Education-related variation in coronary procedure rates and the contribution of private health care in Australia: a prospective cohort study

Veronica Hughes,Rosemary J Korda,Grace Joshy,Emily Banks,Ellie Paige,Jennifer Welsh

doi:10.1186/s12939-020-01235-y

Abstract

BackgroundContemporary 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.MethodsParticipants 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.ResultsAmong 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.ConclusionsThere 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.

Highlights

Contemporary Australian evidence on socioeconomic variation in secondary cardiovascular disease (CVD) care, a possible contributor to inequalities in cardiovascular disease outcomes, is lacking
There is a socioeconomic gradient in coronary procedures with the most disadvantaged patients being less likely to receive angiography following hospital admission for acute myocardial infarction (AMI) or angina, and revascularisation procedures for angina
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

Summary

Introduction

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. People of lower socioeconomic position are more likely to have a major secondary cardiovascular disease (CVD) event [7] and are more likely to die from the disease [8]. Understanding the reasons for these differences is crucial to improving outcomes for more disadvantaged groups and lowering the overall burden of the disease. Socioeconomic gradients in CVD events and mortality are likely to reflect, at least in part, differences in uptake and continuation with secondary prevention strategies, including coronary procedures [9, 10]. Angiography is performed as a diagnostic procedure and, where clinically indicated, revascularisation procedures are used to improve blood flow to the heart [11, 12]

Objectives

Methods

Results

Discussion

Conclusion