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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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