st 2007, 76,351 first AMI patients were identified, of whom 60,498 (79.2 %) were hospitalized. Logistic regression analyses were performed to measure SES differences in pre-hospital mortality after a first AMI and 28-day case-fatality after a first AMI hospitalization. All analyses were stratified by sex and age group (<55, 55–64, 65–74, 75–84, ≥85), and adjusted for age, ethnic origin, marital status, and degree of urbanization. There was an inverse relation between SES and pre-hospital mortality in both sexes. There was also an inverse relation between SES and 28-day case-fatality after hospitalization, but only in men. Compared to elderly men with the highest SES, elderly men with the lowest SES had a higher pre-hospital mortality in both 75–84 year-olds (OR = 1.26; 95 % CI 1.09–1.47) and ≥85 year-olds (OR = 1.26; 1.00–1.58), and a higher 28-day case-fatality in both 75–84 year-olds (OR = 1.26; 1.06–1.50) and ≥85 year-olds (OR = 1.36; 0.99–1.85). Compared to elderly women with the highest SES, elderly women with the lowest SES had a higher pre-hospital mortality in ≥85 year-olds (OR = 1.20; 0.99–1.46). To conclude, in men there are SES inequalities in both pre-hospital mortality and case-fatality after a first AMI, in women these SES inequalities are only shown in pre-hospital mortality. The inequalities persist in the elderly (≥75 years of age). Clinicians and policymakers need to be more vigilant on the population with a low SES background, including the elderly.

Heart failure and socioeconomic status: accumulating evidence of inequality

AIMS

Socioeconomic status (SES) is a powerful predictor of incident coronary disease and adverse cardiovascular outcomes. Understanding the impact of SES on heart failure (HF) development and subsequent outcomes may help to develop effective and equitable prevention, detection, and treatment strategies

METHODS AND RESULTS

A systematic literature review of electronic databases including PubMed, EMBASE, CINAHL, and the Cochrane Library, restricted to human subjects, was carried out. The principal outcomes were incidence, prevalence, hospitalizations, mortality, and treatment of HF. Socioeconomic measures included education, occupation, employment relations, social class, income, housing characteristics, and composite and area level indicators. Additional studies were identified from bibliographies of relevant articles and reviews. Twenty-eight studies were identified. Lower SES was associated with increased incidence of HF, either in the community or presenting to hospital. The adjusted risk of developing HF was increased by ∼30-50% in most reports. Readmission rates following hospitalization were likewise greater in more deprived patients. Although fewer studies examined mortality, lower SES was associated with poorer survival. Evidence defining the equity of medical treatment of patients with HF was scarce and conflicting.

CONCLUSIONS

Socioeconomic deprivation is a powerful independent predictor of HF development and adverse outcomes. However, the precise mechanisms accounting for this risk remain elusive. Heart failure represents the endpoint of numerous different pathophysiological processes and 'chains of events', each modifiable throughout the disease trajectories. The interaction between SES and HF is accordingly complex. Disentangling the many and varied life course processes is challenging. A better understanding of these issues may help attenuate the health inequalities so clearly evident among patients with HF.

Using routine data to monitor inequalities in an acute trust: a retrospective study

Background

Reducing inequalities is one of the priorities of the National Health Service. However, there is no standard system for monitoring inequalities in the care provided by acute trusts. We explore the feasibility of monitoring inequalities within an acute trust using routine data.

Methods

A retrospective study of hospital episode statistics from one acute trust in London over three years (2007 to 2010). Waiting times, length of stay and readmission rates were described for seven common surgical procedures. Inequalities by age, sex, ethnicity and social deprivation were examined using multiple logistic regression, adjusting for the other socio-demographic variables and comorbidities. Sample size calculations were computed to estimate how many years of data would be ideal for this analysis.

Results

This study found that even in a large acute trust, there was not enough power to detect differences between subgroups. There was little evidence of inequalities for the outcome and process measures examined, statistically significant differences by age, sex, ethnicity or deprivation were only found in 11 out of 80 analyses. Bariatric surgery patients who were black African or Caribbean were more likely than white patients to experience a prolonged wait (longer than 64 days, aOR = 2.47, 95% CI: 1.36-4.49). Following a coronary angioplasty, patients from more deprived areas were more likely to have had a prolonged length of stay (aOR = 1.66, 95% CI: 1.25-2.20).

Conclusions

This study found difficulties in using routine data to identify inequalities on a trust level. Little evidence of inequalities in waiting time, length of stay or readmission rates by sex, ethnicity or social deprivation were identified although some differences were identified which warrant further investigation. Even with three years of data from a large trust there was little power to detect inequalities by procedure. Data will therefore need to be pooled from multiple trusts to detect inequalities.

Plasma total and high molecular weight adiponectin levels and risk of coronary heart disease in women

OBJECTIVE

To examine prospectively the association of total and high molecular weight (HMW) adiponectin, and HMW/total adiponectin ratio with risk of incident coronary heart disease (CHD) in women, and to examine to what extent adjustment for potentially intermediary variables would explain this association.

METHODS AND RESULTS

Among 30,111 women from the Nurses' Health Study, 468 women developed non-fatal myocardial infarction or fatal CHD during 14 years of follow-up. Using risk set sampling, controls were selected 2:1 matched on age, smoking, and date of blood draw. Adjusted for matching factors, parental history of myocardial infarction, hormone replacement therapy, alcohol consumption, physical activity, body mass index, hypertension, and low-density lipoprotein cholesterol levels, the relative risk in the highest versus lowest quintile was 0.50 (95%-CI 0.33-0.75; p trend=0.001) for total adiponectin, 0.53 (95%-CI 0.35-0.80; p trend=0.004) for HMW adiponectin, and 0.63 (95%-CI 0.43-0.93; p trend=0.03) for HMW/total adiponectin ratio. After adjustment for diabetes, HDL-cholesterol, HbA1c, and CRP these associations were attenuated and no longer significant (RRs, 0.84; 95%-CI 0.53-1.33; p trend=0.62; 0.95; 95%-CI 0.60-1.52; p trend=0.98; 0.97; 95%-CI 0.64-1.47; p trend=0.80).

CONCLUSIONS

High levels of total and HMW adiponectin, and HMW/total adiponectin ratio are associated with a lower risk of CHD among women. HMW adiponectin and HMW/total adiponectin ratio are not more closely related to risk than total adiponectin. These associations are largely mediated by parameters related to glucose and lipid metabolism and inflammation, especially HDL-cholesterol levels.

Revascularisation and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta-analysis

BACKGROUND

High levels of comorbid physical illness and excess mortality rates have been previously documented in people with severe mental illness, but outcomes following myocardial infarction and other acute coronary syndromes are less clear.

AIMS

To examine inequalities in the provision of invasive coronary procedures (revascularisation, angiography, angioplasty and bypass grafting) and subsequent mortality in people with mental illness and in those with schizophrenia, compared with those without mental ill health.

METHOD

Systematic search and random effects meta-analysis were used according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies of mental health and cardiovascular procedures following cardiac events were eligible but we required a minimum of three independent studies to warrant pooling by procedure type. We searched Medline/PubMed and EMBASE abstract databases and ScienceDirect, Ingenta Select, SpringerLink and Online Wiley Library full text databases.

RESULTS

We identified 22 analyses of possible inequalities in coronary procedures in those with defined mental disorder, of which 10 also reported results in schizophrenia or related psychosis. All studies following acute coronary syndrome originated in the USA. The total sample size was 825 754 individuals. Those with mental disorders received 0.86 (relative risk, RR: 95% CI 0.80-0.92, P<0.0001) of comparable procedures with significantly lower receipt of coronary artery bypass graft (CABG; RR = 0.85, 95% CI 0.72-1.00), cardiac catheterisation (RR = 0.85, 95% CI 0.76-0.95) and percutaneous transluminal coronary angioplasty or percutaneous coronary intervention (PTCA/PCI; RR = 0.87, 95% CI 0.72-1.05). People with a diagnosis of schizophrenia received only 0.53 (95% CI 0.44-0.64, P<0.0001) of the usual procedure rate with significantly lower receipt of CABG (RR = 0.69, 95% CI 0.55-0.85) and PTCA/PCI (RR = 0.50, 95% CI 0.34-0.75). We identified 6 related studies examining mortality following cardiac events: for those with mental illness there was a 1.11 relative risk of mortality up to 1 year (95% CI 1.00-1.24, P = 0.05) but there was insufficient evidence to examine mortality rates in schizophrenia alone.

CONCLUSIONS

Following cardiac events, individuals with mental illness experience a 14% lower rate of invasive coronary interventions (47% in the case of schizophrenia) and they have an 11% increased mortality rate. Further work is required to explore whether these factors are causally linked and whether improvements in medical care might improve survival in those with mental ill health.

Family history of myocardial infarction predicts incident coronary heart disease in postmenopausal women with diabetes: the Women's Health Initiative Observational Study

BACKGROUND

Diabetes is a risk factor for coronary heart disease (CHD) but CHD does not occur in all diabetic individuals. The goal of this study was to assess the relationship between family history of myocardial infarction (MI) and incident CHD in diabetic postmenopausal women.

METHODS

We conducted a prospective cohort study among 2642 diabetic postmenopausal women without CHD at baseline in the Women's Health Initiative Observational Study. Family history was defined as a proband report of MI in first-degree relatives. Incident CHD was defined as non-fatal MI, coronary revascularization, or CHD death.

RESULTS

During 7.3 ( +/- 1.8) years of follow-up, 14.3% of the participants had incident CHD. The risk of incident CHD was 50% higher (HR = 1.50, 95% CI: 1.20-1.87, p = 0.0003) in those with a family history of an MI in at least one first-degree relative, and 79% higher (HR = 1.79, 95% CI: 1.36-2.35, P < 0.0001) if two or more first-degree relatives had an MI, compared to participants without a family history, after adjustment for covariates. The CHD risk increased with elevated systolic blood pressure (SBP) (HR = 1.01, 95% CI: 1.003-1.02, p = 0.001) but decreased with elevated diastolic BP (HR = 0.98, 95% CI: 0.97-0.999, p = 0.005) and with two or more episodes per week of physical activity (HR = 0.70, 95% CI: 0.52-0.93, p = 0.02).

CONCLUSIONS

The results suggest that a family history of MI predicts CHD in diabetic postmenopausal women. Close attention should be paid to BP control and physical activity in these women.