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Persistent Socio-economic Differences in Revascularization After Acute Myocardial Infarction Despite a Universal Health Care System—A Danish Study

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Abstract

Background

Use of invasive revascularization [percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)] after acute myocardial infarction (AMI) in Denmark increased between 1996 and 2004. We investigated how this affected socioeconomic differences in their use.

Materials and methods

All patients aged 30–74 years in hospital for a first AMI in Denmark between 1996 and 2004 were included. Cox proportional hazard models were used to estimate the association between individual income (tertiles) and education (>12, 10–12 and <10 years) and time to revascularization within 6 months. Revascularization was stratified into CABG, acute PCI (within 2 days of admission) and non-acute PCI (after the third day).

Results

A total of 38,803 patients were included. In 1996–1998, 6.8% received CABG, 9.3% non-acute PCI and 2.4% acute PCI; in 2002–2004, these numbers were 11.8, 36.1 and 29.1%. CABG was more likely to be performed for patients with a high income [hazard ratio (HR), 1.18; 95% confidence interval (CI), 1.08–1.28] or a medium income (HR, 1.16; 95% CI, 1.07–1.25) than for those with a low income throughout the period. A similar income gradient was seen for non-acute PCI, but not for acute PCI, for which no gradient was seen. No educational gradient was found for CABG, and that for non-acute and acute PCI decreased during the period; by the end of the period, more patients with low than high education received acute PCI.

Conclusion

In the universal health care system of Denmark, income differences in CABG and non-acute PCI persisted, whereas no such differences were seen for acute PCI.

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References

  1. Rasmussen JN, Rasmussen S, Gislason GH, et al. Mortality after acute myocardial infarction according to income and education. J Epidemiol Community Health 2006;60:351–6.

    Article  PubMed  Google Scholar 

  2. Alter DA, Chong A, Austin PC, et al. Socioeconomic status and mortality after acute myocardial infarction. Ann Intern Med 2006;144:82–93.

    PubMed  Google Scholar 

  3. Tillin T, Forouhi NG, Davey-Smith G, McKeigue PM, Chaturvedi N. Cardiovascular disease mortality in relation to childhood and adulthood socio-economic markers in British South Asian men. Heart 2007; Jul 23:DOI 10.1136/hrt.2006.109165.

  4. Kanjilal S, Gregg EW, Cheng YJ, et al. Socioeconomic status and trends in disparities in 4 major risk factors for cardiovascular disease among US adults, 1971–2002. Arch Intern Med 2006;166:2348–55.

    Article  PubMed  Google Scholar 

  5. Alter DA, Iron K, Austin PC, Naylor CD, SESAMI Study Group. Influence of education and income on atherogenic risk factor profiles among patients hospitalized with acute myocardial infarction. Can J Cardiol 2004;20:1219–28.

    PubMed  Google Scholar 

  6. Osler M, Gerdes LU, Davidsen M, et al. Socioeconomic status and trends in risk factors for cardiovascular diseases in the Danish MONICA population, 1982–1992. J Epidemiol Community Health 2000;54:108–13.

    Article  PubMed  CAS  Google Scholar 

  7. Rasmussen JN, Gislason GH, Rasmussen S, et al. Use of statins and beta blockers after acute myocardial infarction according to income and education. J Epidemiol Community Health 2007; Dec:DOI 10.1136/jech.2006.055525.

  8. Coory M, Scott IA, Baade P. Differential effect of socioeconomic status on rates of invasive coronary procedures across the public and private sectors in Queensland, Australia. J Epidemiol Community Health 2002;56:233–4.

    Article  PubMed  CAS  Google Scholar 

  9. Alter DA, Naylor CD, Austin P, Tu JV. Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction. N Engl J Med 1999;341:1359–67.

    Article  PubMed  CAS  Google Scholar 

  10. Pilote L, Joseph L, Belisle P, Penrod J. Universal health insurance coverage does not eliminate inequities in access to cardiac procedures after acute myocardial infarction. Am Heart J 2003;146:1030–7.

    Article  PubMed  Google Scholar 

  11. Hetemaa T, Keskimaki I, Manderbacka K, Leyland AH, Koskinen S. How did the recent increase in the supply of coronary operations in Finland affect socioeconomic and gender equity in their use? J Epidemiol Community Health 2003;57:178–85.

    Article  PubMed  CAS  Google Scholar 

  12. Hetemaa T, Manderbacka K, Reunanen A, Koskinen S, Keskimaki I. Socioeconomic inequities in invasive cardiac procedures among patients with incident angina pectoris or myocardial infarction. Scand J Public Health 2006;34:116–23.

    Article  PubMed  Google Scholar 

  13. Ancona C, Agabiti N, Forastiere F, et al. Coronary artery bypass graft surgery: socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy. J Epidemiol Community Health 2000;54:930–5.

    Article  PubMed  CAS  Google Scholar 

  14. Picciotto S, Forastiere F, Stafoggia M, et al. Associations of area based deprivation status and individual educational attainment with incidence, treatment, and prognosis of first coronary event in Rome, Italy. J Epidemiol Community Health 2006;60:37–43.

    Article  PubMed  Google Scholar 

  15. Haglund B, Köster M, Nilsson T, Rosén M. Inequality in access to coronary revascularization in Sweden. Scand Cardiovasc J 2004;38:334–9.

    Article  PubMed  Google Scholar 

  16. Manson-Siddle CJ, Robinson MB. Does increased investment in coronary angiography and revascularisation reduce socioeconomic inequalities in utilisation? J Epidemiol Community Health 1999;53:572–7.

    Article  PubMed  CAS  Google Scholar 

  17. Morris RW, Whincup PH, Papacosta O, Walker M, Thomson A. Inequalities in coronary revascularisation during the 1990s: evidence from the British regional heart study. Heart 2005;91:635–40.

    Article  PubMed  CAS  Google Scholar 

  18. Philbin EF, McCullough PA, DiSalvo TG, et al. Socioeconomic status is an important determinant of the use of invasive procedures after acute myocardial infarction in New York State. Circulation 2000;102:107III–115.

    Google Scholar 

  19. Austin P. Technological change around the world: evidence from heart attack care. Health Aff 2001;20:25–42.

    Article  Google Scholar 

  20. Videbaek J. Treatment of cardiovascular diseases. In: Videbaek J, Madsen M, editors. Heart statistics 2004. Copenhagen: Danish Heart Foundation and National Institute of Public Health; 2004. p. 177–241.

    Google Scholar 

  21. Van de WF, Ardissino D, Betriu A, et al. Management of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2003;24:28–66.

    Google Scholar 

  22. Madsen JK, Grande P, Saunamaki K, et al. Danish Multicenter Randomized Study of Invasive Versus Conservative Treatment in Patients with Inducible Ischemia After Thrombolysis in Acute Myocardial Infarction (DANAMI). Circulation 1997;96:748–55.

    PubMed  CAS  Google Scholar 

  23. Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003;349:733–42.

    Article  PubMed  Google Scholar 

  24. Christiansen T. Organization and financing of the Danish health care system. Health Policy 2002;59:107–18.

    Article  PubMed  Google Scholar 

  25. Ovretveit J. Nordic privatization and private healthcare. Int J Health Plann Manage 2003;18:233–46.

    Article  PubMed  Google Scholar 

  26. Andersen TF, Madsen M, Jorgensen J, Mellemkjoer L, Olsen JH. The Danish National Hospital Register. A valuable source of data for modern health sciences. Dan Med Bull 1999;46:263–8.

    PubMed  CAS  Google Scholar 

  27. Madsen M, Davidsen M, Rasmussen S, Abildstrom SZ, Osler M. The validity of the diagnosis of acute myocardial infarction in routine statistics: a comparison of mortality and hospital discharge data with the Danish MONICA registry. J Clin Epidemiol 2003;56:124–30.

    Article  PubMed  Google Scholar 

  28. Salomaa V, Niemela M, Miettinen H, et al. Relationship of socioeconomic status to the incidence and prehospital, 28-day, and 1-year mortality rates of acute coronary events in the FINMONICA myocardial infarction register study. Circulation 2000;101:1913–8.

    PubMed  CAS  Google Scholar 

  29. Rasmussen S, Zwisler AD, Abildstrom SZ, Madsen JK, Madsen M. Hospital variation in mortality after first acute myocardial infarction in Denmark from 1995 to 2002: lower short-term and 1-year mortality in high-volume and specialized hospitals. Med Care 2005;43:970–8.

    Article  PubMed  Google Scholar 

  30. Tu JV, Austin PC, Walld R, et al. Development and validation of the ontario acute myocardial infarction mortality prediction rules. J Am Coll Cardiol 2001;37:992–7.

    Article  PubMed  CAS  Google Scholar 

  31. Hetemaa T, Keskimaki I, Salomaa V, et al. Socioeconomic inequities in invasive cardiac procedures after first myocardial infarction in Finland in 1995. J Clin Epidemiol 2004;57:301–8.

    Article  PubMed  Google Scholar 

  32. Kleinbaum DG, Klein M. Competing risks survival analysis. Survival analysis: a self-learning text. 2nd ed. New York: Springer; 2005. pp. 391–462.

  33. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. Lancet 1999;354:708–15.

  34. Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001;344:1879–87.

    Article  PubMed  CAS  Google Scholar 

  35. Fox KA, Poole-Wilson PA, Henderson RA, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomized intervention trial of unstable angina. Lancet 2002;360:743–51.

    Article  PubMed  CAS  Google Scholar 

  36. Barnhart JM, Monrad ES, Cohen HW. Physicians’ perceptions of the effect of nonclinical factors on coronary revascularization. Heart Dis 2003;5:313–9.

    Article  PubMed  Google Scholar 

  37. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the management of patients with acute myocardial infarction). Circulation 2004;110:588–636.

    Article  PubMed  Google Scholar 

  38. Hemingway H, Crook AM, Feder G, et al. Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization. N Engl J Med 2001;344:645–54.

    Article  PubMed  CAS  Google Scholar 

  39. Alter DA, Naylor CD, Austin PC, Chan BTB, Tu JV. Geography and service supply do not explain socioeconomic gradients in angiography use after acute myocardial infarction. CMAJ 2003;168:261–4.

    PubMed  Google Scholar 

  40. Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA, Zaslavsky AM. Unmet health needs of uninsured adults in the United States. JAMA 2000;284:2061–9.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

The study was supported by the Danish Heart Foundation, grant no. 06-10-B19-A1234-22315F and by Denmark’s Ministry of Interior and Health.

Role of the funding source

The study sponsors had no involvement in the study design; in the collection, analysis, or interpretation of the data; in writing the report; or in the decision to submit the article for publication.

Conflict of interest

The authors declare no conflict of interest.

Author information

Authors and Affiliations

  1. National Institute of Public Health, Øster Farimagsgade 5A, 1399, Copenhagen K, Denmark

    Jeppe N. Rasmussen & Søren Rasmussen

  2. Department of Cardiovascular Medicine, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark

    Tina K. Schramm & Christian Torp-Pedersen

  3. Department of Cardiology, Gentofte University Hospital, Niels Andersens Vej 65, 2900, Hellerup, Denmark

    Gunnar H. Gislason & Steen Z. Abildstrom

  4. Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark

    Lars Køber

  5. Department of Epidemiology, Institute of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9B, 5000, Odense C, Denmark

    Merete Osler

  6. Department of Social Medicine, Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5B, P.O. Box 2099, 1014, Copenhagen K, Denmark

    Finn Diderichsen

  7. Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5B, P.O. Box 2099, 1014, Copenhagen K, Denmark

    Mette Madsen

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  1. Jeppe N. Rasmussen
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Correspondence to Jeppe N. Rasmussen.

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Rasmussen, J.N., Rasmussen, S., Gislason, G.H. et al. Persistent Socio-economic Differences in Revascularization After Acute Myocardial Infarction Despite a Universal Health Care System—A Danish Study. Cardiovasc Drugs Ther 21, 449–457 (2007). https://doi.org/10.1007/s10557-007-6058-7

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  • DOI: https://doi.org/10.1007/s10557-007-6058-7

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