Jacob A Udell1, Nihar R Desai2, Shuang Li3, Laine Thomas3, James A de Lemos4, Phyllis Wright-Slaughter5, Wenying Zhang5, Matthew T Roe3, Deepak L Bhatt6. 1. Cardiovascular Division, Department of Medicine, Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.). jay.udell@utoronto.ca dlbhattmd@post.harvard.edu. 2. Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine and Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (N.R.D.). 3. Cardiovascular Division, Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, NC (S.L., L.T., M.T.R.). 4. Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (J.A.D.L.). 5. Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (P.W.-S., W.Z.). 6. Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.). jay.udell@utoronto.ca dlbhattmd@post.harvard.edu.
Abstract
BACKGROUND: Patients living in disadvantaged neighborhoods are at high risk for adverse outcomes after acute myocardial infarction (MI). Whether residential socioeconomic status (SES) is associated with quality of in-hospital care among patients presenting with MI is unclear. METHODS AND RESULTS: Multivariable logistic regression was used to examine the relationship between SES, quality of care, and in-hospital cardiovascular outcomes among patients with MI from diverse SES neighborhoods from July 2008 to December 2013, at 586 participating hospitals in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines quality improvement program. Patients were categorized according to which SES summary measure group they resided in through linkage with US census block data. Outcomes were in-hospital mortality and major adverse cardiovascular events. Quality of MI care was assessed with the defect-free care measure that delineates the proportion of eligible patients who received all acute and discharge guideline-recommended therapies. Among 390 692 patients, there was a substantially longer median arrival-to-angiography time in lower SES neighborhoods (lowest 8.0 hours, low 5.5 hours, medium 4.8 hours, high 4.5 hours, highest 3.4 hours; P<0.0001), and a higher proportion of ST-segment-elevation myocardial infarction patients treated with fibrinolysis (lowest 23.1%, low 20.2%, medium 18.0%, high 14.2%, highest 5.9%; P<0.0001). However, after adjustment for clinical risk factors, insurance status, and hospital characteristics, socioeconomic disadvantage was not associated with lower rates of guideline-recommended defect-free acute care. Patients presenting from more disadvantaged neighborhoods had a progressively higher independent risk of in-hospital mortality (Pglobal=0.03) and major bleeding (Pglobal<0.001), along with lower quality of discharge care. CONCLUSIONS: In this national registry of MI, patients living in the most disadvantaged neighborhoods received equitable in-hospital care compared with advantaged neighborhoods. However, they experienced substantial delays in receiving angiography. Furthermore, patients living in disadvantaged neighborhoods remain at higher risk of adverse in-hospital outcomes after MI, including mortality. These observations suggest there are further opportunities for improvement in acute and discharge MI care.
BACKGROUND:Patients living in disadvantaged neighborhoods are at high risk for adverse outcomes after acute myocardial infarction (MI). Whether residential socioeconomic status (SES) is associated with quality of in-hospital care among patients presenting with MI is unclear. METHODS AND RESULTS: Multivariable logistic regression was used to examine the relationship between SES, quality of care, and in-hospital cardiovascular outcomes among patients with MI from diverse SES neighborhoods from July 2008 to December 2013, at 586 participating hospitals in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines quality improvement program. Patients were categorized according to which SES summary measure group they resided in through linkage with US census block data. Outcomes were in-hospital mortality and major adverse cardiovascular events. Quality of MI care was assessed with the defect-free care measure that delineates the proportion of eligible patients who received all acute and discharge guideline-recommended therapies. Among 390 692 patients, there was a substantially longer median arrival-to-angiography time in lower SES neighborhoods (lowest 8.0 hours, low 5.5 hours, medium 4.8 hours, high 4.5 hours, highest 3.4 hours; P<0.0001), and a higher proportion of ST-segment-elevation myocardial infarctionpatients treated with fibrinolysis (lowest 23.1%, low 20.2%, medium 18.0%, high 14.2%, highest 5.9%; P<0.0001). However, after adjustment for clinical risk factors, insurance status, and hospital characteristics, socioeconomic disadvantage was not associated with lower rates of guideline-recommended defect-free acute care. Patients presenting from more disadvantaged neighborhoods had a progressively higher independent risk of in-hospital mortality (Pglobal=0.03) and major bleeding (Pglobal<0.001), along with lower quality of discharge care. CONCLUSIONS: In this national registry of MI, patients living in the most disadvantaged neighborhoods received equitable in-hospital care compared with advantaged neighborhoods. However, they experienced substantial delays in receiving angiography. Furthermore, patients living in disadvantaged neighborhoods remain at higher risk of adverse in-hospital outcomes after MI, including mortality. These observations suggest there are further opportunities for improvement in acute and discharge MI care.
Authors: Rishi K Wadhera; Deepak L Bhatt; Amy J H Kind; Yang Song; Kim A Williams; Thomas M Maddox; Robert W Yeh; Liyan Dong; Gheorghe Doros; Alexander Turchin; Karen E Joynt Maddox Journal: Circ Cardiovasc Qual Outcomes Date: 2020-03-31
Authors: Anping Cai; Chrisly Dillon; William B Hillegass; Mark Beasley; Brigitta C Brott; Vera A Bittner; Gilbert J Perry; Ganesh V Halade; Sumanth D Prabhu; Nita A Limdi Journal: J Am Heart Assoc Date: 2019-11-08 Impact factor: 5.501
Authors: Chetan P Huded; Jarrod E Dalton; Anirudh Kumar; Nikolas I Krieger; Nicholas Kassis; Michael Phelan; Kathleen Kravitz; Grant W Reed; Amar Krishnaswamy; Samir R Kapadia; Umesh Khot Journal: J Am Heart Assoc Date: 2021-11-15 Impact factor: 5.501
Authors: Luke P Dawson; Emily Andrew; Ziad Nehme; Jason Bloom; Sinjini Biswas; Shelley Cox; David Anderson; Michael Stephenson; Jeffrey Lefkovits; Andrew J Taylor; David Kaye; Karen Smith; Dion Stub Journal: J Am Heart Assoc Date: 2022-03-24 Impact factor: 6.106