Association of Median Household Income With Burden of Coronary Artery Disease Among Individuals With Diabetes

Income variability and incident cardiovascular disease in diabetes: a population-based cohort study

BACKGROUND AND AIMS

Longitudinal change in income is crucial in explaining cardiovascular health inequalities. However, there is limited evidence for cardiovascular disease (CVD) risk associated with income dynamics over time among individuals with type 2 diabetes (T2D).

METHODS

Using a nationally representative sample from the Korean National Health Insurance Service database, 1 528 108 adults aged 30-64 with T2D and no history of CVD were included from 2009 to 2012 (mean follow-up of 7.3 years). Using monthly health insurance premium information, income levels were assessed annually for the baseline year and the four preceding years. Income variability was defined as the intraindividual standard deviation of the percent change in income over 5 years. The primary outcome was a composite event of incident fatal and nonfatal CVD (myocardial infarction, heart failure, and stroke) using insurance claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated after adjusting for potential confounders.

RESULTS

High-income variability was associated with increased CVD risk (HRhighest vs. lowest quartile 1.25, 95% CI 1.22-1.27; Ptrend < .001). Individuals who experienced an income decline (4 years ago vs. baseline) had increased CVD risk, which was particularly notable when the income decreased to the lowest level (i.e. Medical Aid beneficiaries), regardless of their initial income status. Sustained low income (i.e. lowest income quartile) over 5 years was associated with increased CVD risk (HRn = 5 years vs. n = 0 years 1.38, 95% CI 1.35-1.41; Ptrend < .0001), whereas sustained high income (i.e. highest income quartile) was associated with decreased CVD risk (HRn = 5 years vs. n = 0 years 0.71, 95% CI 0.70-0.72; Ptrend < .0001). Sensitivity analyses, exploring potential mediators, such as lifestyle-related factors and obesity, supported the main results.

CONCLUSIONS

Higher income variability, income declines, and sustained low income were associated with increased CVD risk. Our findings highlight the need to better understand the mechanisms by which income dynamics impact CVD risk among individuals with T2D.

Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey

Background

Socioeconomic factors and the COVID-19 pandemic influence children's physical and mental health. We aimed to investigate the association between a census tract's median household income [MHI in United States Dollars ($)] and pediatric intoxications in Rhode Island, the smallest state in the United States of America. Geographical hotspots, as well as interactions with the COVID-19 pandemic, should be identified.

Methods

This study is a retrospective analysis of ambulance calls for pediatric (<18 years) intoxication in Rhode Island between March 1st, 2018, and February 28th, 2022. March 1st, 2020 was considered the beginning of the COVID-19 pandemic. Prehospital data were joined with information from the United States Census Bureau. The census tracts' case counts and MHI were examined using Poisson regression. Geographical clusters were identified with the Global Moran's I and local indicators of spatial association tests in ArcGIS Pro (Esri Corporation, Redlands, CA).

Results

Inclusion criteria were met by 208 incidents (48% female, median age 16 (IQR 15 to 17) years). The regression model showed a 0.6% increase (IRR 1.006, 95% CI [1.002, 1.01], p = 0.003) in pediatric intoxications for every $ 1,000 increase in MHI. Interaction analysis showed that the effect of MHI was less pronounced during the pandemic (IRR 0.98, 95% CI [0.964, 0.997], p = 0.02). Thirty-four (14%) of the 244 census tracts contributed to geographical clusters, which changed after the onset of the pandemic.

Conclusion

Higher median household income could be a risk factor for pediatric intoxications. Geographical hotspots changed with the pandemic.

Genetically predicted lifestyle factors, socioeconomic status and risk of coronary artery disease in individuals with diabetes: a Mendelian randomization study

Background

This study explores the causal links between genetically predicted lifestyle factors, socioeconomic status, and coronary artery disease (CAD) risk in individuals with diabetes using a bidirectional Mendelian-randomization approach.

Methods

This study explored the potential causal relationships of lifestyle factors and socioeconomic status with the risk of CAD in diabetes patients by a bidirectional, two-sample Mendelian-randomization (MR) analysis.

Results

Genetically predicted smoking initiation (p = 0.005, 95% CI: 1.08-1.55) and insomnia (p = 0.001, 95% CI: 1.06-1.29) were associated with a higher risk of CAD in individuals with diabetes, whereas educational attainment (p = 0.0001, 95% CI: 0.47-0.78) was associated with a lower risk of CAD. The lifetime smoking index (p = 0.016, 95% CI: 1.12-3.03) was suggestively associated with a higher risk of CAD, while household income before taxes (p = 0.048, 95% CI: 0.41-1.00) was suggestively associated with a lower risk of CAD. In addition, we observed a suggestive negative association between the genetically predicted risk of CAD and the lifetime smoking index (p = 0.016, 95% CI: 0.98-0.99) and a significant causal relationship between the risk of CAD and household income before taxes (p = 0.006, 95% CI: 0.97-0.99).

Conclusion

The results of this study provide evidence that smoking initiation, lifetime smoking index and insomnia are associated with an increased risk of CAD in individuals with diabetes, educational attainment and household income before taxes are associated with a reduced risk of CAD in individuals with diabetes, and the possible role of lifetime smoking index and household income before taxes on the risk of CAD in individuals with diabetes. It provides an opportunity for the prevention and management of CAD in individuals with diabetes.

Age at job initiation and risk of coronary heart disease: findings from the UK biobank cohort study

BACKGROUND

Commencing work at an early age has been linked to various risk factors for coronary heart disease (CHD), such as shift work and intensive job strain. However, the relationship between starting work too early and CHD risk remains largely unclear. We examined the association between age at job initiation and the risk of CHD.

METHODS

UK Biobank participants aged 38 to 70 years without cardiovascular disease who provided data on their age at job initiation were included. The primary outcome was CHD, which was ascertained using hospital and death records. The hazard ratios (HRs) and 95% confidence interval (CIs) for the association between age at job initiation and CHD were calculated using multivariable Cox regression.

RESULTS

Of the 501,971 participants, 114,418 eligible participants were included in the final analysis. The median age at job initiation was 19.0 years. During the mean follow-up of 12.6 years, 6,130 (5.4%) first CHD events occurred. We observed that age at job initiation was inversely associated with CHD (HR 0.98, 95% CI 0.97-0.99), and the association was potentially J-shaped. The HRs for the < 17-year, 17-18-year, and 19-21-year age groups were 1.29 (95%CI 1.18-1.41), 1.12 (95% CI 1.03-1.22) and 1.05 (95% CI 0.97-1.14), respectively, compared with those of the ≥ 22-year group.

CONCLUSIONS

Age at job initiation was associated with incident CHD, which was independent of socioeconomic status. Participants who commenced employment before the age of 19 years exhibited a higher risk of developing CHD later in adulthood.

Association of socioeconomic status with cardiovascular disease and cardiovascular risk factors: a systematic review and meta-analysis

Aim

Cardiovascular disease (CVD) remains one of the leading causes of mortality worldwide, and several studies have indicated the association between socioeconomic status (SES) with CVD and cardiovascular risk factors (CVRFs). It is necessary to elucidate the association of SES and CVRFs with CVD.

Subject and methods

We searched PubMed, Embase, Web of Science, and the Cochrane Library for publications, using "socioeconomic status," "cardiovascular disease," and corresponding synonyms to obtain literature. The quality of studies was evaluated using the National Institutes of Health Quality Assessment Tool (NIH-QAT). All analyses were performed using Stata V.12.0.

Results

There were 31 eligible studies included in this meta-analysis. All studies presented a low risk of bias via NIH-QAT assessment. As for CVD incidence/mortality, pooled hazard ratios (HR) of low and middle vs. high income were [HR = 1.22 (1.17-1.28); HR = 1.12 (1.09-1.16)] and [HR = 1.37 (1.21-1.56); HR = 1.19 (1.06-1.34)]. The HR of education were [HR = 1.44 (1.28-1.63); HR = 1.2 (1.11-1.3)] and [HR = 1.5 (1.22-1.83); HR = 1.13 (1.05-1.22)]. The HR of deprivation were [HR = 1.28 (1.16-1.41); HR = 1.07 (1.03-1.11)] and [HR = 1.19 (1.11-1.29); HR = 1.1 (1.02-1.17)]. SES was negatively correlated with CVD outcomes. A subgroup analysis of gender and national income level also yielded a negative correlation, and additional details were also obtained.

Conclusions

SES is inversely correlated with CVD outcomes and the prevalence of CVRFs. As for CVD incidence, women may be more sensitive to income and education. In terms of CVD mortality, men may be more sensitive to income and education, and people from low- and middle-income countries are sensitive to income and education.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-023-01825-4.

The association of disparities in neighborhood median household income and mortality in patients admitted to the hospital with atrial fibrillation

BACKGROUND

Lower neighborhood median household income (nMHI) is associated with increased adverse outcomes in patients with atrial fibrillation (AF). However, its effect on mortality is yet unknown.

METHODS

Data from the regional United States (U.S.) electronic medical records database, Research Action for Health Network (REACHnet), was extracted for adult patients with AF at Tulane Medical Center over 10 years. Annual nMHI & neighborhood high school graduation (HSG) data was collected from the US Census bureau. Only African Americans (AA) and Caucasians (CC) who had socioeconomic data were included. Low nMHI and low HSG were defined as ≤$25,000 & <90% respectively. High nMHI and HSG were defined as >$50,000 & ≥90% respectively. Primary endpoints were all cause and cardiovascular (CV) mortality. Cox-proportional hazard ratios were used to evaluate the endpoints.

RESULTS

We included 4616 patients diagnosed with AF. During a median follow up of 4.6 years, 434 patients died of which 32.7% patients had CV mortality. There was a stepwise decrease in incidence of both all-cause and CV mortality as nMHI increased. Patients with low nMHI had the greatest risk of all-cause mortality (HR 1.9, C.I. 1.2-3.2, P 0.004). The association between low nMHI and all-cause mortality persisted after adjusting for age, sex, race, HSG and stroke risk factors using CHA₂DS₂VASC, delta CHA₂DS₂VASC scores and oral anticoagulant use. CV mortality followed a similar trend as all-cause mortality, however, this association was not significant after adjusting for the above variables. Apart from low nMHI, CHA₂DS₂VASC delta CHA₂DS₂VASC were statistically significant independent predictors of both all-cause and CV mortality.

CONCLUSION

Low nMHI is an independent risk factor for all cause and CV mortality in AF. Higher burden of co-morbidities is the driving force behind this disparity. Future studies should evaluate the role of educational and therapeutic intervention in these populations to reduce mortality.

The Influence of Socioeconomic Status (SES) and Processing Speed on the Psychological Adjustment and Wellbeing of Pediatric Brain Tumor Survivors

Simple Summary

Processing speed (PS) is one of the most impaired functions in pediatric brain tumor survivors (PBTSs) and it has been linked to difficulties in their psychological functioning, together with other non-insult-related risk factors, such as socio-economic status (SES). Given the psychological adjustment difficulties observed in PBTS, the aim of the current study was to explore the relationship between SES and psychological functioning, measured with the Child Behavioral Checklist (CBCL) and the Strengths and Difficulties Questionnaire, and considering the contribution of PS as a mediator. The results demonstrated that the influence of SES on the CBCL total index was mediated by PS. Furthermore, PS was found to have a mediating effect on the SES–internalizing problems relationship but not on the SES–externalizing problems relationship. These findings suggest that PS may be a rehabilitation target to prevent psychological distress and should be addressed, especially for PBTSs who live in a disadvantaged situation.

Abstract

(1) Background: The relationship between processing speed (PS) and psychological adjustment in the healthy population is well established, as is that between low socio-economic status (SES) and psychological distress. While PS is one of the most impaired functions in pediatric brain tumor survivors (PBTSs), previous research has demonstrated that low SES may be a predictor of increased psychosocial risk in PBTSs. Given the psychological adjustment difficulties observed in PBTS, in the current study we aimed to explore the relationship between SES and psychological functioning, considering the contribution of PS as a mediator. (2) Methods: demographic and clinical data of 80 children (age range: 4–17 y.o.) were retrospectively collected. Psychological measures were the parent-compiled versions of the Child Behavioral Checklist (CBCL) and the Strengths and Difficulties Questionnaire (SDQ). Mediation analysis models were performed on psychological measures with and without the inclusion of covariates. (3) Results: The influence of SES on the CBCL total index was mediated by PS. Furthermore, PS was found to have a mediating effect on the relationship between SES and internalizing problems but not on the relationship between SES and externalizing problems. (4) Conclusions: The results suggest that PS may be a rehabilitation target for the prevention of psychological distress and should be addressed especially for PBTSs who live in a disadvantaged situation.

Socioeconomic inequalities and type 2 diabetes complications: A systematic review

BACKGROUND AND OBJECTIVES

A socioeconomic gradient related to type 2 diabetes (T2D) prevalence has been demonstrated in high-income countries. However, there is no evidence of such a socioeconomic gradient regarding diabetes complications. Thus, the aim of this systematic review was to collect data on risk of complications according to socioeconomic status in patients with T2D.

METHODS

PubMed and EMBASE were searched for English-language observational studies evaluating the prevalence or incidence of micro- and macrovascular complications according to individual and geographical socioeconomic status (SES). Observational studies reporting the prevalence and risk of micro- and macrovascular diabetes complications, according to an individual or geographical index of deprivation, were selected, and estimated crude and adjusted risks for each complication were reported.

RESULTS

Among the 28 included studies, most described a clear relationship between SES and diabetes complications, especially retinopathy (in 9 of 14 studies) and cardiopathy (in 8 of 9 studies). Both individual and area-based low SES was associated with an increased risk of complications. However, very few studies adjusted their analyses according to HbA_1c level.

CONCLUSION

Evaluation of SES is necessary for every T2D patient, as it appears to be a risk factor for diabetes complications. However, the available studies are insufficient for gradation of the impact of low socioeconomic level on each of these complications. Regardless, strategies for the improved screening, follow-up and care of high-risk patients should now be implemented.

Psychosocial Risk Factors and Ischemic Heart Disease: A New Perspective

BACKGROUND

Cardiovascular disease is the most common cause of morbidity and mortality worldwide, with ischemic heart disease (IHD) accounting for roughly 50% of these events in industrialized nations. In recent years, the relative importance of IHD in less industrialized countries is also rising at an alarming and steadily-increasing rate.

OBJECTIVES

Many experimental, observational and epidemiological studies have demonstrated the importance of psychosocial risk factors in the development and clinical manifestations of IHD. They act both indirectly, associated with an unhealthy lifestyle; and directly, through the activation of inflammatory cascades and the sympathetic nervous system. They also cluster with biological risk factors to increase the incidence and clinical manifestations of IHD. From these assumptions, there emerges the potential that an integrated approach that incorporates psychological therapy in various forms might reduce IHD patients' symptoms and maladaptive behaviors, and thereby enhance their prognosis.

METHODS

To date, three psychotherapeutic approaches have been utilized within cardiac psychology practice: (1) cognitive-behavioral psychotherapy; (2) psychodynamic psychotherapy; and (3) ontopsychological psychotherapy. The current article briefly describes these three approaches and how their use might enhance the care of IHD patients.

RESULTS

A range of psychological characteristics influence the development, course and management of cardiac patients' IHD. Among others, these include patients' emotions, attitudes, behaviors, relationships, and stressors. State-of- the-art literature suggests that psychological interventions should be considered in much the same way as medical interventions, in terms of their relevance to both patient management and outcomes.

CONCLUSION

For this reason, it is essential that professional psychological and psychotherapeutic support be rendered available to cardiology patients, as a means to enhance both the effectiveness and efficiency of care.

Neighborhood Socioeconomic Status and Adverse Outcomes in Patients With Cardiovascular Disease

Neighborhood socioeconomic status (nSES) is associated with cardiovascular morbidity and mortality in the general population; however, its effect on high-risk patients with prevalent coronary artery disease (CAD) is unclear. We hypothesized "double jeopardy," whereby the association between nSES and adverse outcomes would be greater in high-risk patients with heart failure (HF) and/or previous myocardial infarction (MI) compared with those without. We followed 3,635 patients (mean age 63.2 years, 42% with HF, 25% with previous MI) with known or suspected CAD over a median of 3.3 years for all-cause death and cardiovascular death or nonfatal MI. Patients were categorized by a composite nSES score, and proportional hazards models were used to determine the association between nSES and outcomes. Cross-product interaction terms for previous MI × nSES and HF × nSES were analyzed. Compared with high nSES patients, low nSES patients had increased risk of all-cause death (hazard ratio [HR] = 1.61; 95% confidence interval [CI] = 1.20, 2.15) and cardiovascular death or MI (subdistribution HR [sHR] = 1.82; 95% CI = 1.30, 2.54). Associations were more pronounced among patients without HF or previous MI. Low nSES patients without HF had a higher risk of all-cause death (HR = 2.27; 95% CI = 1.41, 3.65) compared with those with HF (HR = 1.21; 95% CI = 0.82, 1.77, P interaction = 0.04). Similarly, low nSES patients without previous MI had a higher risk of cardiovascular death or MI (sHR = 2.72; 95% CI = 1.73, 4.28) compared with those with previous MI (sHR = 1.02; 95% CI = 0.58, 1.81, P interaction = 0.02). In conclusion, low nSES was independently associated with all-cause death and cardiovascular death or MI in patients with CAD; however, associations were greater in patients without HF or previous MI compared with those with HF or MI.

Demographic, social, economic and geographic factors associated with long-term outcomes in a cohort of cardiac arrest survivors

BACKGROUND

Demographic, social, economic and geographic factors are associated with increased short-term mortality after cardiac arrest. We sought to determine if these factors are additionally associated with long-term outcome differences using a detailed clinical database linked to state-wide administrative data.

METHODS

We included cardiac arrest patients surviving to hospital discharge from five hospitals in the United States from 2005 to 2013, with follow-up through 2015. We obtained information on sex, race, arrest location, initial rhythm, median ZIP code income, post-arrest illness severity, cardiac catheterization, internal cardioverter-defibrillator insertion, rural residence and drive time from residence to the nearest acute care hospital. We used Cox proportional hazard models identify predictors of mortality.

RESULTS

We included 891 patients followed for 2081 patient-years. There were 340 deaths with median survival 6 years. In adjusted models we identified an interaction effect between median ZIP code income and cardiac catheterization. Among patients who had cardiac catheterization there was an attenuated benefit from cardiac catheterization at progressively lower neighborhood incomes (adjusted HR: 0.21 to 0.46 to 0.56). Residence more than 20 min from the nearest acute care hospital was associated with increased hazard of death (adjusted HR: 1.48; 95%CI: 1.35-1.62), after controlling for rural residence and residence in a Medically Underserved Area/Population. Female patients showed less benefit following ICD placement (male adjusted HR: 0.49; female adjusted HR: 0.66).

CONCLUSIONS

There are persistent long-term outcome differences in cardiac arrest survival based on sex, income, and geographic access acute care.

Area Median Income and Metropolitan Versus Nonmetropolitan Location of Care for Acute Coronary Syndromes: A Complex Interaction of Social Determinants

Background

Metropolitan versus nonmetropolitan status and area median income may independently affect care for and outcomes of acute coronary syndromes. We sought to determine whether location of care modifies the association among area income, receipt of cardiac catheterization, and mortality following an acute coronary syndrome in a universal health care system.

Methods and Results

We studied a cohort of 14 012 acute coronary syndrome patients admitted to cardiology services between April 18, 2004, and December 31, 2011, in southern Alberta, Canada. We used multivariable logistic regression to determine the odds of cardiac catheterization within 1 day and 7 days of admission and the odds of 30‐day and 1‐year mortality according to area median household income quintile for patients presenting at metropolitan and nonmetropolitan hospitals. In models adjusting for area income, patients who presented at nonmetropolitan facilities had lower adjusted odds of receiving cardiac catheterization within 1 day of admission (odds ratio 0.22, 95% CI 0.11–0.46, P<0.001). Among nonmetropolitan patients, when examined by socioeconomic status, each incremental decrease in income quintile was associated with 10% lower adjusted odds of receiving cardiac catheterization within 7 days (P<0.001) and 24% higher adjusted odds of 30‐day mortality (P=0.008) but no significant difference for 1‐year mortality (P=0.12). There were no differences in adjusted mortality among metropolitan patients.

Conclusion

Within a universal health care system, the association among area income and receipt of cardiac catheterization and 30‐day mortality differed depending on the location of initial medical care for acute coronary syndromes. Care protocols are required to improve access to care and outcomes in patients from low‐income nonmetropolitan communities.

Understanding the social determinants of health among Indigenous Canadians: priorities for health promotion policies and actions

Background

Indigenous Canadians have a life expectancy 12 years lower than the national average and experience higher rates of preventable chronic diseases compared with non-Indigenous Canadians. Transgenerational trauma from past assimilation policies have affected the health of Indigenous populations.

Objective

The purpose of this paper is to comprehensively examine the social determinants of health (SDH), in order to identify priorities for health promotion policies and actions.

Design

We undertook a series of systematic reviews focusing on four major SDH (i.e. income, education, employment, and housing) among Indigenous peoples in Alberta, following the protocol Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Equity.

Results

We found that the four SDH disproportionately affect the health of Indigenous peoples. Our systematic review highlighted 1) limited information regarding relationships and interactions among income, personal and social circumstances, and health outcomes; 2) limited knowledge of factors contributing to current housing status and its impacts on health outcomes; and 3) the limited number of studies involving the barriers to, and opportunities for, education.

Conclusions

These findings may help to inform efforts to promote health equity and improve health outcomes of Indigenous Canadians. However, there is still a great need for in-depth subgroup studies to understand SDH (e.g. age, Indigenous ethnicity, dwelling area, etc.) and intersectoral collaborations (e.g. community and various government departments) to reduce health disparities faced by Indigenous Canadians.

Increased coronary artery disease severity in black women undergoing coronary bypass surgery

Race and sex disparities are believed to play an important role in heart disease. The purpose of this study was to examine the association between race, sex, and number of diseased vessels at the time of coronary artery bypass grafting (CABG), and subsequent postoperative outcomes. The 13,774 patients undergoing first-time, isolated CABG between 1992 and 2011 were included. Trend in the number of diseased vessels between black and white patients, stratified by sex, were analyzed using a Cochran-Armitage trend test. Models were adjusted for age, procedural status (elective vs. nonelective), and payor type (private vs. nonprivate insurance). Black female CABG patients presented with an increasingly greater number of diseased vessels than white female CABG patients (adjusted P(trend) = 0.0021). A similar trend was not observed between black and white male CABG patients (adjusted P(trend) = 0.18). Black female CABG patients were also more likely to have longer intensive care unit and hospital lengths of stay than other race-sex groups.Our findings suggest that black female CABG patients have more advanced coronary artery disease than white female CABG patients. Further research is needed to determine the benefit of targeted preventive care and preoperative workup for this high-risk group.

Impact of postdischarge statin withdrawal on long-term outcomes in patients with acute myocardial infarction

Many patients discontinue statin after acute myocardial infarction (AMI) despite its necessity. However, limited data are available describing the clinical impact of statin withdrawal after AMI. This study enrolled 3,807 patients in the Korean multicenter registry who survived for 1 year after AMI. All patients were prescribed statin at discharge and were divided into 2 groups on the basis of statin withdrawal history; 603 patients had a history of statin discontinuation and 3,204 patients continued statin therapy. The primary outcome was mortality from any cause. We also analyzed the incidence of cardiac death, nonfatal myocardial infarction, any revascularization, and stroke. The duration of follow-up was 4 years after AMI. Statin withdrawal was associated with higher mortality than continued statin treatment (hazard ratio 3.45, 95% confidence interval 2.81 to 4.24, p <0.001), primarily as the result of increased cardiac mortality (hazard ratio 4.65, 95% confidence interval 3.14 to 6.87, p <0.001). However, the incidences of nonfatal myocardial infarction, any revascularization, and stroke were not different between the groups. Analysis by propensity score matching did not affect the results. In conclusion, many patients experienced statin withdrawal after AMI, which significantly increased long-term mortality in the present study. Careful education and monitoring are needed to reduce adverse cardiac outcomes in patients after AMI.

Low socioeconomic status is associated with worse survival in children with cancer: a systematic review

BACKGROUND

While low socioeconomic status (SES) has been associated with inferior cancer outcome among adults, its impact in pediatric oncology is unclear. Our objective was therefore to conduct a systematic review to determine the impact of SES upon outcome in children with cancer.

METHODS

We searched Ovid Medline, EMBASE and CINAHL from inception to December 2012. Studies for which survival-related outcomes were reported by socioeconomic subgroups were eligible for inclusion. Two reviewers independently assessed articles and extracted data. Given anticipated heterogeneity, no quantitative meta-analyses were planned a priori.

RESULTS

Of 7,737 publications, 527 in ten languages met criteria for full review; 36 studies met final inclusion criteria. In low- and middle-income countries (LMIC), lower SES was uniformly associated with inferior survival, regardless of the measure chosen. The majority of associations were statistically significant. Of 52 associations between socioeconomic variables and outcome among high-income country (HIC) children, 38 (73.1%) found low SES to be associated with worse survival, 15 of which were statistically significant. Of the remaining 14 (no association or high SES associated with worse survival), only one was statistically significant. Both HIC studies examining the effect of insurance found uninsured status to be statistically associated with inferior survival.

CONCLUSIONS

Socioeconomic gradients in which low SES is associated with inferior childhood cancer survival are ubiquitous in LMIC and common in HIC. Future studies should elucidate mechanisms underlying these gradients, allowing the design of interventions mediating socioeconomic effects. Targeting the effect of low SES will allow for further improvements in childhood cancer survival.

Trends in cardiovascular risk factors among people with diabetes in a population based study, Health Survey for England 1994-2009

AIMS

We evaluated trends in cardiovascular risk factors in a population-based sample of people with diabetes in England from 1994 to 2009.

METHODS

Data were obtained from Health Survey for England for 1994, 1998, 2003, 2006, 2008 and 2009. Participants were aged ≥30 years with self-reported diabetes.

RESULTS

The standerdised prevalence of diabetes increased from 2.8% in 1994 to 6.4% in 2009 and the prevalence among males was higher than females throughout. The trend in prevalence was more apparent in manual workers. From 1994 to 2009, mean systolic blood pressure declined from 148 mmHg to 137 mmHg; mean diastolic pressure declined from 80 mmHg to 70 mmHg; mean total cholesterol declined from 6.1 mmol/L to 4.5 mmol/L over the 15 years with linear trends. The proportion prescribed lipid lowering drugs increased from 2.2% to 47.4%. The percentage of current smokers declined from 17.5% to 13.4%. Mean body mass index increased from 27.7 kg/m(2) to 31.6 kg/m(2) with an overall increase of 0.24 kg/m(2) per year. Risk factor trends were generally similar between genders and social classes but the decline in smoking was not significant for men or for manual workers.

CONCLUSIONS

People with clinical diabetes have experienced substantial reductions in blood pressure, total cholesterol and smoking over 15 years. Increasing body mass index and persistence of smoking in lower socioeconomic groups, may compromise these improvements.

Insurance status, not race, is associated with mortality after an acute cardiovascular event in Maryland

BACKGROUND

It is unclear how lack of health insurance or otherwise being underinsured contributes to observed racial disparities in health outcomes related to cardiovascular disease.

OBJECTIVE

To determine the relative risk of death associated with insurance and race after hospital admission for an acute cardiovascular event.

DESIGN

Prospective cohort study in three hospitals in Maryland representing different demographics between 1993 and 2007.

PATIENTS

Patients with an incident admission who were either white or black, and had either private insurance, state-based insurance or were uninsured. 4,908 patients were diagnosed with acute myocardial infarction, 6,759 with coronary atherosclerosis, and 1,293 with stroke.

MAIN MEASURES

Demographic and clinical patient-level data were collected from an administrative billing database and neighborhood household income was collected from the 2000 US Census. The outcome of all-cause mortality was collected from the Social Security Death Master File.

KEY RESULTS

In an analysis adjusted for race, disease severity, location, neighborhood household income among other confounders, being underinsured was associated with an increased risk of death after myocardial infarction (relative hazard, 1.31 [95 % CI: 1.09, 1.59]), coronary atherosclerosis (relative hazard, 1.50 [95 % CI: 1.26, 1.80]) or stroke (relative hazard, 1.25 [95 % CI: 0.91, 1.72]). Black race was not associated with an increased risk of death after myocardial infarction (relative hazard, 1.03 [95 % CI: 0.85, 1.24]), or after stroke (relative hazard, 1.18 [95 % CI: 0.86, 1.61]) and was associated with a decreased risk of death after coronary atherosclerosis (relative hazard, 0.82 [95 % CI: 0.69, 0.98]).

CONCLUSIONS

Race was not associated with an increased risk of death, before or after adjustment. Being underinsured was strongly associated with death among those admitted with myocardial infarction, or a coronary atherosclerosis event. Our results support growing evidence implicating insurance status and socioeconomic factors as important drivers of health disparities, and potentially racial disparities.

Delayed educational reminders for long-term medication adherence in ST-elevation myocardial infarction (DERLA-STEMI): protocol for a pragmatic, cluster-randomized controlled trial

Background

Despite evidence-based recommendations supporting long-term use of cardiac medications in patients post ST-elevation myocardial infarction, adherence is known to decline over time. Discontinuation of cardiac medications in such patients is associated with increased mortality.

Methods/design

This is a pragmatic, cluster-randomized controlled trial with blinded outcome assessment and embedded qualitative process evaluation. Patients from one health region in Ontario, Canada who undergo a coronary angiogram during their admission for ST-elevation myocardial infarction and who survive their initial hospitalization will be included. Allocation of eligible patients to intervention or usual care will take place within one week after the angiogram using a computer-generated random sequence. To avoid treatment contamination, patients treated by the same family physician will be allocated to the same study arm. The intervention consists of recurrent, personalized, paper-based educational messages and reminders sent via post on behalf of the interventional cardiologist to the patient, family physician, and pharmacist urging long-term adherence to secondary prevention medications. The primary outcome is the proportion of patients who report in a phone interview taking all relevant classes of cardiac medications at twelve months. Secondary outcomes to be measured at three and twelve months include proportions of patients who report: actively taking each cardiac medication class of interest (item-by-item); stopping medications due to side effects; taking one or two or three medication classes concurrently; a perfect Morisky Medication Adherence Score for cardiac medication compliance; and having a discussion with their family physician about long-term adherence to cardiac medications. Self-reported measures of adherence will be validated using administrative data for prescriptions filled.

Discussion

This intervention is designed to be easily generalizable. If effective, it could be implemented broadly. If it does not change medication utilization, the process evaluation will offer insights regarding how such an intervention could be optimized in future.

Trial registration

Clinicaltrials.gov NCT01325116

Geriatric Syndromes and Depressed Mood in Lower-income Singaporeans with Diabetes: Implications for Diabetes Management and Health Promotion

Introduction: This study aims to determine the association of geriatric syndromes and depressed mood among respondents with diabetes in a lower income community; and their association with self-management, lifestyle behaviour, and healthcare utilisation. This paper focuses primarily on the 114 respondents with diabetes aged 50+ to inform policy formulation at the community level. Materials and Methods: A pilot community health assessment was conducted in 4 blocks of 1- and 2-room apartments in Toa Payoh district from July to November 2009. Using a standard questionnaire, interviewers conducted face-to-face interviews with household members on chronic diseases, geriatric syndromes and health-related behaviour. Data were analysed using SPSSv15. Results: A total of 795 respondents were assessed with a response rate of 61.8%. Of 515 (64.8%) aged 50+ analysed in this study, 22.1% reported having diabetes, of whom 31.6% reported being depressed. Respondents with diabetes who reported being depressed had a higher prevalence of geriatric syndromes compared with those non-depressed; i.e. functional decline (30.6% vs 5.1%, P <0.001); falls (33.3% vs 10.3%, P = 0.003); stumbling (30.6% vs 10.3%, P = 0.007); urinary incontinence (33.3% vs 5.1%, P <0.001), progressive forgetfulness (27.8% vs 6.4%, P = 0.002) and poor eyesight (22.2% vs 6.4%, P = 0.014). They were less likely to comply with medications (86.1% vs 97.3%, P = 0.026) and performed exercise (13.9% vs 53.8%, P <0.001). More had hospital admissions (13.9% vs 7.7%); and they had more outpatient visits per person (2.4 visits vs 0.9 visits, P = 0.03) at Specialist Outpatient Clinics. Conclusion: Geriatric syndromes were associated with the presence of depressed mood among persons with diabetes in the lower income group. As those with depressed mood had more unfavourable self-management and lifestyle behaviour, and utilise higher healthcare services, diabetes management must take these findings into consideration. Key words: Depressed mood, Diabetes mellitus, Geriatric syndromes, Low income

Association between major depression, depressive symptoms and personal income in US adults with diabetes

OBJECTIVE

Although the association between diabetes and depression outcomes has been well studied, very little is known about the association between depression and personal income in adults with diabetes. We examined the association between major depression, number of depressive symptoms and personal income among individuals with diabetes.

METHODS

We used the two-stage Heckman procedure to estimate adjusted personal income by major depression status and number of depressive symptoms for 1818 adults with diabetes from the nationally representative 2006 Medical Expenditure Panel Survey. STATA V.10 was used for statistical analysis to account for the complex survey design.

RESULTS

In a fully adjusted model with major depression as a binary variable, major depression was associated with $2838 lower personal income. In a separate model with depressive symptoms as a continuous variable, each additional symptom was associated with $1235 lower personal income. Compared with being white/non-Hispanic, being black/non-Hispanic (-$4640) was associated with decreased personal income. Compared with excellent health status, fair health status (-$12,172) and poor health status (-$13,835) were associated with lower income. Relative to private insurance, public insurance only (-$8413) and being uninsured (-$9600) were associated with decreased income.

CONCLUSIONS

Among adults with diabetes, major depression and depressive symptoms are associated with lower personal income, after adjusting for relevant confounders. This finding suggests that aggressively diagnosing and treating depression as well as keeping people free of depressive symptoms can have huge human capital savings over the employment lifetime of individuals with diabetes and depression.