Treatment patterns, outcomes vary by patient income for older adults after heart attack
Key takeaways:
- Adjusted 30-day and 1-year mortality rates after MI were higher for older low-income vs. higher-income patients.
- Rates of cardiac catheterization and PCI after MI were lower among lower-income patients.
An analysis of administrative claims data across six high-income countries shows income disparities in treatments and outcomes persist for older adults after acute MI, including countries with universal health insurance.
In a serial cross-sectional analysis of more than 1.1 million adults aged 65 years and older hospitalized with acute MI from the U.S., Canada, England, Israel, the Netherlands and Taiwan, researchers found that adjusted 30-day and 1-year mortality rates after MI were higher for low-income vs. higher-income patients, whereas rates of cardiac catheterization and PCI were lower.
“The conventional wisdom is that the U.S. has the most inequitable health system and delivers care that is most inequitable,” Bruce E. Landon, MD, MBA, professor of health care policy at Harvard Medical School and professor of medicine and practicing internist at Beth Israel Deaconess Medical Center, told Healio. “In this study that isolates care patterns and outcomes after for patients presenting at the identical point in their disease, we actually find that relative to higher-income individuals, care patterns and outcomes for lower-income individuals were worse in just about all of the diverse countries that we examined.”
Landon and colleagues analyzed data from 289,376 patients hospitalized with STEMI and 843,046 adults hospitalized with non-STEMI, all aged 65 years or older, from 2013 through 2018 in the U.S., Canada, England, the Netherlands, Taiwan and Israel. Researchers stratified patients by the top and bottom quintile of income within and across countries. The primary outcome was 30-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay and readmission rates.
The findings were published in JAMA.
Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. In the Netherlands, 30-day mortality among patients admitted with STEMI was 10.2% for those with high income vs. 13.1% for those with low income, for a difference of –2.8 percentage points (95% CI, 4.1 to 1.5).
Differences were larger when assessing 1-year mortality differences for STEMI, with the highest difference observed in Israel (16.2% vs. 25.3%; difference, 9.1 percentage points; 95% CI, 16.7 to –1.6).
Across all six countries, rates of cardiac catheterization and PCI were higher among high- vs. low-income populations, with absolute differences ranging from 1 to 6 percentage points. In England, rates of cardiac catheterization and PCI after STEMI for high-income vs. low-income patients was 73.6% and 67.4%, respectively, for a difference of 6.1 percentage points (95% CI, 1.2-11).
Rates of CABG for patients with STEMI in low- vs. high-income strata were similar; however, rates of CABG for patients with non-STEMI were generally 1 to 2 percentage points higher among high-income patients.
Rates of readmission at 30 days were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income vs. low-income patients across countries, according to the researchers.
The researchers noted that the results the U.S. “is not an outlier” in terms of the care provided to and outcomes among older patients with low vs. high incomes after an acute MI.
“There are clear differences in rates of use of recommended treatments that likely contribute to the outcomes differences we saw,” Landon told Healio. “We need to monitor performance for lower-income populations and with respect to these care processes. We also need more research to ‘unpack’ these findings within countries. To what extent are our findings driven by care seeking from different hospitals vs. different care being delivered within hospitals?”
For more information:
Bruce E. Landon, MD, MBA, can be reached at landon@hcp.med.harvard.edu; Twitter: @bruce_landon.
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