Socioeconomic status and waiting time in the emergency department for patients with chest pain

Introduction

Acute coronary syndrome (ACS) is one of the leading causes of death in the world and timeliness of treatment and diagnosis is of utmost importance to reduce mortality and morbidity. Emergency department (ED) crowding results in longer waiting times and length of stay in the ED and is a globally growing phenomenon with clear negative consequences for patients. Low socioeconomic status (SES) has previously been associated with poor prognosis after ACS, but it remains unclear if treatment and diagnostics in the acute state is a contributing factor. ED length of stay has been linked to crowding and poor patient outcomes whereas mechanisms for generally worse prognosis in low SES remains poorly understood.

Purpose

To investigate whether SES, measured as disposable income, is associated with ED waiting times among patients with the most common chief complaint in ACS, chest pain.

Methods

A registry-based cohort study on all 140,388 patients arriving at 14 Swedish emergency departments between 2015 and 2019 with chest pain as their chief complaint registered in the Swedish Emergency Registry (SVAR). Individual-level sociodemographic and clinical data were linked from multiple national registries. The associations between disposable income quintiles and ED length of stay and time to doctor were assessed using multivariable regression models adjusting for age, sex, education, comorbidities (diabetes, hypertension, hyperlipidemia, obesity and cardiovascular disease) and ED-visit characteristics (arrival mode, triage level, arrival time (day, evening or night as well as weekday or weekend) and hospital type).

Results

Median length of stay was 11 minutes (4.4%) longer among patients in the lowest income quintile, 4:04 [hours:minutes] (95% confidence interval [CI] 4:02–4:05), compared to patients in the highest income quintile (3:53, 95% CI 3:52–3:55). Similarly, time to doctor was 6 min (8.7%) longer among patients in the lowest income quintile (1:15 min, 95% CI 1:14–1:16) than patients in the highest income quintile (1:09, 95% CI 1:08–1:10). The associations were independent of adjustment for studied confounders and mediators.

Conclusions

Among ED chest pain patients, low income was associated with longer length of stay and time to doctor which may impact negatively on patients with serious cardiovascular diagnosis such as ACS. Longer waiting times may delay diagnosis and timely treatment for the individual patient such as anti-ischemic and antithrombotic therapy.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported by grants provided by Region Stockholm (ALF-project)

Socioeconomic status, secondary prevention activities during the first year after a myocardial infarction and target attainments

Background

Socioeconomic status (SES) is a strong predictor of recurrent events post-myocardial infarction (MI) with unclear underlying mechanisms. To what extent SES is associated with secondary prevention activities (SPAs) and attainment of quality-of-care treatment goals is unknown.

Purpose

We aimed to assess the association between SES and SPAs during the first year post-MI and attained treatment targets at the 1-year follow-up.

Methods

Nationwide Swedeheart registry-based cohort study on 30,191 18–76 year old 11–15 month survivors of a first MI (8,180 women) 2006–2013. Complementary individual-level clinical data and data on SES (age and gender stratified quintiles of disposable income, level of education, and marital status), were linked from other national registries. Associations between SES and the outcomes were estimated in multivariable logistic regression models with basic adjustment for potential registry-related confounding.

Results

The associations between all indicators of SES and attendance to patient education and physical training programs were strong, moderate for dietary program attendance but absent for participation in smoking cessation program (Table 1). Higher SES was also associated with repeated lipid profile measurements and the highest vs lowest income with intensified statin therapy.

Correspondingly, higher SES was associated with having achieved target levels of LDL-C, blood pressure, and HbA1c as well as with persistence to and being on high intensity statin treatment (Figure 1). Further, higher SES was strongly associated with having quit smoking. No association with income was however observed regarding the weekly physical activity goal.

Conclusions

Higher SES was strongly associated with most SPAs including programs aiming at life style change and risk factor control as well as with attainment of corresponding secondary prevention targets. This may be explanatory for higher long-term risk of recurrent disease.

Figure 1. Target Attainment Forest Plots

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Stockholm City Council and The Swedish Heart and Lung Association

4952Level A evidence - for A-level patients only? Participants in clinical trials post myocardial infarction have higher socioeconomic status and better prognosis

Introduction

Randomized clinical trials (RCT) produce the highest level of evidence and therefore form the basis for many guidelines. Their Achilles heel is external validity which is still poorly studied. Participants in clinical trials may partly be selected on unknown mechanisms in particular regarding socioeconomic status. To what extent participants in clinical trials after myocardial infarction (MI) are representative for the overall MI population is unknown.

Purpose

To investigate whether participants in clinical trials after myocardial infarction differ regarding socioeconomic status (SES), risk factor profile, prior and recurrent cardiovascular disease (CVD) events.

Methods

A total of 34,084 patients attending follow up after myocardial infarction between 2007 and 2014 were identified in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) out of which 3,037 had participated in a clinical trial. Information on disposable income, education level, marital status, prior CVD, risk factors and treatment were retrieved from national registers and patients were followed regarding recurrent CVD. Participants in clinical trials were compared to non-participants using logistic and Cox regression analyses. In a multivariable Cox-regression analysis adjustments were made for gender, age, inclusion-year, diabetes, LVEF, previous MI, previous stroke, prior cardiac surgery, ECG rhythm, eGFR, lipid levels, smoking status, use of ASA, use of ACE-I, use of beta-blockers, use of statins, level of education, disposable income and family status.

Results

Trial participants were more likely to be men (odds ratio (OR): 1.42; 95% CI: 1.29–1.55)), to be married (1.17; 1.09–1.27), to have a high income (1.58; 1.45–1.72), have a post-secondary education (>12 years) (1.33; 1.22–1.46) and less likely to be smokers (0.81; 0.72–0.90), have a reduced EF <30% (0.61; 0.46–0.80), history of previous stroke (0.79; 0.65–0.97) or MI (0.86; 0.77–0.97) compared to non-participants. The risk for recurrent CVD was lower among the participants compared to the non-participants (HR: 0.77; 95% CI: 0.67–0.88) and is illustrated in figure 1. In a fully adjusted model the lower risk remained after adjusting for age, gender, risk factors, prior disease including EF, evidence based treatments and SES (HR: 0.85; 95% CI: 0.74–0.97).

Trial participation and recurrent CVD

Conclusion

Participants in clinical trials after MI constitute a highly selected group with higher SES, a more favourable risk profile and a better overall prognosis. The lower risk after full adjustments imply that additional selection bias exists. The external validity of post MI- trials in general can thus be questioned. To what extent results from clinical trials apply to the overall post MI population should be carefully scrutinized. Real world registry data are important.

Acknowledgement/Funding

Familjen Janne Elgqvists Stiftelse

[Extraperitoneal cicatricial hernia repair with implantation of non-resorbable synthetic mesh]

Large incisional hernias and recurrences were treated by extraperitoneal implantation of polypropylene mesh using a sublay technique in 37 patients. There were 10 minor (5 haematoma, 3 seroma, 2 patients with postoperative increased temperature) and 2 major complications (1 case of skin necorsis, 1 deed wound infection with fistulation and involvement of mesh). Within a mean follow-up time of 17 months, we saw 3 recurrences.

Acute dietary effects on plasma lipids, lipoproteins and lipolytic enzymes in healthy normal males

Diurnal plasma lipids and lipoproteins were studied in twelve healthy young males on corn oil and palm oil diets, respectively. The major triglyceridy. Lecithin-cholesterol acyl transferase, lipoprotein lipase and hepatic triglyceride lipase were also measured. diurnal changes of triglycerides and cholesterol were confined to lipoproteins of d less than 1.006 kg/l. There was a diurnal rise of lecithin-cholesterol acyl transferase activity with corn oil but not with palm oil. Fasting and postprandial postheparin lipoprotein lipase and hepatic triglyceride lipase were similar but there was a significant correlation of postprandial hepatic lipase with postprandial plasma triglycerides on palm oil. Marked diurnal changes of triglyceride fatty acids were observed not only in 'very low density lipoprotein' but also in high-density lipoprotein amounting to approximately one third of total high density lipoprotein triglyceride fatty acids.