Neighborhood Socioeconomic Disadvantage and Care after Myocardial Infarction in the National Cardiovascular Data Registry

Jacob A. Udell, Nihar R. Desai, Shuang Li, Laine Thomas, James A de Lemos, Phyllis Wright-Slaughter, Wenying Zhang, Matthew T. Roe, Deepak L. Bhatt

Research output: Contribution to journalArticle

2 Citations (Scopus)

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.

Original languageEnglish (US)
Article numbere004054
JournalCirculation: Cardiovascular Quality and Outcomes
Volume11
Issue number6
DOIs
StatePublished - Jun 1 2018

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Registries
Myocardial Infarction
Social Class
Vulnerable Populations
Quality of Health Care
Guidelines
Hospital Mortality
Angiography
Insurance Coverage
Fibrinolysis
Censuses
Quality Improvement
Patient Care
Logistic Models
Hemorrhage
Mortality

Keywords

  • angiography
  • hospital mortality
  • myocardial infarction
  • percutaneous coronary intervention
  • risk factors
  • social class

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Neighborhood Socioeconomic Disadvantage and Care after Myocardial Infarction in the National Cardiovascular Data Registry. / Udell, Jacob A.; Desai, Nihar R.; Li, Shuang; Thomas, Laine; de Lemos, James A; Wright-Slaughter, Phyllis; Zhang, Wenying; Roe, Matthew T.; Bhatt, Deepak L.

In: Circulation: Cardiovascular Quality and Outcomes, Vol. 11, No. 6, e004054, 01.06.2018.

Research output: Contribution to journalArticle

Udell, Jacob A. ; Desai, Nihar R. ; Li, Shuang ; Thomas, Laine ; de Lemos, James A ; Wright-Slaughter, Phyllis ; Zhang, Wenying ; Roe, Matthew T. ; Bhatt, Deepak L. / Neighborhood Socioeconomic Disadvantage and Care after Myocardial Infarction in the National Cardiovascular Data Registry. In: Circulation: Cardiovascular Quality and Outcomes. 2018 ; Vol. 11, No. 6.
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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.",
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AU - Udell, Jacob A.

AU - Desai, Nihar R.

AU - Li, Shuang

AU - Thomas, Laine

AU - de Lemos, James A

AU - Wright-Slaughter, Phyllis

AU - Zhang, Wenying

AU - Roe, Matthew T.

AU - Bhatt, Deepak L.

PY - 2018/6/1

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N2 - 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.

AB - 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.

KW - angiography

KW - hospital mortality

KW - myocardial infarction

KW - percutaneous coronary intervention

KW - risk factors

KW - social class

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