Abstract
BackgroundThe Medicare program provides universal access to hospital care for the elderly; however, mortality disparities may still persist in this population. The association of individual education and area income with survival and recurrence post Myocardial Infarction (MI) was assessed in a national sample.MethodsIndividual level education from the National Longitudinal Mortality Study was linked to Medicare and National Death Index records over the period of 1991-2001 to test the association of individual education and zip code tabulation area median income with survival and recurrence post-MI. Survival was partitioned into 3 periods: in-hospital, discharge to 1 year, and 1 year to 5 years and recurrence was partitioned into two periods: 28 day to 1 year, and 1 year to 5 years.ResultsFirst MIs were found in 8,043 women and 7,929 men. In women and men 66-79 years of age, less than a high school education compared with a college degree or more was associated with 1-5 year mortality in both women (HRR 1.61, 95% confidence interval 1.03-2.50) and men (HRR 1.37, 1.06-1.76). Education was also associated with 1-5 year recurrence in men (HRR 1.68, 1.18-2.41, < High School compared with college degree or more), but not women. Across the spectrum of survival and recurrence periods median zip code level income was inconsistently associated with outcomes. Associations were limited to discharge-1 year survival (RR lowest versus highest quintile 1.31, 95% confidence interval 1.03-1.67) and 28 day-1 year recurrence (RR lowest versus highest quintile 1.72, 95% confidence interval 1.14-2.57) in older men.ConclusionsDespite the Medicare entitlement program, disparities related to individual socioeconomic status remain. Additional research is needed to elucidate the barriers and mechanisms to eliminating health disparities among the elderly.
Highlights
The Medicare program provides universal access to hospital care for the elderly; mortality disparities may still persist in this population
Socioeconomic status (SES) has been associated with mortality and incident coronary heart disease [1,2,3], and the Medicare entitlement program seeks to mitigate some of these SES differentials by providing universal access to healthcare to US citizens aged 65 years or
An estimated 515,000 incident myocardial infarction (MI) cases occur in the US each year and with an average age >65 years, most are among the Medicare eligible population [6]
Summary
The Medicare program provides universal access to hospital care for the elderly; mortality disparities may still persist in this population. Socioeconomic status (SES) has been associated with mortality and incident coronary heart disease [1,2,3], and the Medicare entitlement program seeks to mitigate some of these SES differentials by providing universal access to healthcare to US citizens aged 65 years or chronic diseases [5]. Furthering our understanding of the role of area and individual SES on survival and recurrence post MI among Medicare beneficiaries may have significant public health impacts. Several international studies in locales with universal health care have found significant associations between area and/or individual socioeconomic traits with survival post MI [7,8,9,10,11,12]. In a large Medicare population, significant but modest associations were found for 30 day and 1 year mortality for beneficiaries residing in zip codes with the lowest median income [13], and in a Chicago based Medicare population, Medicaid recipients (defined as higher poverty status) in higher income zip codes did not have a survival benefit, while non-Medicaid recipients in zip codes with higher income had a lower mortality risk [14]
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