Socioeconomic disparities in the management of coronary heart disease in 438 general practices in Australia

Reduced Income and Its Associations with Physical Inactivity, Unhealthy Habits, and Cardiac Complications in the Hypertensive Population

(1) Background: A low socioeconomic status significantly increases the risk of hypertension and its associated cardiovascular diseases due to limited access to healthcare and may be even more accentuated by the presence of unhealthy lifestyle habits. The aim of the present research was to study if associations exist between having a family income under the poverty threshold and having an unhealthy diet, being physically inactive, being an alcohol drinker, perceiving one's own health as bad, and suffering from congestive heart failure, coronary heart disease, angina pectoris, heart attack, or stroke. Additionally, the odds ratios of having these unhealthy habits and of suffering from the abovementioned cardiac complications of participants under the poverty threshold were calculated. (2) Methods: This cross-sectional study was based on the National Health and Nutrition Examination Survey (NHANES) 2011-2020. The sample comprised 6120 adults with hypertension (3188 males and 2932 females). A descriptive analysis and non-parametric chi-squared tests were used to study the associations. A binary logistic regression model and backward LR method were used to calculate the odds ratios, normalized by age and sex. (3) Results: The chi-squared test showed associations between having a family income under the poverty threshold and being physically inactive (p < 0.001), having an unhealthy diet (p < 0.001), being an alcohol drinker (p < 0.001), perceiving one's own health as bad (p < 0.001), and suffering from congestive heart failure (p = 0.002), heart attack (p = 0.001), or stroke (p = 0.02). A significantly increased odds ratio for these unhealthy habits and cardiac complications, and also for having coronary heart disease and angina pectoris, were found for hypertension sufferers under the poverty threshold. (4) Conclusions: It was confirmed that having a family income under the poverty threshold is associated with perceiving one's own health as bad, having a series of negative habits in terms of physical activity, diet, and alcohol consumption, and with suffering from congestive heart failure, heart attack, or stroke. Increased odds ratios for these unhealthy habits and these conditions, plus coronary heart disease and angina pectoris, were found for hypertension sufferers under the poverty threshold.

Application of the Australian Bureau of Statistics Socio-Economic Indexes for Areas in cardiovascular disease research: a scoping review identifying implications for research

Objective To scope how the Australian Bureau of Statistics Socio-Economic Indexes for Areas (SEIFA) has been applied to measure socio-economic status (SES) in peer-reviewed cardiovascular disease (CVD) research. Methods The Joanna Briggs Institute's scoping review methodology was used. Results The search retrieved 2788 unique citations, and 49 studies were included. Studies were heterogeneous in their approach to analysis using SEIFA. Not all studies provided information as to what version was used and how SEIFA was applied in analysis. Spatial unit of analysis varied between studies, with participant postcode most frequently applied. Study quality varied. Conclusions The use of SEIFA in Australian CVD peer-reviewed research is widespread, with variations in the application of SEIFA to measure SES as an exposure. There is a need to improve the reporting of how SEIFA is applied in the methods sections of research papers for greater transparency and to ensure accurate interpretation of CVD research.

Comparing secondary prevention for patients with coronary heart disease and stroke attending Australian general practices: a cross-sectional study using nationwide electronic database

OBJECTIVES

To compare secondary prevention care for patients with coronary heart disease (CHD) and stroke, exploring particularly the influences due to frequency and regularity of primary care visits.

SETTING

Secondary prevention for patients (≥18 years) in the National Prescription Service administrative electronic health record database collated from 458 Australian general practice sites across all states and territories.

DESIGN

Retrospective cross-sectional and panel study. Patient and care-level characteristics were compared for differing CHD/stroke diagnoses. Associations between the type of cardiovascular diagnosis and medication prescription as well as risk factor assessment were examined using multivariable logistic regression.

PARTICIPANTS

Patients with three or more general practice encounters within 2 years of their latest visit during 2016-2020.

OUTCOME MEASURES

Proportions and odds ratios (ORs) for (1) prescription of antihypertensives, antilipidaemics and antiplatelets and (2) assessment of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) in patients with stroke only compared against those with CHD only and those with both conditions.

RESULTS

There were 111 892 patients with CHD only, 27 863 with stroke only and 9791 with both conditions. Relative to patients with CHD, patients with stroke were underprescribed antihypertensives (70.8% vs 82.8%), antilipidaemics (63.1% vs 78.7%) and antiplatelets (42.2% vs 45.7%). With sociodemographic factors, comorbidities and level of care considered as covariates, the odds of non-prescription of any recommended secondary prevention medications were higher in patients with stroke only (adjusted OR 1.37; 95% CI (1.31, 1.44)) compared with patients with CHD only. Patients with stroke only were also more likely to have neither BP nor LDL-C monitored (adjusted OR 1.26; 95% CI (1.18, 1.34)). Frequent and regular general practitioner encounters were independently associated with the prescription of secondary prevention medications (p<0.001).

CONCLUSIONS

Secondary prevention management is suboptimal in cardiovascular disease patients and worse post-stroke compared with post-CHD. More frequent and regular primary care encounters were associated with improved secondary prevention.

Out-of-pocket expenditure on community healthcare services at end-of-life among decedents from cardiovascular disease in six European countries and Israel

OBJECTIVES

Most people who develop chronic diseases, including cardiovascular disease (CVD), live in their homes in the community in their last year of life. Since cost-sharing is common in most countries, including those with universal health insurance, these people incur out of pocket expenditure (OOPE). The study aims to identify the prevalence and measure the size of OOPE among CVD decedents at end-of-life (EOL) explore differences among countries in OOPE, and examine whether the decedents' characteristics or their countries' health policy affects OOPE more.

METHODS

SHARE data among people aged 50 + from seven European countries (including Israel) who died from CVD are analyzed. Decedents' family members are interviewed to learn about OOPE on their relatives' account.

RESULTS

We identified 1,335 individuals who had died from CVD (average age 80.8 years, 54% men). More than half of CVD-decedent people spend OOPE on community services at EOL and their expenditure varies widely among countries. About one-third of people in France and Spain had OOPE, rising to around two-thirds in Israel and Italy and almost all in Greece. The average OOPE is 391.9 PPT, with wide variance across countries. Significant odds of OOPE exist in the country variable only, and significant differences exist in the amount of OOPE among countries and duration of illness preceding death.

CONCLUSIONS

Since improving CVD care efficiency and effectiveness are key aims, healthcare policymakers should broaden the investigation into expanding public funding for community services in order to mitigate OOPE, alleviate the economic burden on households, mitigate forgoing of community services due to price, and reduce rehospitalization.

Social, Geographical and Income Inequality as Demonstrated by the Coronary Calcium Score: An Ecological Study in Sydney, Australia

BACKGROUND

The coronary calcium score is a non-invasive biomarker of coronary artery disease. The concept of "arterial age" transforms the coronary calcium score to an expected age based on the degree of coronary atherosclerosis. This study aimed to investigate the relationship of socioeconomic status with the burden of coronary artery disease within Sydney, Australia.

METHODS

This was an ecological study at the postcode level of patients aged 45 and above who had completed a CT coronary calcium scan within New South Wales (NSW), Australia from January 2012 to December 2020. Arterial age difference was calculated as arterial age minus chronological age. Socioeconomic data was obtained for median income, Index of Relative Socio-economic Advantage and Disadvantage (IRSAD) score and median property price. Linear regression was used for analysis.

RESULTS

There were 17,102 patients across 325 postcodes within NSW, comprising 9129 males with a median arterial age difference of 7 years and 7972 females with -9 years. Income, IRSAD score and property price each had an inverse relationship with arterial age difference (p-values < 0.05).

CONCLUSIONS

Income, socioeconomic status and local property prices are significantly correlated with premature coronary aging. Healthcare resource allocation and prevention should target the inequalities identified to reduce the burden of coronary artery disease.

Religiosity Is Associated with Reduced Risk of All-Cause and Coronary Heart Disease Mortality among Jewish Men

Previous studies have found an inverse association between religiosity and mortality. However, most of these studies were carried out with Christian participants. This longitudinal study aimed to determine whether a composite variable based on self-reported religious education and religious practices is associated with coronary heart disease (CHD) and all-cause mortality in 9237 Jewish men aged 40-65 years at baseline, over a 32-year follow-up. Jewish men were characterized by their degree of religiosity, from the Ultra-Orthodox ("Haredim")-the strictest observers of the Jewish religious rules, and in descending order: religious, traditional, secular, and agnostic. Demographic and physical assessments were made in 1963 with a 32-year follow-up. The results indicate that Haredim participants, in comparison to the agnostic participants, had lower CHD mortality. Hazard ratio (HR) and 95% confidence interval (95% CI)-adjusted by age, cigarette smoking, systolic blood pressure, diabetes, socioeconomic status, BMI, and cholesterol, was: [HR = 0.68 (95% CI 0.58,0.80)] for Haredim; [HR = 0.82 (95% CI 0.69,0.96)] for religious; [HR = 0.85 (95% CI 0.73-1.00)] for traditional; and [HR = 0.92 (95% CI 0.79-01.06) for secular, respectively (p for trend = 0.001). The same pattern was observed for total mortality. This study shows an association between religious practice among men and a decreased rate of CHD and total mortality.

One-year readmission and mortality following ischaemic stroke by diabetes status, sex, and socioeconomic disadvantage: An analysis of 27,802 strokes from 2012 to 2017

OBJECTIVE

We estimated the 1-year incidence of readmission to hospital and 1-year all-cause mortality following ischaemic stroke (IS), by diabetes status, sex, and socioeconomic disadvantage.

METHODS

This study included all individuals aged ≥30 years who were discharged from hospital following an IS between July 2012 and June 2017 in Victoria, Australia (n = 25,421). Individuals were followed from discharge until readmission (for all-causes, cardiovascular readmission, and readmission for IS) or death, censoring at 1-year of follow-up.

RESULTS

The 1-year cumulative incidence of all-cause readmission following an IS was 56.1% (95% CI: 55.5-56.7); 24% of first all-cause admission were attributed to cardiovascular disease. People with diabetes were at an excess risk of all-cause, cardiovascular, and IS readmission following an IS (adjusted sub-HRs: 1.13 [95% CI: 1.09-1.17], 1.14 [1.07-1.21], and 1.17 [1.06-1.29], for people with vs. without diabetes, respectively) and 1-year mortality (adjusted HR: 1.11 [1.03-1.19]). There was no significant difference between men and women in all-cause and cardiovascular readmission risk, while women were at higher risk of IS readmission (sub-HR: 1.10 [1.01-1.21] for women vs. men) and mortality (HR: 1.12 [1.05-1.20]). There was no relationship between socioeconomic disadvantage and risk of cardiovascular or IS readmission, while 1-year mortality risk did increase with increasing socioeconomic disadvantage (HR for most vs. least disadvantaged quintile: 1.15 [1.03-1.27]; p_trend = 0.006), and all-cause readmission risk decreased (sub-HR: 0.94 [0.90-0.99]; p_trend = 0.001).

CONCLUSIONS

There is a high risk of readmission following IS. Decreasing the readmission rate will require more complex interventions than solely improving post-discharge cardiovascular management.

Trends in percentages of gestational diabetes mellitus attributable to overweight, obesity, and morbid obesity in regional Victoria: an eight-year population-based panel study

BACKGROUND

Gestational diabetes mellitus (GDM) is the fastest growing type of diabetes in Australia with rates trebling over the past decades partially explained by rising obesity rates and maternal age among childbearing women. Percentage of GDM attributable to obesity has been documented, mostly focusing on metropolitan populations. In parts of regional (areas outside capital cities) and rural Australia where overweight, obesity and morbid obesity are more prevalent, intertwined with socioeconomic disadvantage and higher migrant communities, trends over time in adjusted percentages of GDM attributed to obesity are unknown.

METHODS

In this population-based retrospective panel study, women, without pre-existing diabetes, delivering singletons between 2010 and 2017 in a tertiary regional hospital that serves 26% of Victoria's 6.5 million Australian population were eligible for inclusion. Secular trends in GDM by body mass index (BMI) and age were evaluated. The percentage of GDM that would have been prevented each year with the elimination of overweight or obesity was estimated using risk-adjusted regression-based population attributable fractions (AFp). Trends in the AFp over time were tested using the augmented Dickey-Fuller test.

RESULTS

Overall 7348 women, contributing to 10,028 births were included. The age of expecting mothers, their BMI, proportion of women born overseas, and GDM incidence significantly rose over time with GDM rising from 3.5% in 2010 to 13.7% in 2017, p <  0.001, increasing in all BMI categories. The incidence was consistently highest among women with obesity (13.8%) and morbid obesity (21.6%). However, the highest relative increase was among women with BMI < 25 kg/m2, rising from 1.4% in 2010 to 7.0% in 2017. Adjusting for age, country of birth, socioeconomic status, comorbidities, antenatal and intrapartum factors, an estimated 8.6% (confidence interval (CI) 6.1-11.0%), 15.6% (95% CI 12.2-19.0%), and 19.5% (95% CI 15.3-23.6%) of GDM would have been prevented by eliminating maternal overweight, obesity, and morbid obesity, respectively. However, despite the rise in obesity over time, percentages of GDM attributable to overweight, obesity, and morbid obesity significantly dropped over time. Scenario analyses supported these findings.

CONCLUSIONS

Besides increasing prevalence of obesity over time, this study suggests that GDM risk factors, other than obesity, are also increasing over time.

Associations between regular GP contact, diabetes monitoring and glucose control: an observational study using general practice data

OBJECTIVE

Continuity and regularity of general practitioner (GP) contacts are associated with reduced hospitalisation in type 2 diabetes (T2DM). We assessed associations of these GP contact patterns with intermediate outcomes reflecting patient monitoring and health.

DESIGN

Observational longitudinal cohort study using general practice data 2011-2017.

SETTING

193 Australian general practices in Western Australia and New South Wales participating in the MedicineInsight programme run by NPS MedicineWise.

PARTICIPANTS

22 791 patients aged 18 and above with T2DM.

INTERVENTIONS

Regularity was assessed based on variation in the number of days between GP visits, with more regular contacts assumed to indicate planned, proactive care. Informational continuity (claims for care planning incentives) and relational continuity (usual provider of care index) were assessed separately.

OUTCOME MEASURES

Process of care indicators were glycosylated haemoglobin (HbA1c) test underuse (8 months without test), estimated glomerular filtration rate (eGFR) underuse (14 months) and HbA1c overuse (two tests within 80 days). The clinical indicator was T2DM control (HbA1c 6.5% (47.5 mmol/mol)-7.5% (58.5 mmol/mol)).

RESULTS

The quintile with most regular contact had reduced odds of HbA1c and eGFR underuse (OR 0.74, 95% CI 0.67 to 0.81 and OR 0.78, 95% CI 0.70 to 0.86, respectively), but increased odds of HbA1c overuse (OR 1.20, 95% CI 1.05 to 1.38). Informational continuity was associated with reduced odds of HbA1c underuse (OR 0.53, 95% CI 0.49 to 0.56), reduced eGFR underuse (OR 0.62, 95% CI 0.58 to 0.67) and higher odds of HbA1c overuse (OR 1.48, 95% CI 1.34 to 1.64). Neither had significant associations with HbA1c level. Results for relational continuity differed.

CONCLUSIONS

This study provides evidence that regularity and continuity influence processes of care in the management of patients with diabetes, though this did not result in the recording of HbA1c within target range. Research should capture these intermediate outcomes to better understand how GP contact patterns may influence health rather than solely assessing associations with hospitalisation outcomes.

Investigating inequities in cardiovascular care and outcomes for Queensland Aboriginal and Torres Strait Islander people: protocol for a hospital-based retrospective cohort data linkage project

INTRODUCTION

Cardiovascular disease (CVD) represents a significant burden of disease for Aboriginal and Torres Strait Islander people, a population that continues to experience a lower life expectancy than other Australians. The aim of the Better Cardiac Care Data Linkage project is to describe patient care pathways and to identify disparities in care and health outcomes between Aboriginal and Torres Strait Islander people and other Queensland residents diagnosed with CVD in the state of Queensland.

METHODS

This is a population-based retrospective cohort study using linked regional, state and national health and administrative data collections to describe disparities in CVD healthcare in primary and secondary prevention settings and during hospitalisation. The CVD cohort will be identified from the Queensland Hospital Admitted Patient Data Collection for admissions that occurred between 1 July 2010 and 31 June 2016 and will include relevant International Classification of Disease codes for ischaemic heart disease, congestive heart failure, stroke, acute rheumatic fever and rheumatic heart disease. Person-level data will be linked by Data Linkage Queensland and the Australian Institute of Health and Welfare (AIHW) in accordance with ethical and public health approvals to describe the patient journey prior to, during and post the hospital admission.

ANALYSIS

This project will focus largely on descriptive epidemiological measures and multivariate analysis of clinical care standards and outcomes for Aboriginal and Torres Strait Islander people compared with other Queenslanders, including identification of risk factors for suboptimal care and change over time. Variation in care pathways and patient outcomes will be compared by Indigenous status, sex, age group, remoteness of residence, year of index hospitalisation and socioeconomic status. Cox models for time-to-event data and mixed models or generalised estimating equations for longitudinal data will be used to measure change over time where temporal effects exist.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Human Research Ethics Committees of the Prince Charles Hospital (HREC/15/QPCH/289) and the AIHW (EO2016-1-233). The Northern Territory Department of Health and Menzies School of Health Research have also provided reciprocal ethical approval of the project (HREC 2019-3490). The deidentified results will be summarised in a report and shared with investigators, advisory groups, Queensland Health and key stakeholders. Findings will be disseminated through workshops, conferences and will be published in peer-reviewed journals.

Socioeconomic characteristics of patients with coronary heart disease in relation to their cardiovascular risk profile

OBJECTIVE

People's socioeconomic status (SES) has a major impact on the risk of atherosclerotic cardiovascular disease (ASCVD) in primary prevention. In patients with existing ASCVD these associations are less documented. Here, we evaluate to what extent SES is still associated with patients' risk profile in secondary prevention.

METHODS

Based on results from a large sample of patients with coronary heart disease from the European Action on Secondary and Primary Prevention through Intervention to Reduce Events study, the relationship between SES and cardiovascular risk was examined. A SES summary score was empirically constructed from the patients' educational level, self-perceived income, living situation and perception of loneliness.

RESULTS

Analyses are based on observations in 8261 patients with coronary heart disease from 27 countries. Multivariate logistic regression analyses demonstrate that a low SES is associated (OR, 95% CI) with lifestyles such as smoking in men (1.63, 1.37 to 1.95), physical activity in men (1.51, 1.28 to 1.78) and women (1.77, 1.32 to 2.37) and obesity in men 1.28 (1.11 to 1.49) and women 1.65 (1.30 to 2.10). Patients with a low SES have more raised blood pressure in men (1.24, 1.07 to 1.43) and women (1.31, 1.03 to 1.67), used less statins and were less adherent to them. Cardiac rehabilitation programmes were less advised and attended by patients with a low SES. Access to statins in middle-income countries was suboptimal leaving about 80% of patients not reaching the low-density lipoprotein cholesterol target of <1.8 mmol/L. Patients' socioeconomic level was also strongly associated with markers of well-being.

CONCLUSION

These results illustrate the complexity of the associations between SES, well-being and secondary prevention in patients with ASCVD. They emphasise the need for integrating innovative policies in programmes of cardiac rehabilitation and secondary prevention.