Abstract

BackgroundPerception of low subjective social status (SSS) relative to others in society or in the community has been associated with increased risk of cardiovascular disease. Our objectives were to determine whether low SSS in society was associated with barriers to access to care or hospital readmission in patients with established cardiovascular disease, and whether perceptions of discordantly high SSS in the community modified this association.MethodsWe conducted a prospective cohort study from 2009 to 2013 in Canada, United States, and Switzerland in patients admitted to hospital with acute coronary syndrome (ACS). Data on access to care and SSS variables were obtained at baseline. Readmission data were obtained 12 months post-discharge. We conducted multivariable logistic regression to model the odds of access to care and readmission outcomes in those with low versus high societal SSS.ResultsOne thousand ninety patients admitted with ACS provided both societal and community SSS rankings. The low societal SSS cohort had greater odds of reporting that their health was affected by lack of health care access (OR 1.48, 95% CI 1.11, 1.97) and of experiencing cardiac readmissions (1.88, 95% CI 1.15, 3.06). Within the low societal SSS cohort, there was a trend toward fewer access to care barriers for those with discordantly high community SSS though findings varied based on the outcome variable. There were no statistically significant differences in readmissions based on community SSS rankings.ConclusionLow societal SSS is associated with increased barriers to access to care and cardiac readmissions. Though attenuated, these trends remained even when adjusting for clinical and sociodemographic factors, suggesting that perceived low societal SSS has health effects above and beyond objective socioeconomic factors. Furthermore, high community SSS may potentially mitigate the risk of experiencing barriers to access to health care in those with low societal SSS, though these associations were not statistically significant. Subjective social status relative to society versus relative to the community seem to represent distinct concepts. Insight into the differences between these two SSS constructs is imperative in the understanding of cardiovascular health and future development of public health policies.

Highlights

  • Perception of low subjective social status (SSS) relative to others in society or in the community has been associated with increased risk of cardiovascular disease

  • Study population Study participants were from the GENESIS PRAXY (Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary Syndrome) prospective cohort study of patients hospitalized with acute coronary syndrome (ACS)

  • We considered two different approaches to create cohorts based on concordance and discordance in societal and community SSS rankings

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Summary

Introduction

Perception of low subjective social status (SSS) relative to others in society or in the community has been associated with increased risk of cardiovascular disease. Individuals with lower objective socioeconomic status (SES), such as those with lower income, lower educational attainment, or working in lower status occupations, consistently experience increased mortality, increased prevalence of coronary artery disease, and worse prognosis after an acute coronary syndrome (ACS) event relative to those with higher objective SES [1,2,3,4,5,6]. Because these disparities exist not just when comparing the rich versus the poor but along a gradient even among those with relatively high status [7], absolute material deprivation does not fully explain the disparities in outcomes. One cross-sectional study considers the combined effect of both ladder rankings on the prevalence of cardiovascular risk factors [17]

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