Abstract 43: Access to Care, Income, Education and Coronary Heart Disease Outcomes in the Reasons for Geographic and Racial Differences in Stroke Study

Abstract

Background: We have shown that individuals aged <65 years with the combination of low income (INC) and low education (EDU) are at high risk of coronary heart disease (CHD). Access to healthcare is often cited as a major contributor to this relationship, but few studies have examined these relationships for combinations of INC and EDU. We hypothesize that he association between INC+EDU categories and incident CHD is mediated by insurance status, rural residence, and living in a health professional shortage area (HPSA). Methods: We used data from 24,666 participants free of CHD at baseline in the national prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study of black and white participants aged > 45 years recruited between 2003-2007. Low INC (<$35,000) and low EDU (<high school graduation) were used to define four groups (Table column headings). Cox proportional hazards models examined the mediating effects of having health insurance, rural residence, and HPSA residence on the association between combinations of INC-EDU and CHD, stratified on age 65. Results: A total of 1,046 events occurred over mean follow-up 6.4±2.3 years. For those <65, low INC+EDU and low INC+high EDU were associated with higher risk for CHD (Table). In unadjusted models, HPSA residence was not significantly associated with CHD incidence for either younger or older participants, but having health insurance (HR 0.74 [95% CI 0.55-0.99]) and rural residence (HR 1.41 [95% CI 1.14-1.73]) were significantly associated with CHD for younger but not older participants. There was no evidence of mediation by access to care variables (Table). Conclusion: Access to care variables did not mediate the relationship between low INC, especially low INC+EDU, and CHD observed in younger REGARDS participants. Access to care as reflected in health insurance or rural or HPSA residence may not play a major role in the higher risk for CHD in middle aged adults living in low socioeconomic circumstances.