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Berger C, Hammer H, Costa M, Lowiec P, Yagensky A, Scutelnic A, Antonenko K, Biletska O, Karaszewski B, Sarikaya H, Zdrojewski T, Klymiuk A, Bassetti CLA, Yashchuk N, Chwojnicki K, Arnold M, Saner H, Heldner MR. Baseline characteristics, reperfusion treatment secondary prevention and outcome after acute ischemic stroke in three different socioeconomic environments in Europe. Eur Stroke J 2024:23969873241245518. [PMID: 38745422 DOI: 10.1177/23969873241245518] [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: 05/16/2024] Open
Abstract
INTRODUCTION The differences in vascular risk factors' and stroke burden across Europe are notable, however there is limited understanding of the influence of socioeconomic environment on the quality of secondary prevention and outcome after acute ischemic stroke. PATIENTS AND METHODS In this observational multicenter cohort study, we analyzed baseline characteristics, reperfusion treatment, outcome and secondary prevention in patients with acute ischemic stroke from three tertiary-care teaching hospitals with similar service population size in different socioeconomic environments: Bern/CH/n = 293 (high-income), Gdansk/PL/n = 140 (high-income), and Lutsk/UA/n = 188 (lower-middle-income). RESULTS We analyzed 621 patients (43.2% women, median age = 71.4 years), admitted between 07 and 12/2019. Significant differences were observed in median BMI (CH = 26/PL = 27.7/UA = 27.8), stroke severity [(median NIHSS CH = 4(0-40)/PL = 11(0-33)/UA = 7(1-30)], initial neuroimaging (CT:CH = 21.6%/PL = 50.7%/UA = 71.3%), conservative treatment (CH = 34.1%/PL = 38.6%/UA = 95.2%) (each p < 0.001), in arterial hypertension (CH = 63.8%/PL = 72.6%/UA = 87.2%), atrial fibrillation (CH = 28.3%/PL = 41.4%/UA = 39.4%), hyperlipidemia (CH = 84.9%/PL = 76.4%/UA = 17%) (each p < 0.001) and active smoking (CH = 32.2%/PL = 27.3%/UA = 10.2%) (p < 0.007). Three-months favorable outcome (mRS = 0-2) was seen in CH = 63.1%/PL = 50%/UA = 59% (unadjusted-p = 0.01/adjusted-p CH-PL/CH-UA = 0.601/0.981), excellent outcome (mRS = 0-1) in CH = 48.5%/PL = 32.1%/UA = 27% (unadjusted-p < 0.001/adjusted-p CH-PL/CH-UA = 0.201/0.08 and adjusted-OR CH-UA = 2.09). Three-months mortality was similar between groups (CH = 17.2%/PL = 15.7%/UA = 4.8%) (unadjusted-p = 0.71/adjusted-p CH-PL/CH-UA = 0.087/0.24). Three-months recurrent stroke/TIA occurred in CH = 3.1%/PL = 10.7%/UA = 3.1%, adjusted-p/OR CH-PL = 0.04/0.32). Three-months follow-up medication intake rates were the same for antihypertensives. Statin/OAC intake was lowest in UA = 67.1%/25.5% (CH = 87.3%/39.2%/unadjusted-p < 0.001/adjusted-p CH-UA = 0.02/0.012/adjusted-OR CH-UA = 2.33/2.18). Oral intake of antidiabetics was lowest in CH = 10.8% (PL = 15.7%/UA = 16.1%/unadjusted-p = 0.245/adjusted-p CH-PL/CH-UA = 0.061/0.002/adjusted-OR CH-UA = 0.25). Smoking rates decreased in all groups during follow-up. DISCUSSION AND CONCLUSION Substantial differences in presentation, treatment and secondary prevention measures, are linked to a twofold difference in adjusted 3-months excellent outcome between Switzerland and Ukraine. This underscores the importance of socioeconomic factors that influence stroke outcomes, emphasizing the necessity for targeted interventions to address disparities in treatment and secondary prevention strategies.
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Affiliation(s)
- Charlotte Berger
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Helly Hammer
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Marino Costa
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Pawel Lowiec
- Department of Neurology, Medical University of Gdansk, Gdansk, Poland
| | - Andriy Yagensky
- Regional Center for Cardiovascular Disease, Lutsk City Hospital, Lutsk, Ukraine
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Kateryna Antonenko
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Olga Biletska
- Regional Center for Cardiovascular Disease, Lutsk City Hospital, Lutsk, Ukraine
| | | | - Hakan Sarikaya
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Tomasz Zdrojewski
- Department of Cardiovascular Prevention, Medical University of Gdansk, Gdansk, Poland
| | - Anastasiia Klymiuk
- Regional Center for Cardiovascular Disease, Lutsk City Hospital, Lutsk, Ukraine
| | - Claudio LA Bassetti
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Natalia Yashchuk
- Regional Center for Cardiovascular Disease, Lutsk City Hospital, Lutsk, Ukraine
| | - Kamil Chwojnicki
- Department of Neurology, Medical University of Gdansk, Gdansk, Poland
- Department of Anaesthesiology and Intensive Care, Medical University of Gdansk, Gdansk, Poland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Hugo Saner
- Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
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Tizón-Marcos H, Vaquerizo B, Ferré JM, Farré N, Lidón RM, Garcia-Picart J, Regueiro A, Ariza A, Carrillo X, Duran X, Poirier P, Cladellas M, Camps-Vilaró A, Ribas N, Cubero-Gallego H, Marrugat J. Socioeconomic Status and Prognosis of Patients With ST-Elevation Myocardial Infarction Managed by the Emergency-Intervention “Codi IAM” Network. Front Cardiovasc Med 2022; 9:847982. [PMID: 35548422 PMCID: PMC9082814 DOI: 10.3389/fcvm.2022.847982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/18/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDespite the spread of ST-elevation myocardial infarction (STEMI) emergency intervention networks, inequalities in healthcare access still have a negative impact on cardiovascular prognosis. The Family Income Ratio of Barcelona (FIRB) is a socioeconomic status (SES) indicator that is annually calculated. Our aim was to evaluate whether SES had an effect on mortality and complications in patients managed by the “Codi IAM” network in Barcelona.MethodsThis is a cohort study with 3,322 consecutive patients with STEMI treated in Barcelona from 2010 to 2016. Collected data include treatment delays, clinical and risk factor characteristics, and SES. The patients were assigned to three SES groups according to FIRB score. A logistic regression analysis was conducted to estimate the adjusted effect of SES on 30-day mortality, 30-day composite cardiovascular end point, and 1-year mortality.ResultsThe mean age of the patients was 65 ± 13% years, 25% were women, and 21% had diabetes mellitus. Patients with low SES were younger, more often hypertensive, diabetic, dyslipidemic (p < 0.003), had longer reperfusion delays (p < 0.03) compared to participants with higher SES. Low SES was not independently associated with 30-day mortality (OR: 0.95;9 5% CI: 0.7–1.3), 30-day cardiovascular composite end point (OR: 1.03; 95% CI: 0.84–1.26), or 1-year all-cause mortality (HR: 1.09; 95% CI: 0.76–1.56).ConclusionAlthough the low-SES patients with STEMI in Barcelona city were younger, had worse clinical profiles, and had longer revascularization delays, their 30-day and 1-year outcomes were comparable to those of the higher-SES patients.
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Affiliation(s)
- Helena Tizón-Marcos
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- *Correspondence: Helena Tizón-Marcos
| | - Beatriz Vaquerizo
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Josepa Mauri Ferré
- Hospital Universitari GermansTrias I. Pujol, Servicio de Cardiología, Badalona, Spain
- Departament de Salut, Generalitat de Catalunya, Barcelona, Spain
| | - Núria Farré
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Rosa-Maria Lidón
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Hospital Universitari de la Valld'Hebron, Servicio de Cardiología, Barcelona, Spain
| | - Joan Garcia-Picart
- Hospital de la Santa Creu I. Sant Pau, Servicio de Cardiología, Barcelona, Spain
| | - Ander Regueiro
- Hospital Clínic i Provincial, Servicio de Cardiología, Barcelona, Spain
| | - Albert Ariza
- Hospital Universitario de Bellvitge, Servicio de Cardiología, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Carrillo
- Hospital Universitari GermansTrias I. Pujol, Servicio de Cardiología, Badalona, Spain
| | - Xavier Duran
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- AMIB, Assessoria Metodològica i Bioestadística, Barcelona, Spain
| | - Paul Poirier
- Insititut Universitaire de Cardiologie et Pneumologie de Québec, Québec, QC, Canada
| | - Mercè Cladellas
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Anna Camps-Vilaró
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Núria Ribas
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Hector Cubero-Gallego
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
| | - Jaume Marrugat
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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Huded CP, Dalton JE, Kumar A, Krieger NI, Kassis N, Phelan M, Kravitz K, Reed GW, Krishnaswamy A, Kapadia SR, Khot U. Relationship of Neighborhood Deprivation and Outcomes of a Comprehensive ST Elevation Myocardial Infarction Protocol. J Am Heart Assoc 2021; 10:e024540. [PMID: 34779652 PMCID: PMC9075260 DOI: 10.1161/jaha.121.024540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background We evaluated whether a comprehensive ST‐segment–elevation myocardial infarction protocol (CSP) focusing on guideline‐directed medical therapy, transradial percutaneous coronary intervention, and rapid door‐to‐balloon time improves process and outcome metrics in patients with moderate or high socioeconomic deprivation. Methods and Results A total of 1761 patients with ST‐segment–elevation myocardial infarction treated with percutaneous coronary intervention at a single hospital before (January 1, 2011–July 14, 2014) and after (July 15, 2014– July 15, 2019) CSP implementation were included in an observational cohort study. Neighborhood deprivation was assessed by the Area Deprivation Index and was categorized as low (≤50th percentile; 29.0%), moderate (51st –90th percentile; 40.8%), and high (>90th percentile; 30.2%). The primary process outcome was door‐to‐balloon time. Achievement of guideline‐recommend door‐to‐balloon time goals improved in all deprivation groups after CSP implementation (low, 67.8% before CSP versus 88.5% after CSP; moderate, 50.7% before CSP versus 77.6% after CSP; high, 65.5% before CSP versus 85.6% after CSP; all P<0.001). Median door‐to‐balloon time among emergency department/in‐hospital patients was significantly noninferior in higher versus lower deprivation groups after CSP (noninferiority limit=5 minutes; Pnoninferiority high versus moderate = 0.002, high versus low <0.001, moderate versus low = 0.02). In‐hospital mortality, the primary clinical outcome, was significantly lower after CSP in patients with moderate/high deprivation in unadjusted (before CSP 7.0% versus after CSP 3.1%; odds ratio [OR], 0.42 [95% CI, 0.25–0.72]; P=0.002) and risk‐adjusted (OR, 0.42 [95% CI, 0.23–0.77]; P=0.005) models. Conclusions A CSP was associated with improved ST‐segment–elevation myocardial infarction care across all deprivation groups and reduced mortality in those from moderate or high deprivation neighborhoods. Standardized initiatives to reduce care variability may mitigate social determinants of health in time‐sensitive conditions such as ST‐segment–elevation myocardial infarction.
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Affiliation(s)
- Chetan P Huded
- Department of Cardiology Saint Luke's Mid-America Heart Institute Kansas City MO
| | - Jarrod E Dalton
- Department of Quantitative Health Sciences Lerner Research Institute Cleveland Clinic Cleveland OH
| | - Anirudh Kumar
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH.,Center for Healthcare Delivery Innovation Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Nikolas I Krieger
- Department of Quantitative Health Sciences Lerner Research Institute Cleveland Clinic Cleveland OH
| | - Nicholas Kassis
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH.,Center for Healthcare Delivery Innovation Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Michael Phelan
- Department of Emergency Medicine Emergency Services Institute Cleveland Clinic Cleveland OH
| | - Kathleen Kravitz
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Grant W Reed
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Samir R Kapadia
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
| | - Umesh Khot
- Department of Cardiovascular Medicine Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH.,Center for Healthcare Delivery Innovation Thoracic Institute Cleveland Clinic Heart, Vascular Cleveland OH
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Socioeconomic differences in coronary procedures and survival after out-of-hospital cardiac arrest: A nationwide Danish study. Resuscitation 2020; 153:10-19. [DOI: 10.1016/j.resuscitation.2020.05.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 12/22/2022]
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Odoi EW, Nagle N, DuClos C, Kintziger KW. Disparities in Temporal and Geographic Patterns of Myocardial Infarction Hospitalization Risks in Florida. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4734. [PMID: 31783516 PMCID: PMC6926732 DOI: 10.3390/ijerph16234734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 11/23/2019] [Accepted: 11/24/2019] [Indexed: 12/12/2022]
Abstract
Knowledge of geographical disparities in myocardial infarction (MI) is critical for guiding health planning and resource allocation. The objectives of this study were to identify geographic disparities in MI hospitalization risks in Florida and assess temporal changes in these disparities between 2005 and 2014. This study used retrospective data on MI hospitalizations that occurred among Florida residents between 2005 and 2014. We identified spatial clusters of hospitalization risks using Kulldorff's circular and Tango's flexible spatial scan statistics. Counties with persistently high or low MI hospitalization risks were identified. There was a 20% decline in hospitalization risks during the study period. However, we found persistent clustering of high risks in the Big Bend region, South Central and southeast Florida, and persistent clustering of low risks primarily in the South. Risks decreased by 7%-21% in high-risk clusters and by 9%-28% in low-risk clusters. The risk decreased in the high-risk cluster in the southeast but increased in the Big Bend area during the last four years of the study. Overall, risks in low-risk clusters were ahead those for high-risk clusters by at least 10 years. Despite MI risk declining over the study period, disparities in MI risks persist. Eliminating/reducing those disparities will require prioritizing high-risk clusters for interventions.
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Affiliation(s)
- Evah W. Odoi
- Comparative and Experimental Medicine, College of Veterinary Medicine, The University of Tennessee, Knoxville, TN 37996, USA;
| | - Nicholas Nagle
- Department of Geography, The University of Tennessee, Knoxville, TN 37996, USA;
| | - Chris DuClos
- Environmental Public Health Tracking, Division of Community Health Promotion, Florida Department of Health, Tallahassee, FL 32399, USA;
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Malki N, Hägg S, Tiikkaja S, Koupil I, Sparén P, Ploner A. Short-term and long-term case-fatality rates for myocardial infarction and ischaemic stroke by socioeconomic position and sex: a population-based cohort study in Sweden, 1990-1994 and 2005-2009. BMJ Open 2019; 9:e026192. [PMID: 31278093 PMCID: PMC6615790 DOI: 10.1136/bmjopen-2018-026192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Case-fatality rates (CFRs) for myocardial infarction (MI) and ischaemic stroke (IS) have decreased over time due to better prevention, medication and hospital care. It is unclear whether these improvements have been equally distributed according to socioeconomic position (SEP) and sex. The aim of this study is to analyse differences in short-term and long-term CFR for MI and IS by SEP and sex between the periods 1990-1994 to 2005-2009 for the entire Swedish population. DESIGN Population-based cohort study based on Swedish national registers. METHODS We used logistic regression and flexible parametric models to estimate short-term CFR (death before reaching the hospital or on the disease event day) and long-term CFR (1 year case-fatality conditional on surviving short-term) across five distinct SEP groups, as well as CFR differences (CFRDs) between SEP groups for both MI and IS from 1990-1994 to 2005-2009. : Result S: Overall short-term CFR for both MI and IS decreased between study periods. For MI, differences in short-term and long-term CFR between the least and most favourable SEP group were generally stable, except in long-term CFR among women; intermediate SEP groups mostly managed to catch up with the most favourable SEP group. For IS, short-term CFRD generally decreased compared with the most favourable group; but long-term CFRD were mostly stable, except for an increase for older subjects. CONCLUSION Despite a general decline in CFR for MI and IS across all SEP groups and both sexes as well as some reductions in CFRD, we found persistent and even increasing CFRD among the least advantaged SEP groups, older patients and women. We speculate that targeted prevention rather than treatment strategies have the potential to reduce these inequalities.
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Affiliation(s)
- Ninoa Malki
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Sara Hägg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Sanna Tiikkaja
- Centre of Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Public Health and Caring Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Ilona Koupil
- Centre for Health Equity Studies, Stockholm University/Karolinska Institutet, Stockholm, Sweden
| | - Pär Sparén
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Alexander Ploner
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Steele L, Palmer J, Lloyd A, Fotheringham J, Iqbal J, Grech ED. Impact of socioeconomic status on survival following ST-elevation myocardial infarction in a universal healthcare system. Int J Cardiol 2019; 276:26-30. [DOI: 10.1016/j.ijcard.2018.11.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/02/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
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Kämpfer J, Yagensky A, Zdrojewski T, Windecker S, Meier B, Pavelko M, Sichkaruk I, Kasprzyk P, Gruchala M, Giacomini M, Räber L, Saner H. Long-term outcomes after acute myocardial infarction in countries with different socioeconomic environments: an international prospective cohort study. BMJ Open 2017; 7:e012715. [PMID: 28801383 PMCID: PMC5724143 DOI: 10.1136/bmjopen-2016-012715] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 01/20/2017] [Accepted: 03/10/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hospital-based data on the impact of socioeconomic environment on long-term survival after myocardial infarction (MI) are lacking. We compared outcome and quality of secondary prevention in patients after MI living in three different socioeconomic environments including patients from three tertiary-care teaching hospitals with similar service population size in Switzerland, Poland and Ukraine. METHODS This is a prospective cohort study of patients with a first MI in three different tertiary-care teaching hospitals in Bern (Switzerland), Gdansk (Poland) and Lutsk (Ukraine) during the acute phase in the year 2010 and follow-up of these patients with a questionnaire and, if necessary, telephone interviews 3.5 years after the acute event. The study cohort comprises all consecutive patients hospitalised in every one of the three study centres during the year 2010 for a first MI in the age ≤75 years who survived ≥30 days. RESULTS The proportion of patients with ST-segment elevation myocardial infarction (STEMI) was high in Gdansk (Poland) (80%) and in Lutsk (Ukraine) (74%), while the ratio of STEMIs to non-STEMIs was nearly 50:50 in Bern (Switzerland) (50.6% STEMIs). Percutaneous coronary intervention (PCI) was the first choice therapy both in Bern (Switzerland) (100%) and in Gdansk (Poland) (92%), while it was not performed at all in Lutsk (Ukraine). We found substantial differences in treatment and also in secondary prevention interventions including cardiac rehabilitation. All-cause mortality at 3.5 year follow-up was 4.6% in Bern (Switzerland), 8.5% in Gdansk (Poland) and 14.6% in Lutsk (Ukraine). CONCLUSION Substantial differences in treatment and secondary prevention measures according to low-income, middle-income and high-income socioeconomic situation are associated with a threefold difference in mortality 3.5 years after the acute event. Countries with low socioeconomic environment should increase efforts and be supported to improve care including secondary prevention in particular for MI patients. A greater number of PCIs per million inhabitants itself does not guarantee lower mortality scores.
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Affiliation(s)
- Judith Kämpfer
- Preventive Cardiology and Sports Medicine, Bern University Hospital, Bern, Switzerland
| | - Andriy Yagensky
- Regional Center for Cardiovascular Disease, Lutsk City Hospital, Lutsk, Ukraine
| | - Tomasz Zdrojewski
- Department of Preventive Medicine and Education, Medical University of Gdansk, Gdansk, Poland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Bernhard Meier
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Mykhailo Pavelko
- Regional Center for Cardiovascular Disease, Lutsk City Hospital, Lutsk, Ukraine
| | - Iryna Sichkaruk
- Regional Center for Cardiovascular Disease, Lutsk City Hospital, Lutsk, Ukraine
| | - Piotr Kasprzyk
- Department of Preventive Medicine and Education, Medical University of Gdansk, Gdansk, Poland
| | - Marzin Gruchala
- Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Mikael Giacomini
- Preventive Cardiology and Sports Medicine, Bern University Hospital, Bern, Switzerland
| | - Lukas Räber
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Hugo Saner
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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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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Lumme S, Manderbacka K, Keskimäki I. Trends of relative and absolute socioeconomic equity in access to coronary revascularisations in 1995-2010 in Finland: a register study. Int J Equity Health 2017; 16:37. [PMID: 28222730 PMCID: PMC5320656 DOI: 10.1186/s12939-017-0536-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 02/14/2017] [Indexed: 11/30/2022] Open
Abstract
Background Resources for coronary revascularisations have increased substantially since the early 1990s in Finland. At the same time, ischaemic heart disease (IHD) mortality has decreased markedly. This study aims to examine how these changes have influenced trends in absolute and relative differences between socioeconomic groups in revascularisations and age group differences in them using IHD mortality as a proxy for need. Methods Hospital Discharge Register data on revascularisations among Finns aged 45–84 in 1995–2010 were individually linked to population registers to obtain socio-demographic data. We measured absolute and relative income group differences in revascularisation and IHD mortality with slope index of inequality (SII) and concentration index (C), and relative equity taking need for care into account with horizontal inequity index (HII). Results The supply of procedures doubled during the years. Socioeconomic distribution of revascularisations was in absolute and relative terms equal in 1995 (Men: SII = −12, C = −0.00; Women, SII = −30, C = −0.03), but differences favouring low-income groups emerged by 2010 (M: SII = −340, C = −0.08; W: SII = −195, C = −0.14). IHD mortality decreased markedly, but absolute and relative differences favouring the better-off existed throughout study years. Absolute differences decreased somewhat (M: SII = −760 in 1995, SII = −681 in 2010; W: SII = −318 in 1995, SII = −211 in 2010), but relative differences increased significantly (M: C = −0.14 in 1995, C = −0.26 in 2010; W: C = −0.15 in 1995, C = −0.25 in 2010). HII was greater than zero in each year indicating inequity favouring the better-off. HII increased from 0.15 to 0.18 among men and from 0.10 to 0.12 among women. We found significant and increasing age group differences in HII. Conclusions Despite large increase in supply of revascularisations and decrease in IHD mortality, there is still marked socioeconomic inequity in revascularisations in Finland. However, since changes in absolute distributions of both supply and need for coronary care have favoured low-income groups, absolute inequity can be claimed to have decreased although it cannot be quantified numerically.
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Affiliation(s)
- Sonja Lumme
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland.
| | - Kristiina Manderbacka
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland
| | - Ilmo Keskimäki
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland.,Faculty of Social Sciences, University of Tampere, Tampere, FI-33014 University of Tampere, Finland
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Coronary angiography and myocardial revascularization following the first acute myocardial infarction in Norway during 2001–2009: Analyzing time trends and educational inequalities using data from the CVDNOR project. Int J Cardiol 2016; 212:122-8. [DOI: 10.1016/j.ijcard.2016.03.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 03/13/2016] [Accepted: 03/15/2016] [Indexed: 01/31/2023]
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Hagen TP, Häkkinen U, Iversen T, Klitkou ST, Moger TA. Socio-economic Inequality in the Use of Procedures and Mortality Among AMI Patients: Quantifying the Effects Along Different Paths. HEALTH ECONOMICS 2015; 24 Suppl 2:102-115. [PMID: 26633871 DOI: 10.1002/hec.3269] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 07/02/2015] [Accepted: 08/04/2015] [Indexed: 06/05/2023]
Abstract
It is not known whether inequality in access to cardiac procedures translates into inequality in mortality. In this paper, we use a path analysis model to quantify both the direct effect of socio-economic status on mortality and the indirect effect of socio-economic status on mortality as mediated by the provision of cardiac procedures. The study links microdata from the Finnish and Norwegian national patient registers describing treatment episodes with data from prescription registers, causes-of-death registers and registers covering education and income. We show that socio-economic variables affect access to percutaneous coronary intervention in both countries, but that these effects are only moderate and that the indirect effects of the socio-economic factors on mortality through access to percutaneous coronary intervention are minor. The direct effects of income and education on mortality are significantly larger. We conclude that the socio-economic gradient in the use of percutaneous coronary intervention adds to socio-economic differences in mortality to little or no extent.
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Affiliation(s)
- Terje P Hagen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Unto Häkkinen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Centre for Health and Social Economics (CHESS), National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Tor Iversen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Søren Toksvig Klitkou
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Tron Anders Moger
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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Hagen TP, Häkkinen U, Belicza E, Fatore G, Goude F. Acute Myocardial Infarction, Use of Percutaneous Coronary Intervention, and Mortality: A Comparative Effectiveness Analysis Covering Seven European Countries. HEALTH ECONOMICS 2015; 24 Suppl 2:88-101. [PMID: 26633870 DOI: 10.1002/hec.3263] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 05/04/2015] [Accepted: 08/09/2015] [Indexed: 06/05/2023]
Abstract
Percutaneous coronary interventions (PCI) on acute myocardial infarction (AMI) patients have increased substantially in the last 12-15 years because of its clinical effectiveness. The expansion of PCI treatment for AMI patients raises two questions: How did PCI utilization rates vary across European regions, and which healthcare system and regional characteristic variables correlated with the utilization rate? Were the differences in use of PCI associated with differences in outcome, operationalized as 30-day mortality? We obtained our results from a dataset based on the administrative information systems of the populations of seven European countries. PCI rates were highest in the Netherlands, followed by Sweden and Hungary. The probability of receiving PCI was highest in regions with their own PCI facilities and in healthcare systems with activity-based reimbursement systems. Thirty-day mortality rates differed considerably between the countries with the highest rates in Hungary, Scotland, and Finland. Mortality was lowest in Sweden and Norway. The associations between PCI and mortality were remarkable in all age groups and across most countries. Despite extensive risk adjustment, we interpret the associations both as effects of selection and treatments. We observed a lower effect of PCI in the higher age groups in Hungary.
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Affiliation(s)
- Terje P Hagen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Unto Häkkinen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Centre for Health and Social Economics, National Institute for Health and Welfare, Helsinki, Finland
| | - Eva Belicza
- Health Services Management Training Center, Semmelweis University, Budapest, Hungary
| | - Giovanni Fatore
- Centre for Research on Health and Social Care Management, Bocconi University, Milano, Italy
| | - Fanny Goude
- Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
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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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Osler M, Prescott E, Wium-Andersen IK, Ibfelt EH, Jørgensen MB, Andersen PK, Jørgensen TSH, Wium-Andersen MK, Mårtensson S. The Impact of Comorbid Depression on Educational Inequality in Survival after Acute Coronary Syndrome in a Cohort of 83 062 Patients and a Matched Reference Population. PLoS One 2015; 10:e0141598. [PMID: 26513652 PMCID: PMC4626047 DOI: 10.1371/journal.pone.0141598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/09/2015] [Indexed: 11/28/2022] Open
Abstract
Background Patients with low socioeconomic position have higher rates of mortality after diagnosis of acute coronary syndrome (ACS), but little is known about the mechanisms behind this social inequality. The aim of the present study was to examine whether any educational inequality in survival after ACS was influenced by comorbid conditions including depression. Methods From 2001 to 2009 all first-time ACS patients were identified in the Danish National Patient Registry. This cohort of 83 062 ACS patients and a matched reference population were followed for incident depression and mortality until December 2012 by linkage to person, patients and prescription registries. Educational status was defined at study entry and the impact of potential confounders and mediators (age, gender, cohabitation status, somatic comorbidity and depression) on the relation between education and mortality were identified by drawing a directed acyclic graph and analysed using multiple Cox regression analyses. Findings During follow-up, 29 583(35.6%) of ACS patients and 19 105(22.9%) of the reference population died. Cox regression analyses showed an increased mortality in the lowest educated compared to those with high education in both ACS patients and the reference population. Adjustment for previous and incident depression or other covariables only attenuated the relations slightly. This pattern of associations was seen for mortality after 30 days, 1 year and during total follow-up. Conclusion In this study the relative excess mortality rate in lower educated ACS patients was comparable with the excess risk associated with low education in the background population. This educational inequality in survival remained after adjustment for somatic comorbidity and depression.
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Affiliation(s)
- Merete Osler
- Research Center for Prevention and Health, Rigshospitalet – Glostrup, Copenhagen University, Glostrup, Denmark
- * E-mail:
| | - Eva Prescott
- Department of Cardiology Y, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Else Helene Ibfelt
- Research Center for Prevention and Health, Rigshospitalet – Glostrup, Copenhagen University, Glostrup, Denmark
| | | | - Per Kragh Andersen
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Terese Sara Høj Jørgensen
- Research Center for Prevention and Health, Rigshospitalet – Glostrup, Copenhagen University, Glostrup, Denmark
| | | | - Solvej Mårtensson
- Research Center for Prevention and Health, Rigshospitalet – Glostrup, Copenhagen University, Glostrup, Denmark
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Bucholz EM, Ma S, Normand SLT, Krumholz HM. Race, Socioeconomic Status, and Life Expectancy After Acute Myocardial Infarction. Circulation 2015; 132:1338-46. [PMID: 26369354 DOI: 10.1161/circulationaha.115.017009] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 07/21/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous studies have been unable to disentangle the negative associations of black race and low socioeconomic status (SES) with long-term outcomes of patients after acute myocardial infarction (AMI). Such information could assist in efforts to address both racial and socioeconomic disparities. METHODS AND RESULTS We used data from the Cooperative Cardiovascular Project, a prospective cohort study of Medicare beneficiaries hospitalized with AMI with 17 years of follow-up, to evaluate the relationship between race, area-level SES (measured by zip code-level median household income), and life expectancy after AMI. Life expectancy was estimated by using Cox proportional hazards regression with extrapolation using exponential models. Of the 141 095 patients with AMI, 6.3% were black and 6.8% resided in low-SES areas; 26% of black patients lived in low-SES areas in comparison with 5.7% of white patients. Post-myocardial infarction life expectancy estimates were shorter for black patients than for white patients across all socioeconomic levels in patients ≤ 75 years of age. After adjustment for patient and treatment characteristics, the association between race and life expectancy persisted but was attenuated. Younger black patients (<68 years) had shorter life expectancies than white patients, whereas older black patients had longer life expectancies. The largest white-black gap in life expectancy occurred in patients residing in high- and medium-SES areas (P=0.02 interaction). CONCLUSIONS Black and white patients residing in low-SES areas have similar life expectancies after AMI, which are lower than those living in higher-SES areas. Racial disparities were most prominent among patients living in high-SES areas.
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Affiliation(s)
- Emily M Bucholz
- From Yale School of Medicine, New Haven, CT (E.M.B.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.M.B.); Department of Biostatistics, Yale School of Public Health, New Haven, CT (S.M.); Department of Biostatistics, Harvard School of Public Health, and Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.T.N.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven CT (H.M.K.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Robert Wood Johnson Clinical Scholars Program, Department of Medicine (H.M.K.); and the Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Shuangge Ma
- From Yale School of Medicine, New Haven, CT (E.M.B.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.M.B.); Department of Biostatistics, Yale School of Public Health, New Haven, CT (S.M.); Department of Biostatistics, Harvard School of Public Health, and Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.T.N.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven CT (H.M.K.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Robert Wood Johnson Clinical Scholars Program, Department of Medicine (H.M.K.); and the Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Sharon-Lise T Normand
- From Yale School of Medicine, New Haven, CT (E.M.B.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.M.B.); Department of Biostatistics, Yale School of Public Health, New Haven, CT (S.M.); Department of Biostatistics, Harvard School of Public Health, and Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.T.N.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven CT (H.M.K.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Robert Wood Johnson Clinical Scholars Program, Department of Medicine (H.M.K.); and the Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Harlan M Krumholz
- From Yale School of Medicine, New Haven, CT (E.M.B.); Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (E.M.B.); Department of Biostatistics, Yale School of Public Health, New Haven, CT (S.M.); Department of Biostatistics, Harvard School of Public Health, and Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.T.N.); Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven CT (H.M.K.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Robert Wood Johnson Clinical Scholars Program, Department of Medicine (H.M.K.); and the Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine, New Haven, CT (H.M.K.).
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Lundborg P, Nilsson M, Vikström J. Heterogeneity in the impact of health shocks on labour outcomes: evidence from Swedish workers. ACTA ACUST UNITED AC 2015. [DOI: 10.1093/oep/gpv034] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Consuegra-Sánchez L, Melgarejo-Moreno A, Galcerá-Tomás J, Alonso-Fernández N, Díaz-Pastor Á, Escudero-García G, Jaulent-Huertas L, Vicente-Gilabert M. Educational Level and Long-term Mortality in Patients With Acute Myocardial Infarction. ACTA ACUST UNITED AC 2015; 68:935-42. [PMID: 25892734 DOI: 10.1016/j.rec.2014.11.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 11/26/2014] [Indexed: 12/29/2022]
Abstract
INTRODUCTION AND OBJECTIVES The value of socioeconomic status as a prognostic marker in acute myocardial infarction is controversial. The aim of this study was to evaluate the impact of educational level, as a marker of socioeconomic status, on the prognosis of long-term survival after acute myocardial infarction. METHODS We conducted a prospective, observational study of 5797 patients admitted to hospital with acute myocardial infarction. We studied long-term all-cause mortality (median 8.5 years) using adjusted regression models. RESULTS We found that 73.1% of patients had primary school education (n=4240), 14.5% had secondary school education (including high school) (n=843), 7.0% was illiterate (n=407), and 5.3% had higher education (n=307). Patients with secondary school or higher education were significantly younger, more were male, and they had fewer risk factors and comorbidity. These patients arrived sooner at hospital and had less severe heart failure. During admission they received more reperfusion therapy and their crude mortality was lower. Their drug treatment in hospital and at discharge followed guideline recommendations more closely. On multivariate analysis, secondary school or higher education was an independent predictor and protective factor for long-term mortality (hazard ratio=0.85; 95% confidence interval, 0.74-0.98). CONCLUSIONS Our study shows an inverse and independent relationship between educational level and long-term mortality in patients with acute myocardial infarction.
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Affiliation(s)
| | | | - José Galcerá-Tomás
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Nuria Alonso-Fernández
- Servicio de Medicina Intensiva, Hospital Universitario de Santa Lucía, Cartagena, Murcia, Spain
| | - Ángela Díaz-Pastor
- Servicio de Medicina Intensiva, Hospital Universitario de Santa Lucía, Cartagena, Murcia, Spain
| | - Germán Escudero-García
- Servicio de Medicina Intensiva, Hospital Universitario de Santa Lucía, Cartagena, Murcia, Spain
| | | | - Marta Vicente-Gilabert
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
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Yeh HJ, Chou YJ, Yang NP, Huang N. Receipt of physical therapy among osteoarthritis patients and its influencing factors. Arch Phys Med Rehabil 2015; 96:1021-7. [PMID: 25701638 DOI: 10.1016/j.apmr.2015.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 01/31/2015] [Accepted: 02/03/2015] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To explore major patient and provider characteristics influencing the receipt of physical therapy (PT) among patients newly diagnosed with osteoarthritis. DESIGN A population-based, cross-sectional study on outpatient PT for patients newly diagnosed with osteoarthritis within the period of 2005 to 2010. SETTING Sample of 1 million National Health Insurance enrollees. PARTICIPANTS People aged ≥18 years with an incidence of osteoarthritis and receiving initial outpatient treatment. A total of 29,012 patients were included (N=29,012). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The outcome variable of interest was the probability of receiving PT within 1 year of osteoarthritis diagnosis. Both individual and provider characteristics were investigated to determine their influence on PT receipt. RESULTS Of the 29,012 included patients with osteoarthritis, only 24.8% of them received PT within the first year of diagnosis. Men and older adults were less likely to receive PT. In addition, low-income patients with osteoarthritis were less likely to receive PT. Furthermore, PT receipt was increased in patients treated by physicians who were women and by physicians who specialized in rehabilitation medicine. In addition, we observed a pattern indicating that the lower the accreditation level of the practice setting, the greater the probability of receiving PT. CONCLUSIONS Because of the National Health Insurance program in Taiwan, direct medical costs of PT have been substantially reduced; however, variations are still observed among different patient and provider characteristics. The major role of providers in PT receipt for patients with osteoarthritis should not be ignored.
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Affiliation(s)
- Huan-Jui Yeh
- Department of Physical Medicine and Rehabilitation, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan; Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Yiing-Jenq Chou
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Nan-Ping Yang
- Department of Orthopedics, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan.
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Brattström O, Eriksson M, Larsson E, Oldner A. Socio-economic status and co-morbidity as risk factors for trauma. Eur J Epidemiol 2014; 30:151-7. [PMID: 25377535 DOI: 10.1007/s10654-014-9969-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 10/25/2014] [Indexed: 12/17/2022]
Abstract
Clinical experience and previous studies indicate that low socioeconomic positions are overrepresented in trauma populations. The reason for this social variation in injury risk is likely to be multifactorial. Both individual and environmental sources of explanation are plausible to contribute. We investigated the impact of the influence of socioeconomic factors and co-morbidity on the risk of becoming a trauma victim in a case-control study including 7,382 trauma patients matched in a one to five ratio with controls matched by age-, gender- and municipality from a level 1 trauma centre. Data from the trauma cohort were linked to national registries. Associations between socioeconomic factors and co-morbidity were estimated by conditional logistic regression. The trauma patients had been treated for psychiatric, substance abuse and somatic diagnoses to a higher extent than the controls. In the conditional logistic regression analysis a low level of education and income as well as co-morbidity (divided into psychiatric, substance abuse and somatic diagnoses) were all independent risk factors for trauma. Analysing patients with an injury severity score >15 separately did not alter the results, except for somatic diagnoses not being a risk factor. Recent treatment for substance abuse significantly increased the risk for trauma. Low level of education and income as well as psychiatric, substance abuse and somatic co-morbidity were all independent risk factors for trauma. Active substance abuse strongly influenced the risk for trauma and had a time dependent pattern. These insights can facilitate future implementation of injury prevention strategies tailored to specific risk groups.
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Affiliation(s)
- Olof Brattström
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden,
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Educational inequalities in 28 day and 1-year mortality after hospitalisation for incident acute myocardial infarction--a nationwide cohort study. Int J Cardiol 2014; 177:874-80. [PMID: 25453405 DOI: 10.1016/j.ijcard.2014.10.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 10/09/2014] [Accepted: 10/18/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND There is little recent evidence on the impact of comorbidities and access to revascularisation procedures on educational inequalities in mortality after acute myocardial infarction (AMI). The aim of the study was to investigate educational inequalities in mortality among all patients hospitalised for an incident AMI during 2001-2009 in Norway. METHODS Data were obtained through the Cardiovascular Disease in Norway (CVDNOR) project. Incident AMI was defined as an AMI-hospitalisation without any AMI-events in the previous 7 years. Education was categorised as basic, upper secondary or tertiary (college/university). Cox regression was used to assess educational differences in 28-day and 29-365-day mortality after an incident AMI in terms of hazard ratios and relative index of inequality (RII). RII can be interpreted as the ratio in mortality between the 0 th and the 100th percentile of the education distribution. RESULTS 111 993 incident AMIs were included (39.4% women). Among patients aged 35-69, RIIs (95% CI) adjusted for age, sex and year were 1.86 (1.59-2.18) and 2.10 (1.69-2.59) for 28-day and 29-365-day mortality respectively. Among patients aged 70-94 the corresponding RIIs were 1.12 (1.06-1.30) and 1.28 (1.19-1.38). Educational inequalities in mortality were attenuated after adjustment for comorbidities and revascularisation, but were still significant. Educational inequalities did not decrease during 2001-2009. CONCLUSION Educational inequalities in both 28-day and 29-365 day mortality were strong and persistent during 2001-2009. Further research is needed to investigate if these disparities are driven by inequalities in the severity of the AMI or by inequitable access to treatment and rehabilitation.
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Comparison of long-term mortality after acute myocardial infarction treated by percutaneous coronary intervention in patients living alone versus not living alone at the time of hospitalization. Am J Cardiol 2014; 114:522-7. [PMID: 24998090 DOI: 10.1016/j.amjcard.2014.05.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 05/15/2014] [Accepted: 05/15/2014] [Indexed: 11/20/2022]
Abstract
Living alone was reported to be associated with increased risk of cardiovascular disease. There are, however, limited data on the relation between living alone and all-cause mortality in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). The Coronary REvascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) AMI registry was a cohort study of patients with AMI enrolled in 26 hospitals in Japan from 2005 through 2007. For the current analysis, we included those patients who underwent PCI within 24 hours of symptom onset, and we assessed their living status to determine if living alone would be an independent prognostic risk factor. Among 4,109 patients eligible for the current analysis of 5,429 patients enrolled in the CREDO-Kyoto AMI registry, 515 patients (12.5%) were living alone at the time of hospital admission. The cumulative 5-year incidence of all-cause death was 18.3% in the living alone group and 20.1% in the not living alone group (log-rank p = 0.77). After adjusting for potential confounders, risk of the living alone group relative to the not living alone group for all-cause death was not significantly different (adjusted hazard ratio 0.82, 95% confidence interval 0.65 to 1.02, p = 0.08). In a subgroup analysis stratified by age, the adjusted risk for all-cause death was also not different between the living alone group and the not living alone group both in the older population (aged ≥75 years) and the younger population (aged <75 years). In conclusion, living alone was not associated with higher long-term mortality in patients with AMI who underwent PCI.
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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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Coady SA, Johnson NJ, Hakes JK, Sorlie PD. Individual education, area income, and mortality and recurrence of myocardial infarction in a Medicare cohort: the National Longitudinal Mortality Study. BMC Public Health 2014; 14:705. [PMID: 25011538 PMCID: PMC4227052 DOI: 10.1186/1471-2458-14-705] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 06/09/2014] [Indexed: 11/25/2022] Open
Abstract
Background The Medicare program provides universal access to hospital care for the elderly; however, mortality disparities may still persist in this population. The association of individual education and area income with survival and recurrence post Myocardial Infarction (MI) was assessed in a national sample. Methods Individual level education from the National Longitudinal Mortality Study was linked to Medicare and National Death Index records over the period of 1991-2001 to test the association of individual education and zip code tabulation area median income with survival and recurrence post-MI. Survival was partitioned into 3 periods: in-hospital, discharge to 1 year, and 1 year to 5 years and recurrence was partitioned into two periods: 28 day to 1 year, and 1 year to 5 years. Results First MIs were found in 8,043 women and 7,929 men. In women and men 66-79 years of age, less than a high school education compared with a college degree or more was associated with 1-5 year mortality in both women (HRR 1.61, 95% confidence interval 1.03-2.50) and men (HRR 1.37, 1.06-1.76). Education was also associated with 1-5 year recurrence in men (HRR 1.68, 1.18-2.41, < High School compared with college degree or more), but not women. Across the spectrum of survival and recurrence periods median zip code level income was inconsistently associated with outcomes. Associations were limited to discharge-1 year survival (RR lowest versus highest quintile 1.31, 95% confidence interval 1.03-1.67) and 28 day-1 year recurrence (RR lowest versus highest quintile 1.72, 95% confidence interval 1.14-2.57) in older men. Conclusions Despite the Medicare entitlement program, disparities related to individual socioeconomic status remain. Additional research is needed to elucidate the barriers and mechanisms to eliminating health disparities among the elderly.
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Affiliation(s)
- Sean A Coady
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, 2 Rockledge Ctr, 6701 Rockledge Dr,, Rm10200 MSC 7936, Bethesda 20817 MD, USA.
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Socioeconomic factors and concomitant diseases are related to the risk for venous thromboembolism during long time follow-up. J Thromb Thrombolysis 2014; 36:58-64. [PMID: 23247894 DOI: 10.1007/s11239-012-0858-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
While the risk for arterial vascular disease has been shown to be influenced by socioeconomic status (SES), there is limited information whether SES also influences the risk for venous thromboembolism (VTE). To evaluate whether there is an association between SES and VTE incidence. In 1990, all 730,050 inhabitants (379,465 women and 350,585 men) above 25 years of age in the County of Skåne in Sweden were evaluated with regard to age, household income, marital status, country of birth, number of years of residence in Sweden, educational level, and concomitant diseases. The cohort was hereafter prospectively investigated regarding diagnosis of, or death from VTE (deep venous thrombosis or pulmonary embolism ), during 1991-2003. The association between socioeconomic data and concomitant diseases at the baseline investigation 1990 and incidence of VTE during follow-up was examined by Cox proportional hazard models. During the 13 years prospective follow-up, 10,212 women and 7,922 men were diagnosed with VTE. In both genders, age above 40 years at baseline, low income, single status, and a lower level of education were associated with an increased risk of VTE. However, both men and women born outside of Sweden have a lower risk for VTE during follow-up, however. Age above 40 years, low income, single marital status, and lower level of education were independently related to an increased risk of VTE diagnosis during 13 years of prospective follow-up.
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The importance of socioeconomic factors for compliance and outcome at screening for abdominal aortic aneurysm in 65-year-old men. J Vasc Surg 2013; 58:50-5. [DOI: 10.1016/j.jvs.2012.12.080] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 12/21/2012] [Accepted: 12/26/2012] [Indexed: 11/17/2022]
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Alter DA, Franklin B, Ko DT, Austin PC, Lee DS, Oh PI, Stukel TA, Tu JV. Socioeconomic status, functional recovery, and long-term mortality among patients surviving acute myocardial infarction. PLoS One 2013; 8:e65130. [PMID: 23755180 PMCID: PMC3670842 DOI: 10.1371/journal.pone.0065130] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 04/22/2013] [Indexed: 11/18/2022] Open
Abstract
Objectives To examine the relationship between socio-economic status (SES), functional recovery and long-term mortality following acute myocardial infarction (AMI). Background The extent to which SES mortality disparities are explained by differences in functional recovery following AMI is unclear. Methods We prospectively examined 1368 patients who survived at least one-year following an index AMI between 1999 and 2003 in Ontario, Canada. Each patient was linked to administrative data and followed over 9.6 years to track mortality. All patients underwent medical chart abstraction and telephone interviews following AMI to identify individual-level SES, clinical factors, processes of care (i.e., use of, and adherence, to evidence-based medications, physician visits, invasive cardiac procedures, referrals to cardiac rehabilitation), as well as changes in psychosocial stressors, quality of life, and self-reported functional capacity. Results As compared with their lower SES counterparts, higher SES patients experienced greater functional recovery (1.80 ml/kg/min average increase in peak V02, P<0.001) after adjusting for all baseline clinical factors. Post-AMI functional recovery was the strongest modifiable predictor of long-term mortality (Adjusted HR for each ml/kg/min increase in functional capacity: 0.91; 95% CI: 0.87–0.94, P<0.001) irrespective of SES (P = 0.51 for interaction between SES, functional recovery, and mortality). SES-mortality associations were attenuated by 27% after adjustments for functional recovery, rendering the residual SES-mortality association no longer statistically significant (Adjusted HR: 0.84; 95% CI:0.70–1.00, P = 0.05). The effects of functional recovery on SES-mortality associations were not explained by access inequities to physician specialists or cardiac rehabilitation. Conclusions Functional recovery may play an important role in explaining SES-mortality gradients following AMI.
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Affiliation(s)
- David A Alter
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Randall DA, Jorm LR, Lujic S, O'Loughlin AJ, Eades SJ, Leyland AH. Disparities in revascularization rates after acute myocardial infarction between aboriginal and non-aboriginal people in Australia. Circulation 2013; 127:811-9. [PMID: 23319820 DOI: 10.1161/circulationaha.112.000566] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study examined revascularization rates after acute myocardial infarction (AMI) for Aboriginal and non-Aboriginal patients sequentially controlling for admitting hospital and risk factors. METHODS AND RESULTS Hospital data from the state of New South Wales, Australia (July 2000 through December 2008) were linked to mortality data (July 2000 through December 2009). The study sample were all people aged 25 to 84 years admitted to public hospitals with a diagnosis of AMI (n=59 282). Single level and multilevel Cox regression was used to estimate rates of revascularization within 30 days of admission. A third (32.9%) of Aboriginal AMI patients had a revascularization within 30 days compared with 39.7% non-Aboriginal patients. Aboriginal patients had a revascularization rate 37% lower than non-Aboriginal patients of the same age, sex, year of admission, and AMI type (adjusted hazard ratio, 0.63; 95% confidence interval, 0.57-0.70). Within the same hospital, however, Aboriginal patients had a revascularization rate 18% lower (adjusted hazard ratio, 0.82; 95% confidence interval, 0.74-0.91). Accounting for comorbidities, substance use and private health insurance further explained the disparity (adjusted hazard ratio, 0.96; 95% confidence interval, 0.87-1.07). Hospitals varied markedly in procedure rates, and this variation was associated with hospital size, remoteness, and catheterization laboratory facilities. CONCLUSIONS Aboriginal Australians were less likely to have revascularization procedures after AMI than non-Aboriginal Australians, and this was largely explained by lower revascularization rates at the hospital of first admission for all patients admitted to smaller regional and rural hospitals, a higher comorbidity burden for Aboriginal people, and to a lesser extent a lower rate of private health insurance among Aboriginal patients.
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Affiliation(s)
- Deborah A Randall
- Centre for Health Research, Building 3, Campbelltown Campus, University of Western Sydney, Locked Bag 1797 Penrith NSW 2751, Australia.
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Wieslander I, Mårtensson J, Fridlund B, Svedberg P. Factors influencing female patients’ recovery after their first myocardial infarction as experienced by cardiac rehabilitation nurses. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ojn.2013.32032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Jakobsen L, Niemann T, Thorsgaard N, Thuesen L, Lassen JF, Jensen LO, Thayssen P, Ravkilde J, Tilsted HH, Mehnert F, Johnsen SP. Dimensions of Socioeconomic Status and Clinical Outcome After Primary Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2012; 5:641-8. [DOI: 10.1161/circinterventions.112.968271] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lars Jakobsen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark (L.J., F.M., S.P.J.); Department of Internal Medicine, Herning Hospital, Herning, Denmark (L.J., T.N., N.T.); Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark (L.T., J.F.L.); Department of Cardiology, Odense University Hospital, Odense, Denmark (L.O.J., P.T.); and Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark (J.R., H.H.T.)
| | - Troels Niemann
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark (L.J., F.M., S.P.J.); Department of Internal Medicine, Herning Hospital, Herning, Denmark (L.J., T.N., N.T.); Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark (L.T., J.F.L.); Department of Cardiology, Odense University Hospital, Odense, Denmark (L.O.J., P.T.); and Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark (J.R., H.H.T.)
| | - Niels Thorsgaard
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark (L.J., F.M., S.P.J.); Department of Internal Medicine, Herning Hospital, Herning, Denmark (L.J., T.N., N.T.); Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark (L.T., J.F.L.); Department of Cardiology, Odense University Hospital, Odense, Denmark (L.O.J., P.T.); and Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark (J.R., H.H.T.)
| | - Leif Thuesen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark (L.J., F.M., S.P.J.); Department of Internal Medicine, Herning Hospital, Herning, Denmark (L.J., T.N., N.T.); Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark (L.T., J.F.L.); Department of Cardiology, Odense University Hospital, Odense, Denmark (L.O.J., P.T.); and Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark (J.R., H.H.T.)
| | - Jens F. Lassen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark (L.J., F.M., S.P.J.); Department of Internal Medicine, Herning Hospital, Herning, Denmark (L.J., T.N., N.T.); Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark (L.T., J.F.L.); Department of Cardiology, Odense University Hospital, Odense, Denmark (L.O.J., P.T.); and Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark (J.R., H.H.T.)
| | - Lisette O. Jensen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark (L.J., F.M., S.P.J.); Department of Internal Medicine, Herning Hospital, Herning, Denmark (L.J., T.N., N.T.); Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark (L.T., J.F.L.); Department of Cardiology, Odense University Hospital, Odense, Denmark (L.O.J., P.T.); and Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark (J.R., H.H.T.)
| | - Per Thayssen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark (L.J., F.M., S.P.J.); Department of Internal Medicine, Herning Hospital, Herning, Denmark (L.J., T.N., N.T.); Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark (L.T., J.F.L.); Department of Cardiology, Odense University Hospital, Odense, Denmark (L.O.J., P.T.); and Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark (J.R., H.H.T.)
| | - Jan Ravkilde
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark (L.J., F.M., S.P.J.); Department of Internal Medicine, Herning Hospital, Herning, Denmark (L.J., T.N., N.T.); Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark (L.T., J.F.L.); Department of Cardiology, Odense University Hospital, Odense, Denmark (L.O.J., P.T.); and Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark (J.R., H.H.T.)
| | - Hans H. Tilsted
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark (L.J., F.M., S.P.J.); Department of Internal Medicine, Herning Hospital, Herning, Denmark (L.J., T.N., N.T.); Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark (L.T., J.F.L.); Department of Cardiology, Odense University Hospital, Odense, Denmark (L.O.J., P.T.); and Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark (J.R., H.H.T.)
| | - Frank Mehnert
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark (L.J., F.M., S.P.J.); Department of Internal Medicine, Herning Hospital, Herning, Denmark (L.J., T.N., N.T.); Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark (L.T., J.F.L.); Department of Cardiology, Odense University Hospital, Odense, Denmark (L.O.J., P.T.); and Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark (J.R., H.H.T.)
| | - Søren P. Johnsen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark (L.J., F.M., S.P.J.); Department of Internal Medicine, Herning Hospital, Herning, Denmark (L.J., T.N., N.T.); Department of Cardiology, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark (L.T., J.F.L.); Department of Cardiology, Odense University Hospital, Odense, Denmark (L.O.J., P.T.); and Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark (J.R., H.H.T.)
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The relation between socioeconomic status and short-term mortality after acute myocardial infarction persists in the elderly: results from a nationwide study. Eur J Epidemiol 2012; 27:605-13. [PMID: 22669358 PMCID: PMC3444695 DOI: 10.1007/s10654-012-9700-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 05/21/2012] [Indexed: 02/06/2023]
Abstract
We assessed whether the previously observed relationship between socioeconomic status (SES) and short-term mortality (pre-hospital mortality and 28-day case-fatality) after a first acute myocardial infarction (AMI) in persons <75 years, are also observed in the elderly (i.e. ≥75 years), and whether these relationships vary by sex. A nationwide register based cohort study was conducted. Between January 1st 1998 and December 31st 2007, 76,351 first AMI patients were identified, of whom 60,498 (79.2 %) were hospitalized. Logistic regression analyses were performed to measure SES differences in pre-hospital mortality after a first AMI and 28-day case-fatality after a first AMI hospitalization. All analyses were stratified by sex and age group (<55, 55–64, 65–74, 75–84, ≥85), and adjusted for age, ethnic origin, marital status, and degree of urbanization. There was an inverse relation between SES and pre-hospital mortality in both sexes. There was also an inverse relation between SES and 28-day case-fatality after hospitalization, but only in men. Compared to elderly men with the highest SES, elderly men with the lowest SES had a higher pre-hospital mortality in both 75–84 year-olds (OR = 1.26; 95 % CI 1.09–1.47) and ≥85 year-olds (OR = 1.26; 1.00–1.58), and a higher 28-day case-fatality in both 75–84 year-olds (OR = 1.26; 1.06–1.50) and ≥85 year-olds (OR = 1.36; 0.99–1.85). Compared to elderly women with the highest SES, elderly women with the lowest SES had a higher pre-hospital mortality in ≥85 year-olds (OR = 1.20; 0.99–1.46). To conclude, in men there are SES inequalities in both pre-hospital mortality and case-fatality after a first AMI, in women these SES inequalities are only shown in pre-hospital mortality. The inequalities persist in the elderly (≥75 years of age). Clinicians and policymakers need to be more vigilant on the population with a low SES background, including the elderly.
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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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Ohrlander T, Merlo J, Ohlsson H, Sonesson B, Acosta S. Socioeconomic position, comorbidity, and mortality in aortic aneurysms: a 13-year prospective cohort study. Ann Vasc Surg 2011; 26:312-21. [PMID: 22079461 DOI: 10.1016/j.avsg.2011.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 01/31/2011] [Accepted: 08/03/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND To evaluate factors associated with incidence and 3-year all-cause mortality in patients with aortic aneurysm (AA). The design is sex and age-stratified (60-79 and 80-90 years) prospective cohort. By using the population register, we constituted a cohort of all men and women born between 1900 and 1930 and living in Scania by 1991, and followed them for 13 years. Identification of AA was based on hospital discharge diagnosis obtained from the Swedish Patient Register or from the information on death certificates from the Cause of Death Register. METHODS We applied stepwise Cox regression and investigated both AA incidence (1991-2003) as well as 3-year survival after the first hospitalization for AA. RESULTS We found an inverse relation between AA incidence and previous hospitalization by diabetes mellitus in women (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.19-0.88) and in men (HR: 0.38; 95% CI: 0.24-0.61) aged 60-79 years. Three-year all-cause mortality after diagnosis of AA was 58.6% in women, 50.2% in men, 72.9% in octogenarians, and 43.7% for nonoctogenarians. Low income, chronic respiratory diseases, cerebrovascular diseases, dementia, systemic connective tissue disorders, renal failure, and malignant neoplasms were independent factors for mortality in 60-79-year-old men with AA. CONCLUSIONS Inferior socioeconomic position is associated with increased 3-year all-cause mortality in 60-79-year-old men with AA.
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Affiliation(s)
- Tomas Ohrlander
- Vascular Center Malmö-Lund, Malmö University Hospital, Malmö, Sweden
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Simpson CR, Buckley BS, McLernon DJ, Sheikh A, Murphy A, Hannaford PC. Five-year prognosis in an incident cohort of people presenting with acute myocardial infarction. PLoS One 2011; 6:e26573. [PMID: 22028911 PMCID: PMC3197664 DOI: 10.1371/journal.pone.0026573] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 09/29/2011] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Following an AMI, it is important for patients and their physicians to appreciate the subsequent risk of death, and the potential benefits of invasive cardiac procedures and secondary preventive therapy. Studies, to-date, have focused largely on high-risk populations. We wished to determine the risk of death in a population-derived cohort of 2,887 patients after a first acute myocardial infarction (AMI). METHODS Logistic regression and survival analysis were conducted to investigate the effect of different baseline characteristics, pharmacological therapies and revascularization procedures on coronary heart disease (CHD) and all-cause mortality outcomes. RESULTS Within five years 44.4% of patients died (27.1% short-term [<30 days] and 23.7% longer-term [≥30 days]). Percutaneous transluminal coronary angioplasty (Adjusted Hazards Ratio (AHR) = 0.49, 95% Confidence Interval (CI) 0.26-0.93), β-blockers (AHR = 0.58, 95%CI 0.46-0.74) and statins (AHR = 0.60, 95%CI 0.47-0.77) were all associated with significant reductions in longer-term CHD-related mortality. However, not all patients received secondary preventive therapy (8.7%). Diabetes (AHR = 1.83, 95%CI 1.43-2.34), stroke (AHR = 1.73, 95%CI 1.35-2.22), heart failure (AHR = 1.69, 95%CI 1.28-2.22), smoking (AHR = 1.72, 95%CI 1.18-2.51) and obesity (>30 kg/m2; AHR = 1.39, 95%CI 1.01-1.90) increased the risk of longer-term mortality independent of other risk factors. CONCLUSIONS It is encouraging that the coronary procedure PTCA and pharmacological secondary prevention therapies were found to be strongly associated with an important reduced risk of subsequent death, although not all patients received these interventions. Smoking, being obese and having cardiovascular related disease at baseline were also associated with an increased likelihood of longer-term mortality, independent of other baseline characteristics. Thus, the provision of smoking cessation, advice on diet (for obese patients) and optimal treatment is likely to be crucial for reducing mortality in all patients after AMI.
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Affiliation(s)
- Colin R Simpson
- eHealth Research Group, Centre for Population Health Sciences, Teviot Place, Medical School, The University of Edinburgh, Edinburgh, United Kingdom.
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Mitchell AJ, Lawrence D. Revascularisation and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta-analysis. Br J Psychiatry 2011; 198:434-41. [PMID: 21628705 DOI: 10.1192/bjp.bp.109.076950] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND High levels of comorbid physical illness and excess mortality rates have been previously documented in people with severe mental illness, but outcomes following myocardial infarction and other acute coronary syndromes are less clear. AIMS To examine inequalities in the provision of invasive coronary procedures (revascularisation, angiography, angioplasty and bypass grafting) and subsequent mortality in people with mental illness and in those with schizophrenia, compared with those without mental ill health. METHOD Systematic search and random effects meta-analysis were used according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies of mental health and cardiovascular procedures following cardiac events were eligible but we required a minimum of three independent studies to warrant pooling by procedure type. We searched Medline/PubMed and EMBASE abstract databases and ScienceDirect, Ingenta Select, SpringerLink and Online Wiley Library full text databases. RESULTS We identified 22 analyses of possible inequalities in coronary procedures in those with defined mental disorder, of which 10 also reported results in schizophrenia or related psychosis. All studies following acute coronary syndrome originated in the USA. The total sample size was 825 754 individuals. Those with mental disorders received 0.86 (relative risk, RR: 95% CI 0.80-0.92, P<0.0001) of comparable procedures with significantly lower receipt of coronary artery bypass graft (CABG; RR = 0.85, 95% CI 0.72-1.00), cardiac catheterisation (RR = 0.85, 95% CI 0.76-0.95) and percutaneous transluminal coronary angioplasty or percutaneous coronary intervention (PTCA/PCI; RR = 0.87, 95% CI 0.72-1.05). People with a diagnosis of schizophrenia received only 0.53 (95% CI 0.44-0.64, P<0.0001) of the usual procedure rate with significantly lower receipt of CABG (RR = 0.69, 95% CI 0.55-0.85) and PTCA/PCI (RR = 0.50, 95% CI 0.34-0.75). We identified 6 related studies examining mortality following cardiac events: for those with mental illness there was a 1.11 relative risk of mortality up to 1 year (95% CI 1.00-1.24, P = 0.05) but there was insufficient evidence to examine mortality rates in schizophrenia alone. CONCLUSIONS Following cardiac events, individuals with mental illness experience a 14% lower rate of invasive coronary interventions (47% in the case of schizophrenia) and they have an 11% increased mortality rate. Further work is required to explore whether these factors are causally linked and whether improvements in medical care might improve survival in those with mental ill health.
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Affiliation(s)
- Alex J Mitchell
- Department of Liaison Psychiatry, Leicestershire Partnership Trust and Department of Cancer Studies and Molecular Medicine, Leicester Royal Infirmary, Leicester, UK.
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Healthy diet in Canadians of low socioeconomic status with coronary heart disease: Not just a matter of knowledge and choice. Heart Lung 2011; 40:156-63. [DOI: 10.1016/j.hrtlng.2010.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 12/16/2009] [Accepted: 01/29/2010] [Indexed: 11/23/2022]
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Ohlsson H, Rosvall M, Hansen O, Chaix B, Merlo J. Socioeconomic position and secondary preventive therapy after an AMI. Pharmacoepidemiol Drug Saf 2010; 19:358-66. [PMID: 20087850 DOI: 10.1002/pds.1917] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
PURPOSE To investigate the association between socioeconomic position and use of lipid-lowering drugs and ACE-inhibitors after an acute myocardial infarction (AMI) when simultaneously considering participation in the national quality register RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive care Admissions), age, sex and previous hospitalizations of the patients. METHODS Population-based prospective cohort study included all 1346 AMI patients cared in the county of Scania, Sweden during 2006 of whom 1061 were register at the RIKS-HIA. Treatment with lipid-lowering and ACE-inhibiting therapy in relation to income was investigated with Cox and logistic regression modelling. RESULTS In the whole population of AMI patients, high income patients had a higher adherence to guidelines for pharmacological secondary prevention than low income patients (HR(lipid-lowering drug): 1.29; 95%CI: 1.12-1.49 and HR(ACE-inhibitor therapy): 1.22; 95%CI: 1.04-1.43). Among RIKS-HIA participants, patients with high income presented a better adherence to lipid-lowering treatment than patients with low income (HR: 1.15; 95%CI: 0.98-1.34). CONCLUSION Our investigation reveals that the Swedish goal of access to health care on equal terms and according to needs is still not fully accomplished. Moreover, since this pattern of inequity in pharmacological secondary prevention may lead to the recurrence of heart disease, these inequities are not only a matter of fairness and social justice, but also a potential (and modifiable) source of ineffectiveness and inefficiency in health care.
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Affiliation(s)
- Henrik Ohlsson
- Faculty of Medicine, Social Epidemiology, Lund University, Malmö, Sweden.
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Gerward S, Tydén P, Engström G, Hedblad B. Marital status and occupation in relation to short-term case fatality after a first coronary event--a population based cohort. BMC Public Health 2010; 10:235. [PMID: 20459706 PMCID: PMC2874781 DOI: 10.1186/1471-2458-10-235] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 05/10/2010] [Indexed: 11/13/2022] Open
Abstract
Background Although marital status and low occupation level has been associated with mortality, the relationship with case fatality rates (CFR) after a coronary event (CE) is unclear. This study explored whether incidence of CE and short-term CFR differ between groups defined in terms of marital status and occupation, and if this could be explained by biological and life-style risk factors. Methods Population-based cohort study of 33,224 subjects (67% men), aged 27 to 61 years, without history of myocardial infarction, who were enrolled between 1974 and 1992. Incidence of CE, and CFR (death during the first day or within 28 days after CE, including out-of-hospital deaths) was examined over a mean follow-up of 21 years. Results A total of 3,035 men (6.0 per 1000 person-years) and 507 women (2.4 per 1000) suffered a first CE during follow-up. CFR (during the 1st day) was 29% in men and 23% in women. After risk factor adjustments, unmarried status in men, but not in women, was significantly associated with increased risk of suffering a CE [hazard ratios (HR) 1.10, 95% CI: 0.97-1.24; 1.42: 1.27-1.58 and 1.77: 1.31-2.40 for never married, divorced and widowed, respectively, compared to married]. Unmarried status, in both gender, was also related with an increased CFR (1st day), taking potential confounders into account (odds ratio (OR) 2.14, 95% CI: 1.63-2.81; 1.91: 1.50-2.43 and 1.49: 0.77-2.89 for never married, divorced and widowed, respectively, compared to married men. Corresponding figures for women was 2.32: 0.93-5.81; 1.87: 1.04-3.36 and 2.74: 1.03-7.28. No differences in CFR (1st day) were observed between occupational groups in neither gender. Conclusions In this population-based Swedish cohort, short-term CFR was significantly related to unmarried status in men and women. This relationship was not explained by biological-, life-style factors or occupational level.
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Affiliation(s)
- Sofia Gerward
- Department of Clinical Sciences in Malmö, Cardiovascular Epidemiology, Skåne University Hospital, Malmö, Sweden.
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Neighborhood disparities in incident hospitalized myocardial infarction in four U.S. communities: the ARIC surveillance study. Ann Epidemiol 2009; 19:867-74. [PMID: 19815428 DOI: 10.1016/j.annepidem.2009.07.092] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 07/13/2009] [Accepted: 07/22/2009] [Indexed: 11/22/2022]
Abstract
PURPOSE Hospital-based surveillance of myocardial infarction (MI) in the United States (U.S.) typically includes age, gender, and race, but not socioeconomic status (SES). We examined the association between neighborhood median household income (nINC) and incident hospitalized MI in four U.S. communities (1993-2002). METHODS Average annual indirect age-standardized MI rates were calculated using community-specific and community-wide nINC tertiles. Poisson generalized linear mixed models were used to calculate MI incidence rate ratios by tertile of census tract nINC (high nINC group referent). RESULTS Within community, and among all race-gender groups, those living in low nINC neighborhoods had an increased risk of MI compared to those living in high nINC neighborhoods. This association was present when both community-specific and community-wide nINC cut points were used. Blacks and, to a lesser extent, women, were disproportionately represented in low nINC neighborhoods, resulting in a higher absolute burden of MI in blacks and women living in low compared with high nINC neighborhoods. CONCLUSIONS These findings suggest a need for the joint consideration of racial, gender, and social disparities in interventions aimed at preventing coronary heart disease.
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