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Weight N, Moledina S, Lawson CA, Van Spall HGC, Wijeysundera HC, Rashid M, Kontopantelis E, Mamas MA. The Intersection of Socioeconomic Differences and Sex in the Management and Outcomes of Acute Myocardial Infarction: A Nationwide Cohort Study. Angiology 2024:33197241273433. [PMID: 39295517 DOI: 10.1177/00033197241273433] [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: 09/21/2024]
Abstract
Patients with lower socioeconomic status (SES) have poorer outcomes following acute myocardial infarction (AMI) than patients with higher SES; however, how sex modifies socioeconomic differences is unclear. Using the United Kingdom (UK) Myocardial Ischaemia National Audit Project (MINAP) registry, alongside Office of National Statistics (ONS) mortality data, we analyzed 736,420 AMI patients between 2005 and 2018, stratified by Index of Multiple Deprivation (IMD) score Quintiles (most affluent [Q1] to most deprived [Q5]). There was no significant difference in probability of in-hospital mortality in our adjusted model according to sex. The probability of 30-day mortality in our adjusted model was similar between men and women throughout Quintiles, ((Q5; Men 7.6%; 95% CI 7.3-7.8% (P < .001), Women; 7.0%; 95% CI 6.8-7.3%, P < .001)) ((Q1; Men 7.1%; 95% CI 6.8-7.4%, P < .001, Women; 6.9%; 95% CI 6.6-7.1%, P < .001)). The probability of one-year mortality in our adjusted model was higher in men throughout all Quintiles (Q1; Men 15.0%; 95% CI 14.8-15.6%), P < .001, Women; 14.5%; 95% CI 14.2-14.9%, P < .001) (Q5; Men 16.9%; 95% CI 16.5-17.3%, P < .001, Women; 15.5%; 95% CI 15.1-15.9 by %, P < .001). Overall, female sex did not significantly influence the effect of deprivation on AMI processes of care and outcomes.
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Affiliation(s)
- Nicholas Weight
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Saadiq Moledina
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Claire A Lawson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Harriette G C Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Research Institute of St Joe's, Hamilton, ON, Canada
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
- Department of Cardiovascular Sciences, Glenfield Hospital, University Hospitals of Leicester NHS Trust Leicester United Kingdom
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, UK
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Anand VV, Zhe ELC, Chin YH, Goh RSJ, Lin C, Kueh MTW, Chong B, Kong G, Tay PWL, Dalakoti M, Muthiah M, Dimitriadis GK, Wang JW, Mehta A, Foo R, Tse G, Figtree GA, Loh PH, Chan MY, Mamas MA, Chew NWS. Socioeconomic deprivation and prognostic outcomes in acute coronary syndrome: A meta-analysis using multidimensional socioeconomic status indices. Int J Cardiol 2023:S0167-5273(23)00597-1. [PMID: 37116760 DOI: 10.1016/j.ijcard.2023.04.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/26/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Low socioeconomic status (SES) is an important prognosticator amongst patients with acute coronary syndrome (ACS). This paper analysed the effects of SES on ACS outcomes. METHODS Medline and Embase were searched for articles reporting outcomes of ACS patients stratified by SES using a multidimensional index, comprising at least 2 of the following components: Income, Education and Employment. A comparative meta-analysis was conducted using random-effects models to estimate the risk ratio of all-cause mortality in low SES vs high SES populations, stratified according to geographical region, study year, follow-up duration and SES index. RESULTS A total of 29 studies comprising of 301,340 individuals were included, of whom 43.7% were classified as low SES. While patients of both SES groups had similar cardiovascular risk profiles, ACS patients of low SES had significantly higher risk of all-cause mortality (adjusted HR:1.19, 95%CI: 1.10-1.1.29, p < 0.001) compared to patients of high SES, with higher 1-year mortality (RR:1.08, 95%CI:1.03-1.13, p = 0.0057) but not 30-day mortality (RR:1.07, 95%CI:0.98-1.16, p = 0.1003). Despite having similar rates of ST-elevation myocardial infarction and non-ST-elevation ACS, individuals with low SES had lower rates of coronary revascularisation (RR:0.95, 95%CI:0.91-0.99, p = 0.0115) and had higher cerebrovascular accident risk (RR:1.25, 95%CI:1.01-1.55, p = 0.0469). Excess mortality risk was independent of region (p = 0.2636), study year (p = 0.7271) and duration of follow-up (p = 0.0604) but was dependent on the SES index used (p < 0.0001). CONCLUSION Low SES is associated with increased mortality post-ACS, with suboptimal coronary revascularisation rates compared to those of high SES. Concerted efforts are needed to address the global ACS-related socioeconomic inequity. REGISTRATION AND PROTOCOL The current study was registered with PROSPERO, ID: CRD42022334482.
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Affiliation(s)
- Vickram Vijay Anand
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ethan Lee Cheng Zhe
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Yip Han Chin
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Rachel Sze Jen Goh
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Chaoxing Lin
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Martin Tze Wah Kueh
- Royal College of Surgeons in Ireland and University College Dublin Malaysia Campus, Malaysia
| | - Bryan Chong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Gwyneth Kong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Phoebe Wen Lin Tay
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Mayank Dalakoti
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Georgios K Dimitriadis
- Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK; Department of Endocrinology ASO/EASO COM, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Jiong-Wei Wang
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Surgery, Cardiovascular Research Institute (CVRI), National University of Singapore, Singapore; Nanomedicine Translational Research Programme, Centre for NanoMedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anurag Mehta
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University Pauley Heart Centre, Richmond, VA, USA
| | - Roger Foo
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; Kent and Medway Medical School, Kent, Canterbury CT2 7NT, UK
| | - Gemma A Figtree
- Northern Clinical School, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Poay Huan Loh
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Mark Y Chan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, UK; Institute of Population Health, University of Manchester, UK
| | - Nicholas W S Chew
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore.
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David F, Philipp J, Henrike AB, Nikolaos PP, Christine PH, Martin C, Oliver PR, Benjamin S. Impact of the Educational Level on Non-Fatal Health Outcomes following Myocardial Infarction. Curr Probl Cardiol 2022; 47:101340. [DOI: 10.1016/j.cpcardiol.2022.101340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/29/2022] [Indexed: 11/03/2022]
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Cafagna G, Seghieri C, Vainieri M, Nuti S. A turnaround strategy: improving equity in order to achieve quality of care and financial sustainability in Italy. Int J Equity Health 2018; 17:169. [PMID: 30454018 PMCID: PMC6245858 DOI: 10.1186/s12939-018-0878-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 10/21/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Equity, financial sustainability, and quality in healthcare are key goals embraced by universal health systems. However, systematic performance management strategies for achieving equity are still weaker than those aimed at achieving financial sustainability and quality of care. Using a vertical equity perspective, the overarching aim of this paper is to examine how improving equity in quality of care impacts on financial sustainability. We applied a simulation to indicators of the heart failure clinical pathway in Tuscany (central Italy), in order to quantify the equity gaps and financial resources that could be reallocated in the absence of performance inequities. METHODS The analysis included all patients hospitalized for heart failure as a principal diagnosis in 2014. We selected five indicators: hospitalization rate, 30-day readmission, cardiology visits, and the utilization of beta-blockers, and ACE inhibitors and sartans. For each indicator, the simulation followed three steps: 1) stratification by socioeconomic status (SES), using education as a proxy for SES; 2) computation of the vertical equity indicator; and 3) assessment of the financial value of the equity gap. RESULTS All indicators showed performance gaps regarding inequities across SES-groups. For the hospitalization rate and 30-day readmission, resources could have been reallocated, if the performance of patients with a low SES had been equal to the performance of patients with a high SES, which amounted to €2,144,422 and €892,790 respectively. In contrast, limited additional resources would have been required for prescriptions and cardiology visits. CONCLUSIONS Reducing equity gaps by improving the performance of low-SES patients may be a crucial strategy to achieving financial sustainability in universal coverage healthcare systems. Universal healthcare systems, which aim to pursue financial sustainability and quality of care, are thus urged to develop performance management actions to improve equity. This approach should not only include the measurement and public disclosure of equity indicators but be part of a comprehensive evidence-based strategy for the management of chronic conditions along the clinical pathway.
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Affiliation(s)
- Gianluca Cafagna
- Health and Management Laboratory (MeS Lab), Institute of Management, Sant’Anna School of Advanced Studies, Piazza Martiri della Libertà, 24, Pisa, Italy
| | - Chiara Seghieri
- Health and Management Laboratory (MeS Lab), Institute of Management, Sant’Anna School of Advanced Studies, Piazza Martiri della Libertà, 24, Pisa, Italy
| | - Milena Vainieri
- Health and Management Laboratory (MeS Lab), Institute of Management, Sant’Anna School of Advanced Studies, Piazza Martiri della Libertà, 24, Pisa, Italy
| | - Sabina Nuti
- Health and Management Laboratory (MeS Lab), Institute of Management, Sant’Anna School of Advanced Studies, Piazza Martiri della Libertà, 24, Pisa, Italy
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Palmieri L, Veronesi G, Corrao G, Traversa G, Ferrario MM, Nicoletti G, Di Lonardo A, Donfrancesco C, Carle F, Giampaoli S. Cardiovascular diseases monitoring: lessons from population-based registries to address future opportunities and challenges in Europe. ACTA ACUST UNITED AC 2018; 76:31. [PMID: 29988313 PMCID: PMC6022302 DOI: 10.1186/s13690-018-0283-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 06/11/2018] [Indexed: 11/10/2022]
Abstract
Background Population-based registries implement the comprehensive collection of all disease events that occur in a well-characterized population within a certain time period and represent the preferred tools for disease monitoring at a population level. Main characteristics of a Population-based registry are to provide answers to defined research questions, also related to clinical and health policy purposes, assuring completeness of event identification, and implementing a process of case adjudication (validation) according to standardised diagnostic criteria. Methods The application of a standard methodology results in the availability of reliable and comparable data and facilitates the transferability of health information for research and evidence-based health policies. Although registries are extremely useful, they require considerable resources to be implemented and maintained, high cost and efforts, to produce stable and reliable indicators. Results Thanks to available health information and information technology, current administrative databases on hospital admissions and discharges, medication use, in-patient care utilization, surgical operations, drug dispensations, ticket exemption and invasive procedures are increasingly available. They represent basic sources of information for implementing Population-based registries.Main strengths and limitations of Population-based registries are described taking into consideration the example of cardiovascular diseases, as well as future challenges and opportunities for implementing Population-based registries at European level. Conclusions The integration of population-based registries and current administrative health databases may help to complete the picture of the disease rebuilding the evolution of the disease as a continuum from the onset to the possible consequent complications.
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Affiliation(s)
- Luigi Palmieri
- 1Department of Cardiovascular, Dysmetabolic and Aging-associated Diseases, Istituto Superiore di Sanità (ISS), Via Giano della Bella, 34 00162 Rome, Italy
| | - Giovanni Veronesi
- 2Research Centre in Epidemiology and Preventive Medicine, Università dell'Insubria, Varese, Italy
| | - Giovanni Corrao
- 3Department of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milan, Italy
| | - Giuseppe Traversa
- 4National Centre for Drug Research and Evaluation, Istituto Superiore di Sanità (ISS), Rome, Italy
| | - Marco M Ferrario
- 2Research Centre in Epidemiology and Preventive Medicine, Università dell'Insubria, Varese, Italy
| | | | - Anna Di Lonardo
- 1Department of Cardiovascular, Dysmetabolic and Aging-associated Diseases, Istituto Superiore di Sanità (ISS), Via Giano della Bella, 34 00162 Rome, Italy
| | - Chiara Donfrancesco
- 1Department of Cardiovascular, Dysmetabolic and Aging-associated Diseases, Istituto Superiore di Sanità (ISS), Via Giano della Bella, 34 00162 Rome, Italy
| | - Flavia Carle
- 6Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Simona Giampaoli
- 1Department of Cardiovascular, Dysmetabolic and Aging-associated Diseases, Istituto Superiore di Sanità (ISS), Via Giano della Bella, 34 00162 Rome, Italy
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Lorenzoni G, Azzolina D, Lanera C, Brianti G, Gregori D, Vanuzzo D, Baldi I. Time trends in first hospitalization for heart failure in a community-based population. Int J Cardiol 2018; 271:195-199. [PMID: 29885830 DOI: 10.1016/j.ijcard.2018.05.132] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 05/22/2018] [Accepted: 05/31/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND This study aims to assess time trends in first hospitalization for heart failure (HF) in a community-based population over the period from 1977 to 2014. METHODS Population-based cohort study using resources from the "Martignacco project" started in 1977 and promoted by the WHO. Three thousand and sixty-six subjects were involved in the project with follow-up through December 2014. Estimates were made for age-specific incidence rates for the first hospitalization for HF by birth cohort, calendar period, and gender. To disentangle the effects of age, calendar period, and birth cohort on the overall temporal trend in HF, we performed an age-period-cohort (APC) analysis. RESULTS An incident hospitalization for HF was reported for 427 subjects. In the APC model, a cohort effect with a turning point in 1930 was observed. After 1930, a sharp decrease in the rate ratios (RRs) occurred in among both genders. The estimated RR in the 1940 birth cohort decreased to 0.43, (95% CI 0.19-0.92), in men and to 0.45, (95% CI 0.16-1.26), in women. A residual effect of calendar period on RR was observed with a plateau in 1995 for women and in 2000 for men, followed by a decline. CONCLUSIONS The current findings showed that HF hospitalization incidence has declined over the period considered in subjects over 65 years living in a geographically defined community in Northeast Italy. Moreover, the age of birth, calendar period of diagnosis, and birth cohort play an important role in the incidence of the first hospitalization for HF.
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Affiliation(s)
- Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Corrado Lanera
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Giorgio Brianti
- Department of Prevention, ASS 4 'Medio Friuli', Udine, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Diego Vanuzzo
- National Association of Hospital Cardiologists, ANMCO (Associazione Nazionale Medici Cardiologi Ospedalieri) and Heart Care Foundation (Fondazione per il Tuo Cuore) Onlus, Firenze, Italy; Center for Cardiovascular Prevention, ASS 4 'Medio Friuli', Udine, Italy
| | - Ileana Baldi
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy.
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Cacciani L, Agabiti N, Bargagli AM, Davoli M. Access to percutaneous transluminal coronary angioplasty and 30-day mortality in patients with incident STEMI: Differentials by educational level and gender over 11 years. PLoS One 2017; 12:e0175038. [PMID: 28384181 PMCID: PMC5383153 DOI: 10.1371/journal.pone.0175038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 03/20/2017] [Indexed: 11/19/2022] Open
Abstract
Background Socioeconomic status and gender are associated with access to cardiac procedures and mortality after AMI, also in countries with universal health care systems. Our objective was to evaluate the association and trends of educational level or gender and the following outcomes: 1) access to PTCA; 2) 30-day mortality. Methods We conducted an observational study based on 14,013 subjects aged 35–74 years, residing in Rome in 2001, and hospitalised for incident STEMI within 2012 in the Lazio region. We estimated adjusted ORs of educational level or gender and: 1) PTCA within 2 days after hospitalisation, 2) 30-day mortality. We evaluated time trends of outcomes, and time trends of educational or gender differentials estimating ORs stratified by time period (two time periods between 2001 and 2012). We performed a hierarchical analysis to account for clustering of hospitals. Results Access to PTCA among patients with incident STEMI increased during the study period, while 30-day mortality was stable. We observed educational differentials in PTCA procedure only in the first time period, and gender differentials in both periods. Patterns for 30-day mortality were less marked, with educational differentials emerging only in the second period, and gender differentials only in the first one, with patients with low educational level and females being disadvantaged. Conclusions Educational differentials in the access to PTCA disappeared in Lazio region over time, coherently with scientific literature, while gender differentials seem to persist. It may be important to assess the role of female gender in patients with STEMI, both from a social and a clinical point of view.
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Affiliation(s)
- Laura Cacciani
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Nera Agabiti
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Anna Maria Bargagli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
- * E-mail:
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Cafagna G, Seghieri C. Educational level and 30-day outcomes after hospitalization for acute myocardial infarction in Italy. BMC Health Serv Res 2017; 17:18. [PMID: 28069004 PMCID: PMC5220616 DOI: 10.1186/s12913-016-1966-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 12/21/2016] [Indexed: 12/01/2022] Open
Abstract
Background There is a growing interest in the factors that influence short-term mortality and readmission after hospitalization for acute myocardial infarction (AMI) since such outcomes are commonly considered as hospital performance measures. Socioeconomic status (SES) is one of the factors contributing to healthcare outcomes after hospitalization for AMI. However, no study has been published on education and 30-day readmission in Europe. The objective of this study is to examine the association between educational level and 30-day mortality and readmission among patients hospitalized for AMI in Tuscany (Italy). Methods A retrospective cohort study using data from hospital discharge records was conducted. The analysis included all patients discharged with a principal diagnosis of AMI between January 1, 2011, and November 30, 2014, from all hospitals in Tuscany. Educational level was categorized as low (no middle school diploma), mid (middle school diploma) and high (high school diploma or more). Three multilevel models were developed, sequentially controlling for patient-level socio-demographic and clinical variables and hospital-level variables. Patients were stratified by age (≤75 and >75 years). Results Mortality analysis included 23,402 patients, readmission analysis included 22,181 patients. In both unadjusted and full-adjusted models, patients with a high education had lower odds of 30-day mortality compared to those patients with low education (OR age ≤ 75 years 0.67, 95% CI:0.47–0.94; OR age > 75 years 0.72, 95% CI:0.54–0.95). With regard to 30-day readmission, only patients aged over 75 years with a high education had lower odds of short-term readmission compared to those patients with low education (OR age > 75 0.73, 95% CI:0.58–0.93). Conclusions Among patients hospitalized in Tuscany for AMI, low levels of education were associated with increased odds of 30-day mortality for both age groups and increased odds of 30-day readmission only for patients aged over 75 years. Our findings suggest that the educational component should not be underestimated in order to improve short-term outcomes, which are considered as performance measures at the hospital level. Hospital managers might consider strategies that are sensitive to patients with low SES, such as providing post-hospitalization support to less-educated patients and promoting a healthier lifestyle, to improve both health equity and performance outcomes.
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Affiliation(s)
- Gianluca Cafagna
- Health and Management Laboratory (MeS Lab), Institute of Management, Sant'Anna School of Advanced Studies, Piazza Martiri della Libertà, 24, Pisa, Italy.
| | - Chiara Seghieri
- Health and Management Laboratory (MeS Lab), Institute of Management, Sant'Anna School of Advanced Studies, Piazza Martiri della Libertà, 24, Pisa, Italy
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Kabbani LS, Wasilenko S, Nypaver TJ, Weaver MR, Taylor AR, Abdul-Nour K, Borgi J, Shepard AD. Socioeconomic disparities affect survival after aortic dissection. J Vasc Surg 2016; 64:1239-1245. [DOI: 10.1016/j.jvs.2016.03.469] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/31/2016] [Indexed: 01/22/2023]
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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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Heo JY, Hong KJ, Shin SD, Song KJ, Ro YS. Association of educational level with delay of prehospital care before reperfusion in STEMI. Am J Emerg Med 2015; 33:1760-9. [DOI: 10.1016/j.ajem.2015.08.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 07/18/2015] [Accepted: 08/11/2015] [Indexed: 01/18/2023] Open
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Kilpi F, Silventoinen K, Konttinen H, Martikainen P. Disentangling the relative importance of different socioeconomic resources for myocardial infarction incidence and survival: a longitudinal study of over 300,000 Finnish adults. Eur J Public Health 2015; 26:260-6. [PMID: 26585783 DOI: 10.1093/eurpub/ckv202] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Lower socioeconomic position (SEP) is associated with an increased risk of myocardial infarction (MI) incidence and mortality, but the relative importance of different socioeconomic resources at different stages of the disease remains unclear. METHODS A nationally representative register-based sample of 40- to 60-year-old Finnish men and women in 1995 (n= 302 885) were followed up for MI incidence and mortality in 1996-2007. We compared the effects of education, occupation, income and wealth on first MI incidence, first-day and long-term fatality. Cox's proportional hazards regression and logistic regression models were estimated adjusting for SEP covariates simultaneously to assess independent effects. RESULTS Fully adjusted models showed greatest relative inequalities of MI incidence by wealth in both sexes, with an increased risk also associated with manual occupations. Education was a significant predictor of incidence in men. Low income was associated with a greater risk of death on the day of MI incidence [odds ratio (OR) = 1.40 in men and 1.95 in women when comparing lowest and highest income quintiles], and in men, with long-term fatality [hazard ratio (HR) = 1.74]. Wealth contributed to inequalities in first-day fatality in men and in long-term fatality in both sexes. CONCLUSION The results show that different socioeconomic resources have diverse effects on the disease process and add new evidence on the significant association of wealth with heart disease onset and fatality. Targeting those with the least resources could improve survival in MI patients and help reduce social inequalities in coronary heart disease mortality.
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Affiliation(s)
- Fanny Kilpi
- 1 Population Research Unit, Department of Social Research, University of Helsinki, Helsinki, Finland
| | - Karri Silventoinen
- 1 Population Research Unit, Department of Social Research, University of Helsinki, Helsinki, Finland
| | - Hanna Konttinen
- 2 Social Psychology, Department of Social Research, University of Helsinki, Helsinki, Finland
| | - Pekka Martikainen
- 1 Population Research Unit, Department of Social Research, University of Helsinki, Helsinki, Finland 3 Centre for Health Equity Studies (CHESS), Stockholms Universitet and Karolinska Institutet, Sweden 4 The Max Planck Institute for Demographic Research, Germany
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Morton RL, Schlackow I, Staplin N, Gray A, Cass A, Haynes R, Emberson J, Herrington W, Landray MJ, Baigent C, Mihaylova B. Impact of Educational Attainment on Health Outcomes in Moderate to Severe CKD. Am J Kidney Dis 2015; 67:31-9. [PMID: 26385817 PMCID: PMC4685934 DOI: 10.1053/j.ajkd.2015.07.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/06/2015] [Indexed: 11/27/2022]
Abstract
Background The inverse association between educational attainment and mortality is well established, but its relevance to vascular events and renal progression in a population with chronic kidney disease (CKD) is less clear. This study aims to determine the association between highest educational attainment and risk of vascular events, cause-specific mortality, and CKD progression. Study Design Prospective epidemiologic analysis among participants in the Study of Heart and Renal Protection (SHARP), a randomized controlled trial. Setting & Participants 9,270 adults with moderate to severe CKD (6,245 not receiving dialysis at baseline) and no history of myocardial infarction or coronary revascularization recruited in Europe, North America, Asia, Australia, and New Zealand. Predictor Highest educational attainment measured at study entry using 6 levels that ranged from “no formal education” to “tertiary education.” Outcomes Any vascular event (any fatal or nonfatal cardiac, cerebrovascular, or peripheral vascular event), cause-specific mortality, and CKD progression during 4.9 years’ median follow-up. Results There was a significant trend (P < 0.001) toward increased vascular risk with decreasing levels of education. Participants with no formal education were at a 46% higher risk of vascular events (relative risk [RR], 1.46; 95% CI, 1.14-1.86) compared with participants with tertiary education. The trend for mortality across education levels was also significant (P < 0.001): all-cause mortality was twice as high among those with no formal education compared with tertiary-educated individuals (RR, 2.05; 95% CI, 1.62-2.58), and significant increases were seen for both vascular (RR, 1.84; 95% CI, 1.21-2.81) and nonvascular (RR, 2.15; 95% CI, 1.60-2.89) deaths. Lifestyle factors and prior disease explain most of the excess mortality risk. Among 6,245 participants not receiving dialysis at baseline, education level was not significantly associated with progression to end-stage renal disease or doubling of creatinine level (P for trend = 0.4). Limitations No data for employment or health insurance coverage. Conclusions Lower educational attainment is associated with increased risk of adverse health outcomes in individuals with CKD.
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Affiliation(s)
- Rachael L Morton
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia; Health Economics Research Centre, University of Oxford, Oxford, United Kingdom
| | - Iryna Schlackow
- Health Economics Research Centre, University of Oxford, Oxford, United Kingdom
| | - Natalie Staplin
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Alastair Gray
- Health Economics Research Centre, University of Oxford, Oxford, United Kingdom
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Richard Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jonathan Emberson
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - William Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Borislava Mihaylova
- Health Economics Research Centre, University of Oxford, Oxford, United Kingdom.
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Nayyar D, Hwang SW. Cardiovascular Health Issues in Inner City Populations. Can J Cardiol 2015; 31:1130-8. [DOI: 10.1016/j.cjca.2015.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/06/2015] [Accepted: 04/06/2015] [Indexed: 11/28/2022] Open
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Bruthans J, Mayer O, De Bacquer D, De Smedt D, Reiner Z, Kotseva K, Cífková R. Educational level and risk profile and risk control in patients with coronary heart disease. Eur J Prev Cardiol 2015; 23:881-90. [PMID: 26283652 DOI: 10.1177/2047487315601078] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/27/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this study was to ascertain way in which conventional risk factors, readiness to modify behaviour and to comply with recommended medication, and the effect of this medication were associated with education in patients with established coronary heart disease (CHD). METHODS The EUROASPIRE IV (EUROpean Action on Secondary Prevention by Intervention to Reduce Events) study was a cross-sectional survey undertaken in 24 European countries to ascertain how recommendations on secondary CHD prevention are being followed in clinical practice. Consecutive patients, men and women ≤80 years of age who had been hospitalized for an acute coronary syndrome or revascularization procedure, were identified retrospectively. Data were collected through an interview with examinations at least six months and no later than three years after hospitalization. RESULTS A total of 7937 patients (1934 (24.37%) women) were evaluated. Patients with primary education were older, with a larger proportion of women. Control of risk factors, as defined by Joint European Societies 4 and 5 guidelines, was significantly better with higher education for current smoking (p = 0.001), overweight and obesity (p = 0.047 and p = 0.029, respectively), low physical activity (p < 0.001) and low high-density lipoprotein (HDL)-cholesterol (p = 0.011) in men, and for obesity (p = 0.005), high blood pressure (p < 0.005 and p < 0.001), low physical activity (p = 0.001), diabetes (p < 0.001) and low HDL-cholesterol (p = 0.023) in women. Patients with primary and secondary education were more often treated with diuretics and antidiabetic drugs. Better control of hypertension was achieved in patients with higher education. CONCLUSION Particular risk communication and control are needed in secondary CHD prevention for patients with lower educational status.
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Affiliation(s)
- Jan Bruthans
- Center for Cardiovascular Prevention, 1st Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic 2nd Department of Internal Medicine, Faculty of Medicine, Charles University, Pilsen, Czech Republic
| | - Otto Mayer
- 2nd Department of Internal Medicine, Faculty of Medicine, Charles University, Pilsen, Czech Republic
| | | | | | - Zeljko Reiner
- Department of Internal Medicine, University Zagreb, Croatia
| | - Kornelia Kotseva
- International Centre for Circulatory Health, Imperial College London, UK
| | - Renata Cífková
- Center for Cardiovascular Prevention, 1st Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
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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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Abbasi SH, De Leon AP, Kassaian SE, Karimi A, Sundin Ö, Jalali A, Soares J, Macassa G. Socioeconomic Status and in-hospital Mortality of Acute Coronary Syndrome: Can Education and Occupation Serve as Preventive Measures? Int J Prev Med 2015; 6:36. [PMID: 25984286 PMCID: PMC4427988 DOI: 10.4103/2008-7802.156266] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 02/01/2015] [Indexed: 12/24/2022] Open
Abstract
Background: Socioeconomic status (SES) can greatly affect the clinical outcome of medical problems. We sought to assess the in-hospital mortality of patients with the acute coronary syndrome (ACS) according to their SES. Methods: All patients admitted to Tehran Heart Center due to 1st-time ACS between March 2004 and August 2011 were assessed. The patients who were illiterate/lowly educated (≤5 years attained education) and were unemployed were considered low-SES patients and those who were employed and had high educational levels (>5 years attained education) were regarded as high-SES patients. Demographic, clinical, paraclinical, and in-hospital medical progress data were recorded. Death during the course of hospitalization was considered the end point, and the impact of SES on in-hospital mortality was evaluated. Results: A total of 6246 hospitalized patients (3290 low SES and 2956 high SES) were included (mean age = 60.3 ± 12.1 years, male = 2772 [44.4%]). Among them, 79 (1.26%) patients died. Univariable analysis showed a significantly higher mortality rate in the low-SES group (1.9% vs. 0.6%; P < 0.001). After adjustment for possible cofounders, SES still showed a significant effect on the in-hospital mortality of the ACS patients in that the high-SES patients had a lower in-hospital mortality rate (odds ratio: 0.304, 95% confidence interval: 0.094–0.980; P = 0.046). Conclusions: This study found that patients with low SES were at a higher risk of in-hospital mortality due to the ACS. Furthermore, the results suggest the need for increased availability of jobs as well as improved levels of education as preventive measures to curb the unfolding deaths owing to coronary artery syndrome.
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Affiliation(s)
- Seyed Hesameddin Abbasi
- Department of Health Sciences, Section of Public Health Sciences, Mid Sweden University, Sundsvall, Sweden ; Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran ; Department of Heart, Family Health Research Center, Iranian Petroleum Health Research Institute, Tehran, Iran
| | - Antonio Ponce De Leon
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden ; Department o de Epidemiologia, Instituto de Medicina Social, Universidade do Estado de Rio de Janeiro, Brazil
| | - Seyed Ebrahim Kassaian
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbasali Karimi
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Örjan Sundin
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Joaquim Soares
- Department of Health Sciences, Section of Public Health Sciences, Mid Sweden University, Sundsvall, Sweden ; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Gloria Macassa
- Department of Health Sciences, Section of Public Health Sciences, Mid Sweden University, Sundsvall, Sweden ; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden ; Department of Occupational and Public Health Sciences University of Gävle, Gävle, Sweden
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Greco C, Rosato S, D'Errigo P, Mureddu GF, Lacorte E, Seccareccia F. Trends in mortality and heart failure after acute myocardial infarction in Italy from 2001 to 2011. Int J Cardiol 2015; 184:115-121. [PMID: 25700282 DOI: 10.1016/j.ijcard.2015.01.073] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 12/16/2014] [Accepted: 01/26/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Uncertainties on long-term outcomes after acute myocardial infarction (AMI) still exist, despite the ongoing progresses in the management of patients with AMI. AIM OF THE STUDY Our aim was to appraise both the early prognosis and prognosis at 1-year after discharge of patients hospitalized due to AMI. METHODS This is a retrospective nationwide cohort study based on data from an administrative database on patients admitted with AMI from 2001 to 2011 in all Italian hospitals sites. Mortality and readmission rates within 30 days, 60 days and 1 year were calculated, as well as re-hospitalizations for all causes and for HF. RESULTS A total of 1,110,822 patients were included. Index admission mortality rate (I-MR) and total in-hospital mortality rate (T-MR) at up to 1 year both decreased respectively from 11.34% to 8.99% and from 16.46% to 14.68% in the years 2001 to 2011 (both p<0.0001), while fatal readmission rate (F-RR) at 1 year increased from 4.75% to 5.28% (p=0.0019). Patients that developed HF during the index admission had significantly higher I-MR and F-RR. I-MR, F-RR, and T-MR, however, remained low at any time point considered (30 days, 60 days and 1 year) in a subgroup of low-risk optimally-treated patients. CONCLUSIONS The risk of fatal readmission at 1 year increased slightly over time, in spite of the remarkable improvements currently achieved in overall prognosis after AMI. The identification of patients at high risk (mainly due to HF complicating AMI), and of patients at low risk is crucial to define and support management strategies.
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Affiliation(s)
- Cesare Greco
- Division of Cardiology, San Giovanni Hospital, Rome, Italy.
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19
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Zhou SM, Lyons RA, Bodger OG, John A, Brunt H, Jones K, Gravenor MB, Brophy S. Local modelling techniques for assessing micro-level impacts of risk factors in complex data: understanding health and socioeconomic inequalities in childhood educational attainments. PLoS One 2014; 9:e113592. [PMID: 25409038 PMCID: PMC4237439 DOI: 10.1371/journal.pone.0113592] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 10/29/2014] [Indexed: 11/29/2022] Open
Abstract
Although inequalities in health and socioeconomic status have an important influence on childhood educational performance, the interactions between these multiple factors relating to variation in educational outcomes at micro-level is unknown, and how to evaluate the many possible interactions of these factors is not well established. This paper aims to examine multi-dimensional deprivation factors and their impact on childhood educational outcomes at micro-level, focusing on geographic areas having widely different disparity patterns, in which each area is characterised by six deprivation domains (Income, Health, Geographical Access to Services, Housing, Physical Environment, and Community Safety). Traditional health statistical studies tend to use one global model to describe the whole population for macro-analysis. In this paper, we combine linked educational and deprivation data across small areas (median population of 1500), then use a local modelling technique, the Takagi-Sugeno fuzzy system, to predict area educational outcomes at ages 7 and 11. We define two new metrics, "Micro-impact of Domain" and "Contribution of Domain", to quantify the variations of local impacts of multidimensional factors on educational outcomes across small areas. The two metrics highlight differing priorities. Our study reveals complex multi-way interactions between the deprivation domains, which could not be provided by traditional health statistical methods based on single global model. We demonstrate that although Income has an expected central role, all domains contribute, and in some areas Health, Environment, Access to Services, Housing and Community Safety each could be the dominant factor. Thus the relative importance of health and socioeconomic factors varies considerably for different areas, depending on the levels of each of the other factors, and therefore each component of deprivation must be considered as part of a wider system. Childhood educational achievement could benefit from policies and intervention strategies that are tailored to the local geographic areas' profiles.
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Affiliation(s)
- Shang-Ming Zhou
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
| | - Ronan A. Lyons
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
| | - Owen G. Bodger
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
| | - Ann John
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
| | - Huw Brunt
- Public Health Wales, Temple of Peace and Health, Cathays Park, Cardiff, United Kingdom
| | - Kerina Jones
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
| | - Mike B. Gravenor
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
| | - Sinead Brophy
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
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Gnavi R, Rusciani R, Dalmasso M, Giammaria M, Anselmino M, Roggeri DP, Roggeri A. Gender, socioeconomic position, revascularization procedures and mortality in patients presenting with STEMI and NSTEMI in the era of primary PCI. Differences or inequities? Int J Cardiol 2014; 176:724-30. [PMID: 25183535 DOI: 10.1016/j.ijcard.2014.07.107] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 07/11/2014] [Accepted: 07/26/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Several studies have reported gender and socioeconomic differences in the use of revascularization procedures in patients with acute myocardial infarction. However, it is not clear whether these differences influence patients' survival. Moreover, most of the studies neither considered STEMI and NSTEMI separately, nor included primary PCI, which nowadays is the treatment of choice in case of AMI. In an unselected population of patients admitted to hospital with a first episode of STEMI and NSTEMI we examined gender and socioeconomic differences in the use of cardiac invasive procedures and in one-year mortality. METHODS Subjects hospitalized with a first episode of STEMI (n=3506) or NSTEMI (n=2286) were selected from the Piedmont (Italy) hospital discharge database. We considered the percentage of patients undergoing PCI, primary PCI and CABG, and in-hospital mortality. Out of hospital mortality was calculated through record linkage with the regional register. The relation between outcomes and gender or educational level was investigated using appropriate multivariate regression models adjusting for available confounders. RESULTS After adjustment for age, comorbidity and hospital characteristics, women and low educated patients had a lower probability of undergoing revascularization procedures. However, neither in-hospital, nor 30-day, nor 1-year mortality showed gender or social disparities. CONCLUSIONS Despite gender and socioeconomic differences in the use of revascularization, no differences emerged in in-hospital and 1-year mortality. These findings could suggest that patients are differently, but equitably, treated; differences are more likely due to an inability to fully adjust for clinical conditions rather than to a selection process at admission.
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Affiliation(s)
- Roberto Gnavi
- Epidemiology Unit, Regione Piemonte, Grugliasco (TO) ASL TO3, Italy.
| | | | - Marco Dalmasso
- Epidemiology Unit, Regione Piemonte, Grugliasco (TO) ASL TO3, Italy
| | - Massimo Giammaria
- Cardiology Department, Maria Vittoria Hospital, Torino ASL TO2, Italy
| | - Monica Anselmino
- Cardiology Department, San Giovanni Bosco Hospital, Torino ASL TO2, Italy
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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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Zhou SM, Lyons RA, Brophy S, Gravenor MB. Constructing compact Takagi-Sugeno rule systems: identification of complex interactions in epidemiological data. PLoS One 2012; 7:e51468. [PMID: 23272108 PMCID: PMC3522708 DOI: 10.1371/journal.pone.0051468] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 11/07/2012] [Indexed: 11/18/2022] Open
Abstract
The Takagi-Sugeno (TS) fuzzy rule system is a widely used data mining technique, and is of particular use in the identification of non-linear interactions between variables. However the number of rules increases dramatically when applied to high dimensional data sets (the curse of dimensionality). Few robust methods are available to identify important rules while removing redundant ones, and this results in limited applicability in fields such as epidemiology or bioinformatics where the interaction of many variables must be considered. Here, we develop a new parsimonious TS rule system. We propose three statistics: R, L, and ω-values, to rank the importance of each TS rule, and a forward selection procedure to construct a final model. We use our method to predict how key components of childhood deprivation combine to influence educational achievement outcome. We show that a parsimonious TS model can be constructed, based on a small subset of rules, that provides an accurate description of the relationship between deprivation indices and educational outcomes. The selected rules shed light on the synergistic relationships between the variables, and reveal that the effect of targeting specific domains of deprivation is crucially dependent on the state of the other domains. Policy decisions need to incorporate these interactions, and deprivation indices should not be considered in isolation. The TS rule system provides a basis for such decision making, and has wide applicability for the identification of non-linear interactions in complex biomedical data.
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Affiliation(s)
- Shang-Ming Zhou
- Centre for Health Information Research and Evaluation, College of Medicine, Swansea University, Swansea, United Kingdom.
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Koopman C, van Oeffelen AAM, Bots ML, Engelfriet PM, Verschuren WMM, van Rossem L, van Dis I, Capewell S, Vaartjes I. Neighbourhood socioeconomic inequalities in incidence of acute myocardial infarction: a cohort study quantifying age- and gender-specific differences in relative and absolute terms. BMC Public Health 2012; 12:617. [PMID: 22870916 PMCID: PMC3490806 DOI: 10.1186/1471-2458-12-617] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 07/31/2012] [Indexed: 12/02/2022] Open
Abstract
Background Socioeconomic status has a profound effect on the risk of having a first acute myocardial infarction (AMI). Information on socioeconomic inequalities in AMI incidence across age- gender-groups is lacking. Our objective was to examine socioeconomic inequalities in the incidence of AMI considering both relative and absolute measures of risk differences, with a particular focus on age and gender. Methods We identified all patients with a first AMI from 1997 to 2007 through linked hospital discharge and death records covering the Dutch population. Relative risks (RR) of AMI incidence were estimated by mean equivalent household income at neighbourhood-level for strata of age and gender using Poisson regression models. Socioeconomic inequalities were also shown within the stratified age-gender groups by calculating the total number of events attributable to socioeconomic disadvantage. Results Between 1997 and 2007, 317,564 people had a first AMI. When comparing the most deprived socioeconomic quintile with the most affluent quintile, the overall RR for AMI was 1.34 (95 % confidence interval (CI): 1.32 – 1.36) in men and 1.44 (95 % CI: 1.42 – 1.47) in women. The socioeconomic gradient decreased with age. Relative socioeconomic inequalities were most apparent in men under 35 years and in women under 65 years. The largest number of events attributable to socioeconomic inequalities was found in men aged 45–74 years and in women aged 65–84 years. The total proportion of AMIs that was attributable to socioeconomic inequalities in the Dutch population of 1997 to 2007 was 14 % in men and 18 % in women. Conclusions Neighbourhood socioeconomic inequalities were observed in AMI incidence in the Netherlands, but the magnitude across age-gender groups depended on whether inequality was expressed in relative or absolute terms. Relative socioeconomic inequalities were high in young persons and women, where the absolute burden of AMI was low. Absolute socioeconomic inequalities in AMI were highest in the age-gender groups of middle-aged men and elderly women, where the number of cases was largest.
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Affiliation(s)
- Carla Koopman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (STR 6,131), PO Box 85500, 3508 GA, Utrecht, The Netherlands
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Socioeconomic differences in incidence and relative survival after a first acute myocardial infarction in the Basque Country, Spain. GACETA SANITARIA 2012; 26:16-23. [DOI: 10.1016/j.gaceta.2011.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 06/27/2011] [Accepted: 06/28/2011] [Indexed: 11/18/2022]
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Kirchmayer U, Agabiti N, Belleudi V, Davoli M, Fusco D, Stafoggia M, Arcà M, Barone AP, Perucci CA. Socio-demographic differences in adherence to evidence-based drug therapy after hospital discharge from acute myocardial infarction: a population-based cohort study in Rome, Italy. J Clin Pharm Ther 2011; 37:37-44. [PMID: 21294760 DOI: 10.1111/j.1365-2710.2010.01242.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Adherence to evidence-based drug therapy after acute myocardial infarction has increased over the last decades, but is still unsatisfactory. Our objectives are to set out to analyse patterns of evidence-based drug therapy after acute myocardial infarction (AMI), and evaluating socio-demographic differences. METHODS A cohort of 3920 AMI patients discharged from hospital in Rome (2006-2007) was selected. Drugs claimed during the 12 months after discharge were retrieved. Drug utilization was defined as density of use (boxes claimed/individual follow-up; chronic use = 6+ boxes/365 days) and therapeutic coverage, calculated through Defined Daily Doses (chronic use: ≥80% of individual follow-up). Patterns of use of single drugs and their combination were described. The association between poly-therapy and gender, age and socio-economic position (small-area composite index based on census data) was analysed through logistic regression, accounting for potential confounders. RESULTS AND DISCUSSION Most patients used single drugs: 90·5% platelet aggregation inhibitors (antiplatelets), 60·0%β-blockers, 78·1% agents acting on the renin-angiotensin system (ACEIs/ARBs), 77·8% HMG CoA reductase inhibitors (statins). Percentages of patients with ≥80% of therapeutic coverage were 81·9% for antiplatelets, 17·8% for β-blockers, 64·4% for ACEIs/ARBs and 76·1% for statins. The multivariate analysis showed gender and age differences in adherence to poly-therapy (females: OR = 0·84; 95% CI 0·72-0·99; 71-80 years age-group: OR = 0·82; 95% CI 0·68-0·99). No differences were observed with respect to socio-economic position. WHAT IS NEW AND CONCLUSION The availability of information systems offers the opportunity to monitor the quality of care and identify weaknesses in public health-care systems. Our results identify specific factors contributing to non-adherence and hence define areas for more targeted health-care interventions. Our results suggest that efforts to improve adherence should focus on women and older patients.
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Affiliation(s)
- U Kirchmayer
- Department of Epidemiology, Lazio Region, Rome, Italy.
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Davies CA, Leyland AH. Trends and inequalities in short-term acute myocardial infarction case fatality in Scotland, 1988-2004. Popul Health Metr 2010; 8:33. [PMID: 21134255 PMCID: PMC3014876 DOI: 10.1186/1478-7954-8-33] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 12/06/2010] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There have been substantial declines in ischemic heart disease in Scotland, partly due to decreases in acute myocardial infarction (AMI) incidence and case fatality (CF). Despite this, Scotland's IHD mortality rates are among the worst in Europe. We examine trends in socioeconomic inequalities in short-term CF after a first AMI event and their associations with age, sex, and geography. METHODS We used linked hospital discharge and death records covering the Scottish population (5.1 million). Between 1988 and 2004, 178,781 of 372,349 patients with a first AMI died on the day of the event (Day0 CF) and 34,198 died within 28 days after surviving the day of their AMI (Day1-27 CF). RESULTS Age-standardized Day0 CF at 30+ years decreased from 51% in 1988-90 to 41% in 2003-04. Day1-27 CF decreased from 29% to 18% over that period. Socioeconomic inequalities in Day0 CF existed for both sexes and persisted over time. The odds of case fatality for men aged 30-59 living in the most deprived areas in 2000-04 were 1.7 (95%CI: 1.3-2.2) times as high as in the least deprived areas and 1.9 (1.1-3.2) times as high for women. There was little evidence of socioeconomic inequality in Day1-27 CF in men or women. After adjustment for socioeconomic deprivation, significant geographic variation still remained for both CF definitions. CONCLUSIONS A high proportion of AMI incidents in Scotland result in death on the day of the first event; many of these are sudden cardiac deaths. Short-term CF has improved, perhaps reflecting treatment advances and reductions in first AMI severity. However, persistent socioeconomic and geographic inequalities suggest these improvements are not uniform across all population groups, emphasizing the need for population-wide primary prevention.
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Affiliation(s)
- Carolyn A Davies
- MRC/CSO Social and Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow, UK, G12 8RZ.
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Fornari C, Donfrancesco C, Riva MA, Palmieri L, Panico S, Vanuzzo D, Ferrario MM, Pilotto L, Giampaoli S, Cesana G. Social status and cardiovascular disease: a Mediterranean case. Results from the Italian Progetto CUORE cohort study. BMC Public Health 2010; 10:574. [PMID: 20868471 PMCID: PMC2955692 DOI: 10.1186/1471-2458-10-574] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 09/24/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Social factors could offer useful information for planning prevention strategy for cardiovascular diseases. This analysis aims to explore the relationship between education, marital status and major cardiovascular risk factors and to evaluate the role of social status indicators in predicting cardiovascular events and deaths in several Italian cohorts. METHODS The population is representative of Italy, where the incidence of the disease is low. Data from the Progetto CUORE, a prospective study of cohorts enrolled between 1983-1997, were used; 7520 men and 13127 women aged 35-69 years free of previous cardiovascular events and followed for an average of 11 years. Educational level and marital status were used as the main indicators of social status. RESULTS About 70% of the studied population had a low or medium level of education (less than high school) and more than 80% was married or cohabitating. There was an inverse relationship between educational level and major cardiovascular risk factors in both genders. Significantly higher major cardiovascular risk factors were detected in married or cohabitating women, with the exception of smoking. Cardiovascular risk score was lower in married or cohabitating men. No relationship between incidence of cardiac events and the two social status indicators was observed. Cardiovascular case-fatality was significantly higher in men who were not married and not cohabitating (HR 3.20, 95%CI: 2.21-4.64). The higher cardiovascular risk observed in those with a low level of education deserves careful attention even if during the follow-up it did not seem to determine an increase of cardiac events. CONCLUSIONS Preventive interventions on cardiovascular risk should be addressed mostly to people with less education. Cardiovascular risk score and case-fatality resulted higher in men living alone while cardiovascular factors were higher in women married or cohabitating. Such gender differences seem peculiar of our population and require further research on unexpected cultural and behavioural influences.
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Affiliation(s)
- Carla Fornari
- Research Centre on Public Health, Department of Clinical and Preventive Medicine, University of Milano-Bicocca, Monza, Italy
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A small-area ecologic study of myocardial infarction, neighborhood deprivation, and sex: a Bayesian modeling approach. Epidemiology 2010; 21:459-66. [PMID: 20489648 DOI: 10.1097/ede.0b013e3181e09925] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Socioeconomic inequalities in the risk of coronary heart disease (CHD) are well documented for men and women. CHD incidence is greater for men but its association with socioeconomic status is usually found to be stronger among women. We explored the sex-specific association between neighborhood deprivation level and the risk of myocardial infarction (MI) at a small-area scale. METHODS We studied 1193 myocardial infarction events in people aged 35-74 years in the Strasbourg metropolitan area, France (2000-2003). We used a deprivation index to assess the neighborhood deprivation level. To take into account spatial dependence and the variability of MI rates due to the small number of events, we used a hierarchical Bayesian modeling approach. We fitted hierarchical Bayesian models to estimate sex-specific relative and absolute MI risks across deprivation categories. We tested departure from additive joint effects of deprivation and sex. RESULTS The risk of MI increased with the deprivation level for both sexes, but was higher for men for all deprivation classes. Relative rates increased along the deprivation scale more steadily for women and followed a different pattern: linear for men and nonlinear for women. Our data provide evidence of effect modification, with departure from an additive joint effect of deprivation and sex. CONCLUSIONS We document sex differences in the socioeconomic gradient of MI risk in Strasbourg. Women appear more susceptible at levels of extreme deprivation; this result is not a chance finding, given the large difference in event rates between men and women.
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Cesaroni G, Agabiti N, Forastiere F, Perucci CA. Socioeconomic Differences in Stroke Incidence and Prognosis Under a Universal Healthcare System. Stroke 2009; 40:2812-9. [DOI: 10.1161/strokeaha.108.542944] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Giulia Cesaroni
- From the Department of Epidemiology, Local Health Authority ASL RME, Rome, Italy
| | - Nera Agabiti
- From the Department of Epidemiology, Local Health Authority ASL RME, Rome, Italy
| | - Francesco Forastiere
- From the Department of Epidemiology, Local Health Authority ASL RME, Rome, Italy
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Agabiti N, Cesaroni G, Picciotto S, Bisanti L, Caranci N, Costa G, Forastiere F, Marinacci C, Pandolfi P, Russo A, Perucci CA. The association of socioeconomic disadvantage with postoperative complications after major elective cardiovascular surgery. J Epidemiol Community Health 2009; 62:882-9. [PMID: 18791046 PMCID: PMC2602741 DOI: 10.1136/jech.2007.067470] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Understanding the mechanism by which both patient- and hospital level factors act in generating disparities has important implications for clinicians and policy-makers. Objective: To measure the association between socioeconomic position (SEP) and postoperative complications after major elective cardiovascular procedures. Design: Multicity hospital-based study. Subjects: Using Hospital Discharge Registries (ICD-9-CM codes), 19 310 patients were identified undergoing five cardiovascular operations (coronary artery bypass grafting (CABG), valve replacement, carotid endarterectomy, major vascular bypass, repair of unruptured abdominal aorta aneurysm (AAA repair)) in four Italian cities, 1997–2000. Measures: For each patient, a five-level median income index by census block of residence was calculated. In-hospital 30-day mortality, cardiovascular complications (CCs) and non-cardiovascular complications (NCCs) were the outcomes. Odds ratios (ORs) were estimated with multilevel logistic regression adjusting for city of residence, gender, age and comorbidities taking into account hospital and individual dependencies. Main results: In-hospital 30-day mortality varied by type of surgery (CABG 3.7%, valve replacement 5.7%, carotid endarterectomy 0.9%, major vascular bypass 8.8%, AAA repair 4.0%). Disadvantaged people were more likely to die after CABG (lowest vs highest income OR 1.93, p trend 0.023). For other surgeries, the relationship between SEP and mortality was less clear. For cardiac surgery, SEP differences in mortality were higher for publicly funded patients in low-volume hospitals (lowest vs highest income OR 3.90, p trend 0.039) than for privately funded patients (OR 1.46, p trend 0.444); however, the difference in the SEP gradients was not statistically significant. Conclusions: Disadvantaged people seem particularly vulnerable to mortality after cardiovascular surgery. Efforts are needed to identify structural factors that may enlarge SEP disparities within hospitals.
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Affiliation(s)
- N Agabiti
- Department of Epidemiology, Local Health Authority Rome E, Via di S Costanza 53, 00198 Rome, Italy.
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Murasko JE. Male–female differences in the association between socioeconomic status and atherosclerotic risk in adolescents. Soc Sci Med 2008; 67:1889-97. [DOI: 10.1016/j.socscimed.2008.09.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Indexed: 10/21/2022]
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A small-area index of socioeconomic deprivation to capture health inequalities in France. Soc Sci Med 2008; 67:2007-16. [DOI: 10.1016/j.socscimed.2008.09.031] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Indexed: 11/23/2022]
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Income and recurrent events after a coronary event in women. Eur J Epidemiol 2008; 23:669-80. [PMID: 18807201 DOI: 10.1007/s10654-008-9285-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Accepted: 08/15/2008] [Indexed: 10/21/2022]
Abstract
Strong evidence supports the existence of a social gradient in poor prognosis in patients with coronary heart disease (CHD). However, knowledge regarding what factors may explain this relationship is limited. We aimed to analyze in women CHD patients the association between personal income and recurrent events and to determine whether lifestyle, biological and psychosocial factors contribute to the explanation of this relationship. Altogether 188 women hospitalized for a cardiac event were assessed for personal income, demographic factors, lipids, inflammatory markers, cortisol, creatinine, lifestyle and psychosocial factors, i.e. alcohol consumption, smoking habits, body-mass index, depressive symptoms, anxiety, vital exhaustion, availability of social interaction, hostility and anger-related characteristics and were followed for cardiovascular death and recurrent acute myocardial infarction (AMI). During the 6-year follow-up 18 patients deceased and 31 experienced cardiovascular death or non-fatal AMI. After adjustment for confounders, patients with medium and high income had lower risk for recurrent events relative to those with low income (HR (95% CI): 0.38 (0.15-0.97) and 0.39 (0.17-0.93), respectively). Controlling for smoking reduced by 12.8% the risk for recurrent events associated with high versus low income, while adjusting for depression decreased the risk for middle versus low income by 13.5%. Anger symptoms explained 16.7% of the risk for recurrent events associated with middle versus low income and 10.2% of the risk for high versus low income. We suggest that in women with CHD low income is associated with recurrent events and that smoking, depressive symptomatology and anger symptoms may contribute to the explanation of this relationship.
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Traffic-related air pollution in relation to incidence and prognosis of coronary heart disease. Epidemiology 2008; 19:121-8. [PMID: 18091421 DOI: 10.1097/ede.0b013e31815c1921] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Long-term air pollution exposure is associated with increased mortality, but the association with incidence of fatal and nonfatal coronary heart disease is less certain. Moreover, it is unknown how chronic exposure to air pollution affects prognosis among survivors of a first coronary event. This study evaluated the association between long-term traffic-related air pollution exposure and incidence of nonfatal and fatal coronary events, as well as subsequent hospital readmission and mortality among myocardial infarction survivors. METHODS The study population comprised all residents of Rome aged 35-84 years during the period 1998-2000. Residential nitrogen dioxide (NO2) exposure as a marker of traffic pollution was assessed by a land-use regression model in 1995-1996 (R = 0.69). A total of 11,167 incident coronary events were observed (4654 fatal, including 3598 out-of-hospital coronary deaths, and 6513 nonfatal). The cohort of 6513 survivors was followed 4.0-7.5 years for readmission or mortality, starting 28 days from the date of first event. Relative risks per 10 mug/m of NO2 exposure, adjusted for age, sex, and socioeconomic status, were calculated by Poisson regression (population-based incidence) and Cox regression (cohort analysis). RESULTS The relative risk for incidence in coronary events per 10 mug/m of NO2 was 1.03 (95% confidence interval = 1.00-1.07). Stronger associations were found for fatal cases (1.07; 1.02-1.12) and out-of-hospital deaths (1.08; 1.02-1.13). Using NO2 exposure at the time of the first event, there was no association of air pollution exposure with either subsequent hospital readmission or mortality among survivors of the first coronary event. CONCLUSIONS Long-term air pollution exposure increases the risk of coronary heart disease, particularly fatal events. Hospital readmission or subsequent mortality among survivors was not associated with traffic air pollution.
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Persistent Socio-economic Differences in Revascularization After Acute Myocardial Infarction Despite a Universal Health Care System—A Danish Study. Cardiovasc Drugs Ther 2007; 21:449-57. [DOI: 10.1007/s10557-007-6058-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Greiser E, Greiser C, Janhsen K. Night-time aircraft noise increases prevalence of prescriptions of antihypertensive and cardiovascular drugs irrespective of social class—the Cologne-Bonn Airport study. J Public Health (Oxf) 2007. [DOI: 10.1007/s10389-007-0137-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Forastiere F, Stafoggia M, Tasco C, Picciotto S, Agabiti N, Cesaroni G, Perucci CA. Socioeconomic status, particulate air pollution, and daily mortality: differential exposure or differential susceptibility. Am J Ind Med 2007; 50:208-16. [PMID: 16847936 DOI: 10.1002/ajim.20368] [Citation(s) in RCA: 177] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Short-term increases in particulate air pollution are linked with increased daily mortality and morbidity. Socioeconomic status (SES) is a determinant of overall health. We investigated whether social class is an effect modifier of the PM(10) (particulate matter with diameter <10 micron)-daily mortality association, and possible mechanisms for this effect modification. METHODS Area-based traffic emissions, income, and SES were available for each resident in Rome. All natural deaths (83,253 subjects) occurring in Rome among city residents (aged 35+ years) during the period 1998-2001 were identified. For each deceased individual, all the previous hospitalizations within 2 years before death were available via a record linkage procedure. PM(10) daily data were available from two urban monitoring sites. A case-crossover analysis was utilized in which control days were selected according to the time stratified approach (same day of the week during the same month). Conditional logistic regression was used. RESULTS Due to the social class distribution in the city, exposure to traffic emissions was higher among those with higher area-based income and SES. Meanwhile, people of lower social class had suffered to a larger extent from chronic diseases before death than more affluent residents, especially diabetes mellitus, hypertension, heart failure, and chronic obstructive pulmonary diseases. Overall, PM(10) (lag 0-1) was strongly associated with mortality (1.1% increase, 95%CI = 0.7-1.6%, per 10 microg/m(3)). The effect was more pronounced among persons with lower income and SES (1.9% and 1.4% per 10 microg/m(3), respectively) compared to those in the upper income and SES levels (0.0% and 0.1%, respectively). CONCLUSIONS The results confirm previous suggestions of a stronger effect of particulate air pollution among people in low social class. Given the uneven geographical distributions of social deprivation and traffic emissions in Rome, the most likely explanation is a differential burden of chronic health conditions conferring a greater susceptibility to less advantaged people.
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Cesaroni G, Agabiti N, Forastiere F, Ancona C, Perucci CA. Socioeconomic differentials in premature mortality in Rome: changes from 1990 to 2001. BMC Public Health 2006; 6:270. [PMID: 17081291 PMCID: PMC1647282 DOI: 10.1186/1471-2458-6-270] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2006] [Accepted: 11/02/2006] [Indexed: 11/28/2022] Open
Abstract
Background While socioeconomic inequalities in mortality have widened in many countries, evidence of social differentials is scarce in Southern Europe. We studied temporal changes in premature mortality across socioeconomic groups in Rome between 1990 and 2001. Methods We analysed all 126,511 death certificates of residents of Rome aged 0–74 years registered between 1990–2001. A 4-level census block index based on the 1991 census was used as an indicator of socioeconomic position (SEP). Using routine mortality data, standardised mortality rates (per 100,000 inhabitants) were calculated by SEP and gender for four time periods. Rate ratios were used to compare mortality by gender and age. Results Overall premature mortality decreased in both genders and in all socioeconomic groups; the change was greater in the highest socio-economic group. In both men and women, inequalities in mortality strengthened during the 1990s and appeared to stabilise at the end of the 20th century. However, for 60–74 year old women the gap continued to widen. Conclusion Socioeconomic inequalities in health in Rome are still present at the beginning of the 21st century. Strategies to monitor the impact of SEP on mortality over time in different populations should be implemented to direct health policies.
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Affiliation(s)
- Giulia Cesaroni
- Department of Epidemiology, Rome E Health Authority, Via Santa Costanza 53, Rome 00198, Italy
| | - Nera Agabiti
- Department of Epidemiology, Rome E Health Authority, Via Santa Costanza 53, Rome 00198, Italy
| | - Francesco Forastiere
- Department of Epidemiology, Rome E Health Authority, Via Santa Costanza 53, Rome 00198, Italy
| | - Carla Ancona
- Department of Epidemiology, Rome E Health Authority, Via Santa Costanza 53, Rome 00198, Italy
| | - Carlo A Perucci
- Department of Epidemiology, Rome E Health Authority, Via Santa Costanza 53, Rome 00198, Italy
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