National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, Australia.
Sax Institute, Sydney, NSW, Australia.
Int J Equity Health. 2020 Aug 14;19(1):139. doi: 10.1186/s12939-020-01235-y.
Contemporary Australian evidence on socioeconomic variation in secondary cardiovascular disease (CVD) care, a possible contributor to inequalities in cardiovascular disease outcomes, is lacking. This study examined the relationship between education, an individual-level indicator of socioeconomic position, and receipt of angiography and revascularisation procedures following incident hospitalisation for acute myocardial infarction (AMI) or angina, and the role of private care in this relationship.
Participants aged ≥45 from the New South Wales population-based 45 and Up Study with no history of prior ischaemic heart disease hospitalised for AMI or angina were followed for receipt of angiography or revascularisation within 30 days of hospital admission, ascertained through linked hospital records. Education attainment, measured on baseline survey, was categorised as low (no school certificate/qualifications), intermediate (school certificate/trade/apprenticeship/diploma) and high (university degree). Cox regression estimated the association (hazard ratios [HRs]) between education and coronary procedure receipt, adjusting for demographic and health-related factors, and testing for linear trend. Private health insurance was investigated as a mediating variable.
Among 4454 patients with AMI, 68.3% received angiography within 30 days of admission (crude rate: 25.8/person-year) and 48.8% received revascularisation (rate: 11.7/person-year); corresponding figures among 4348 angina patients were 59.7% (rate: 17.4/person-year) and 30.8% (rate: 5.3/person-year). Procedure rates decreased with decreasing levels of education. Comparing low to high education, angiography rates were 29% lower among AMI patients (adjusted HR = 0.71, 95% CI: 0.56-0.90) and 40% lower among angina patients (0.60, 0.47-0.76). Patterns were similar for revascularisation among those with angina (0.78, 0.61-0.99) but not AMI (0.93, 0.69-1.25). After adjustment for private health insurance status, the HRs were attenuated and there was little evidence of an association between education and angiography among those admitted for AMI.
There is a socioeconomic gradient in coronary procedures with the most disadvantaged patients being less likely to receive angiography following hospital admission for AMI or angina, and revascularisation procedures for angina. Unequal access to private health care contributes to these differences. The extent to which the remaining variation is clinically appropriate, or whether angiography is being underused among people with low socioeconomic position or overused among those with higher socioeconomic position, is unclear.
目前澳大利亚缺乏有关二级心血管疾病（CVD）治疗中社会经济差异的当代证据，而这种差异可能是心血管疾病结局不平等的一个促成因素。本研究旨在检验教育（个体社会经济地位的指标）与急性心肌梗死（AMI）或心绞痛住院后接受血管造影和血运重建术之间的关系，并探讨私人医疗保健在其中的作用。
新南威尔士州基于人群的 45 岁及以上研究（45 and Up Study）纳入了无既往缺血性心脏病住院史的≥45 岁参与者，随访其在入院后 30 天内接受血管造影或血运重建术的情况，通过链接的医院记录进行确定。基线调查中测量的教育程度分为低（无学校证书/资格）、中（学校证书/贸易/学徒/文凭）和高（大学学位）。Cox 回归估计了教育程度与接受冠状动脉治疗之间的关系（危险比 [HRs]），调整了人口统计学和健康相关因素，并检验了线性趋势。私人医疗保险被视为中介变量。
在 4454 名 AMI 患者中，68.3%的患者在入院后 30 天内接受了血管造影检查（粗率：25.8/人年），48.8%的患者接受了血运重建术（率：11.7/人年）；4348 名心绞痛患者中，相应的比例分别为 59.7%（率：17.4/人年）和 30.8%（率：5.3/人年）。治疗率随教育程度的降低而降低。与高教育程度相比，AMI 患者的血管造影治疗率低 29%（调整 HR=0.71，95%CI：0.56-0.90），心绞痛患者的血管造影治疗率低 40%（0.60，0.47-0.76）。对于心绞痛患者的血运重建术，模式相似（0.78，0.61-0.99），但 AMI 患者并非如此（0.93，0.69-1.25）。调整私人健康保险状况后，HR 值减弱，AMI 患者入院后接受血管造影检查的可能性与教育程度之间几乎没有关联。
在接受冠状动脉治疗方面存在社会经济梯度，最不利的患者在因 AMI 或心绞痛住院后，接受血管造影检查和心绞痛血运重建术的可能性较低。不平等地获得私人医疗保健是造成这些差异的原因之一。尚不清楚剩余的差异在多大程度上是临床适宜的，或者血管造影术在社会经济地位较低的人群中是否使用不足，或者在社会经济地位较高的人群中是否使用过度。
