Fabreau Gabriel E, Leung Alexander A, Southern Danielle A, James Matthew T, Knudtson Merrill L, Ghali William A, Ayanian John Z
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA O'Brien Institute for Public Health, University of Calgary, Alberta, Canada Department of Health Care Policy, Harvard Medical School, Boston, MA
O'Brien Institute for Public Health, University of Calgary, Alberta, Canada.
J Am Heart Assoc. 2016 Feb 23;5(2):e002447. doi: 10.1161/JAHA.115.002447.
Metropolitan versus nonmetropolitan status and area median income may independently affect care for and outcomes of acute coronary syndromes. We sought to determine whether location of care modifies the association among area income, receipt of cardiac catheterization, and mortality following an acute coronary syndrome in a universal health care system.
We studied a cohort of 14 012 acute coronary syndrome patients admitted to cardiology services between April 18, 2004, and December 31, 2011, in southern Alberta, Canada. We used multivariable logistic regression to determine the odds of cardiac catheterization within 1 day and 7 days of admission and the odds of 30-day and 1-year mortality according to area median household income quintile for patients presenting at metropolitan and nonmetropolitan hospitals. In models adjusting for area income, patients who presented at nonmetropolitan facilities had lower adjusted odds of receiving cardiac catheterization within 1 day of admission (odds ratio 0.22, 95% CI 0.11-0.46, P<0.001). Among nonmetropolitan patients, when examined by socioeconomic status, each incremental decrease in income quintile was associated with 10% lower adjusted odds of receiving cardiac catheterization within 7 days (P<0.001) and 24% higher adjusted odds of 30-day mortality (P=0.008) but no significant difference for 1-year mortality (P=0.12). There were no differences in adjusted mortality among metropolitan patients.
Within a universal health care system, the association among area income and receipt of cardiac catheterization and 30-day mortality differed depending on the location of initial medical care for acute coronary syndromes. Care protocols are required to improve access to care and outcomes in patients from low-income nonmetropolitan communities.
大城市与非大城市地区的状况以及地区收入中位数可能会独立影响急性冠状动脉综合征的治疗及预后。我们试图确定在全民医疗保健系统中，治疗地点是否会改变地区收入、心脏导管插入术的接受情况与急性冠状动脉综合征后死亡率之间的关联。
我们研究了2004年4月18日至2011年12月31日期间在加拿大艾伯塔省南部心内科就诊的14012例急性冠状动脉综合征患者。我们使用多变量逻辑回归分析，根据大城市和非大城市医院患者的地区家庭收入中位数五分位数，确定入院1天和7天内进行心脏导管插入术的几率以及30天和1年死亡率的几率。在对地区收入进行校正的模型中，在非大城市医疗机构就诊的患者入院1天内接受心脏导管插入术的校正几率较低（优势比0.22，95%可信区间0.11 - 0.46，P<0.001）。在非大城市患者中，按社会经济地位进行分析时，收入五分位数每增加一次降低，7天内接受心脏导管插入术的校正几率就降低10%（P<0.001），30天死亡率的校正几率就增加24%（P = 0.008），但1年死亡率无显著差异（P = 0.12）。大城市患者的校正死亡率无差异。
在全民医疗保健系统中，地区收入与心脏导管插入术的接受情况以及30天死亡率之间的关联因急性冠状动脉综合征初始医疗护理的地点而异。需要制定护理方案，以改善低收入非大城市社区患者获得治疗的机会及预后。
