High Socioeconomic Status Patients Research Articles

Influence of Socioeconomic Status and Gender on Stroke Treatment and Diagnostics

Female patients and patients with a lower level socioeconomic status (SES) often experience less favorable health outcomes. We aimed to investigate whether gender and socioeconomic status of patients with acute ischemic stroke or transient ischemic attack are associated with different diagnostic and treatment strategies. The risk factors of interest were gender and SES. We predefined our diagnostic and treatment end points according to current stroke guidelines and used multivariate models to adjust for age, stroke severity, and comorbidities. A total of 2606 patients were included in the analysis. Women were less likely to receive antiplatelet agents within the first 48 hours after admission (OR: 0.59, 95% CI: 0.53 to 0.89) and more likely to have their blood glucose measured on admission than men (OR: 1.52, 95% CI: 1.1 to 2.1). With higher SES patients were more likely to receive a TTE or TTE during hospital stay. Women were almost twice as likely to receive a prescription for antidepressants at discharge OR of 1.96 (95% CI: 1.48 to 2.59). Socioeconomic status and gender are associated with some diagnostic and treatment differences of acute ischemic stroke. Most pronounced were a reduced chance for women to receive antiplatelet therapy on admission and a reduced chance for a TTE and TEE with a lower level of SES, whereas the rate of thrombolysis was unbiased by gender and SES.

Area socioeconomic status and mortality after coronary artery bypass graft surgery: The role of hospital volume

Individuals of low socioeconomic status (SES) have reduced access to coronary artery bypass graft surgery (CABG). It is unknown if low-SES CABG patients have reduced access to hospitals with better outcomes. We conducted a retrospective cohort analysis of the California CABG Mortality Reporting Program, consisting of individuals with zip code information who underwent CABG at participating hospitals in 1999-2000 (n = 18,961). Primary outcome measures were inhospital mortality after CABG; primary independent variables of interest were area-level SES, clinical risk factors, and hospital volume. We used 2-level hierarchical random-effects logit models to estimate the relationship between explanatory variables and inhospital mortality. Within high-volume hospitals, patients of low-SES areas had greater mortality than those of mid- and high-SES areas (2.5% vs 1.5% vs 1.8%, P = .024). However, there was no relationship between SES and mortality in lower-volume hospitals. Contrary to expectations, individuals of high-SES areas (42%) underwent surgery at low-volume hospitals more often than patients of low-SES areas (28%, P < .001), although mortality at low-volume hospitals was greater than that at high-volume facilities (P < .001). Discrepancies were not explained by distance traveled. Mortality after CABG is modified by both SES and hospital volume. Within high-volume hospitals, patients of low-SES areas fared worse than patients of higher-SES areas. Patients of high SES tended to have CABG surgery at low-volume hospitals where mortality was greater and therefore had higher mortality than expected.

Patients' beliefs about the causes of heart disease: relationships with risk factors, sex and socio-economic status

Patients' beliefs about the causes of their heart disease (causal attributions) are important to effective medical communication, psychological adaptation, and adherence to advice. We assessed the extent to which causal attributions relate to risk factors, sex and socio-economic status in men and women diagnosed with acute coronary syndrome. We conducted an interview and questionnaire study of 171 acute coronary syndrome patients assessed within 5 days of admission to three hospitals in the London area. Patients rated beliefs in the role of 16 factors in causing their heart disease. Associations between attributions and risk factors were assessed, and differences in beliefs by sex and socio-economic status (defined by educational attainment) analysed. The most common attributions were to stress, smoking, high blood pressure, chance or bad luck, and heredity. Attributions were strongly associated with risk factors: 90% of smokers attributed heart disease to smoking, compared with 0% never smokers; 90.4% of hypertensives attributed heart disease to high blood pressure, 72.2% of patients with a positive family history to heredity, 85% of obese patients to being overweight, and 49% of sedentary patients to lack of exercise. Attributions to stress were related both to current mood and reports of recent life stress. There were few sex differences, but higher socio-economic status patients were more likely to attribute heart disease to heredity and genetic factors. Causal beliefs about heart disease are strongly associated with risk factors. Effective communication about modifiable risk factors may influence causal beliefs and stimulate lifestyle change, thereby promoting secondary prevention.

Socioeconomic status, treatment, and outcomes among elderly patients hospitalized with heart failure: Findings from the National Heart Failure Project

Prior studies have reported conflicting findings concerning the association of socioeconomic status (SES), treatment, and outcomes in patients hospitalized with heart failure (HF). We conducted a retrospective analysis of medical record data from a national sample of Medicare beneficiaries hospitalized with HF between March 1998 and April 1999 (n = 25,086) to assess the association of patient SES, treatment, and outcomes. Patients' SES was designated as lower, lower-middle, higher-middle, and higher using residential ZIP code characteristics. Patients were evaluated for left ventricular systolic function assessment, prescription of angiotensin-converting enzyme inhibitors at discharge, readmission within 1 year of discharge, and mortality within 30 days and 1 year of admission. Hierarchical logistic regression models were used to assess the association of SES, quality of care, and outcomes adjusting for patient, physician, and hospital characteristics. Lower SES patients (relative risk [RR] 0.92, 95% CI 0.87-0.96) were modestly less likely to have had a left ventricular systolic function assessment, but had a similar adjusted likelihood of being prescribed angiotensin-converting enzyme inhibitors (RR 1.03, 95% CI 0.93-1.11) compared with higher SES patients after multivariable adjustment. Socioeconomic status was not associated with 30-day mortality after multivariable adjustment, but lower SES patients had a higher risk of 1-year mortality (RR 1.10, 95% CI 1.02-1.19) and readmission within 1 year of discharge (RR 1.08, 95% CI 1.03-1.12) compared with higher SES patients. Socioeconomic status in patients hospitalized with HF was not strongly associated with quality of care or 30-day mortality. However, the increased risk of 1-year mortality and readmission among patients of lower SES suggest SES may influence outcomes after hospitalization for HF.

STUDENTJAMA. Medical student care of indigent populations.

MEDICAL EDUCATION HAS LONG BEEN RELATED TO CARE OF the poor, especially in public hospitals, where medical education programs have traditionally provided treatment for indigent patients. While medical education now covers a range of clinical environments, poor patients still represent a significant number of those cared for in educational settings. For example, public teaching hospitals currently provide 3 times the amount of indigent care relative to their share of the overall hospital market. Students are also involved in a substantial number of community service programs, such as free clinics, that provide care for a growing population of uninsured patients. Poor patients have a greater number of negative outcomes than patients of higher socioeconomic status. Indigent patients have shorter hospital stays than patients with private insurance, and they are less likely to undergo highcost procedures when hospitalized. Circumstances such as unemployment, homelessness, or lack of means to pay for basic needs may lead clinicians to form negative judgments about patients’ social worth and may also reduce patients’ chances of benefiting from certain kinds of treatment. It is unclear whether indigent patients’ frequent exposure to trainees poses an additional risk to their health outcomes. Studies on outcomes of student care in the general population are rare as well; for example, 1 review noted that there are few empirical data about the risks of studentperformed procedures. Although outcomes data are scarce, it is well documented that medical students face ethical dilemmas during their education, as they mediate between their relative inexperience and the need to practice their clinical skills with patients. It remains unstudied whether such ethical conflicts occur more frequently with indigent patients, although this issue should be a topic of further evaluation. While the actual risks of medical students caring for indigent populations are largely unknown, there is some evidence suggesting that student involvement in indigent care potentially benefits both patients and students. Patients have reported that talking to medical students is helpful and that students often give more time than other members of the health care team. For students, involvement with the underserved in community clinics teaches them to give freely and also encourages activism as they become aware of the barriers to care that disadvantaged populations face. One study reported that a structured volunteer program in a homeless clinic during the first year of residency resulted in a significant increase in volunteer activities later in residency. Although another study reported that residents with a high level of prior exposure to underserved populations did not find public hospitals more desirable practice settings than other residents, this group reported feeling more prepared to treat substance abuse problems and human immunodeficiency virus infection, both of which are more prevalent among the indigent. These results suggest that students working with underserved patients can develop an increased awareness of the issues facing this population and feel more prepared to treat their specific health needs. It is important to note that regardless of prior exposure, women, underrepresented minorities, and international medical graduates have reported a greater preference for practicing in poor innercity settings than other trainees. Thus, in addition to prior experience, other factors may guide students’ future motivations in caring for the poor. It is likely that medical students will continue to care for indigent populations through both public teaching hospitals and community clinics. Further study can assess whether poor patients disproportionately serve as subjects of medical student procedures and whether their results are adverse as a result of medical student care. While medical students working with the poor appear to have greater understanding of issues within this population, future research should also focus on the degree to which these students care for such patients in their subsequent careers. Ultimately, this research can help determine whether student involvement with indigent patients can increase the future number of physicians dedicated to caring for this vulnerable population.

Cutaneous melanoma mortality among the socioeconomically disadvantaged in Massachusetts.

To identify groups for melanoma prevention and early detection programs, this study explored the hypothesis that survival with cutaneous melanoma is disproportionately lower for persons of lower socioeconomic status. Massachusetts Cancer Registry and Registry of Vital Records and Statistics data (1982 through 1987) on 3288 incident cases and 1023 deaths from cutaneous melanoma were analyzed. Mortality/incidence ratios were calculated and compared, predictors of late stage disease were examined with logistic regression analysis, and a proportional hazards regression analysis that used death registration as the outcome measure for incident cases was performed. Lower socioeconomic status was associated with a higher mortality/incidence ratio after adjustment for age and sex. For education, the mortality/incidence ratio was 0.37 in the lower group vs 0.25 in the higher group (rate ratio = 1.48, 95% confidence interval [CI] = 1.08, 2.03). Late stage disease was independently associated with lower income (rate ratio for lowest vs highest tertile = 1.64, 95% CI = 1.20, 2.25), and melanoma mortality among case patients was associated with lower education (rate ratio = 1.52, 95% CI = 1.09, 213). Melanoma patients of lower socioeconomic status may be more likely to die from their melanoma than patients of higher socioeconomic status. Low- SES communities may be appropriate intervention targets.

Is general practitioner decision making associated with patient socio-economic status?

This paper presents a preliminary exploration into the relationship between decisions made by general practitioners (GPs) and the socio-economic status (SES) of patients. There is a large literature on the association between SES, health state and the use of health services, but relatively little has been published on the association between SES and decisions by clinicians once a patient is in the health system. The associations between GP decision making and the patient's SES, health status, gender and insurance status are examined using logit analysis. Three sets of binary choices are analysed: the decision to follow up; to prescribe; and to perform or to order a diagnostic test. Secondary data on consultations for a check up/examination were used to explore these relationships. The results suggest that SES is associated independently with the decision to test and the decision to prescribe but not with the decision to follow up. Patients of high SES are, ceteris paribus, more likely to be tested and less likely to receive a prescription compared with patients of low SES. Women are more likely to be tested and to receive a prescription than men. These findings have implications for the pursuit of equity as a goal of health services policy.

The impact of socioeconomic status on the intensity of ambulatory treatment and health outcomes after hospital discharge for adults with asthma.

To examine whether differences in intensities of care by socioeconomic status and race result in worse health among adults with asthma post-hospital discharge. Patients were enrolled during hospitalization and recontacted three months after discharge. Those aged 18-55 years, with a primary diagnosis of asthma (n = 97). Regular source of care, "intensive" therapy (use of an anti-inflammatory agent, pulmonary function testing, or an asthma specialist), and patient-reported (Intermediate Activities of Daily Living Scale [IADL] score, dyspnea) and performance-based (peak flow rate) measures of health status post-discharge. 28% of patients with a yearly income less than $16,000 had no regular source of care, compared with 11% of those with an income from $16,000 to $29,999 and no patient with an income of at least $30,000 (p = 0.003). Similarly, intensive therapy was received by 40%, 67%, and 81% of these groups (p = 0.005). Education had similar associations. Patients with no regular source of care or who did not receive intensive therapy had significantly worse health. Patients of lower socioeconomic status had health outcomes that were up to 25% lower than those of patients of higher socioeconomic status (p < 0.05 for differences in LADL score, dyspnea, and peak flow by educational levels and for differences in dyspnea by income levels), after adjustment for age, gender, race, insurance status, and baseline health. After further adjustment for source of care and intensity of therapy, differences in health outcomes by socioeconomic status uniformly decreased in magnitude and only the differences in LADL scores and dyspnea by educational levels remained statistically significant. Although nonwhite patients were less likely to have a regular source of care or to receive intensive therapy, there was no difference in health outcomes by race. Patients of lower socioeconomic status who have asthma have worse health outcomes post-hospital discharge, which appear to be due in part to less continuous and less intensive treatment.

The association between socio-demographic variables and endometriosis in relation to other pelvic pathology and to pain reporting

SummaryMultidimensional scalogram analysis was used to gain a clearer understanding of the association between sociodemographic variables and the occurrence of endometriosis in relation to pelvic pain of other origins and the relation of such variables to pain reporting in these two groups. In contrast to previous findings, there were no socio-demographic factors distinctive of endometriosis. Endometriosis patients of higher socioeconomic status and higher educational level are more likely to report premenstrual tension, earlier pain onset, pain of longer duration and intensity which has increased with age, although their endometriosis is more likely to be minimal or mild. This pattern was not evident for other pelvic pain patients, suggesting that the results obtained with endometriosis patients do not just reflect reporting bias but are a specific feature of endometriosis.

Racial and Socioeconomic Aspects of Myocardial Infarction Recovery: Studying Confounds

Cardiovascular disease rates illustrate the excess morbidity and mortality associated with race and social class. However, while prevalence and deaths from heart disease are greater among black and lower socioeconomic status (SES) populations, researchers rarely consider possible confounds between race and SES. In a longitudinal study of 246 older myocardial infarction (MI) patients, differences appeared in both morbid events and death for black and lower SES patients. Simultaneous comparison of race and SES showed significantly different outcomes among black low SES, black high SES, white low SES, and white high SES patients that confirmed the predicted ranking of these groups. Low SES black subjects ranked last in physical functioning and cardiac symptomatology, whereas high SES white subjects ranked first in preventive health opportunities. We also considered the potential race-SES confound as an interaction term in multiple regression analysis, and three recovery outcomes were significantly predicted by the joint effects of these variables. These findings demonstrate that failure to consider SES of black and white patients jointly, as well as individually, can lead to erroneous conclusions about health.

Do the Poor Cost More? A Multihospital Study of Patients' Socioeconomic Status and Use of Hospital Resources

There is controversy about whether hospitalized poor patients use more resources and whether hospitals that provide care for the poor therefore merit supplementary payment under per-case prospective payment systems. We previously reported that patients of low socioeconomic status with connective-tissue disease had longer hospital stays and higher costs than patients of higher socioeconomic status at a single hospital. To examine the generalizability of this phenomenon, we interviewed 16,908 (83 percent) of 20,278 consecutive adult patients (excluding obstetrical and psychiatric patients) admitted in 1987 to five Massachusetts hospitals, to obtain information on three direct measures of socioeconomic status (income, occupation, and education). We divided each measure into three strata. Thus, there were 15 comparisons--three measures of socioeconomic status applied to each of five hospitals. After excluding outliers and adjusting for diagnosis-related group (DRG), we found that the patients of the lowest socioeconomic status had hospital stays 3 to 30 percent longer than those of patients of higher status, the differences varying with the hospital and the indicator of socioeconomic status (P less than or equal to 0.05 for 11 of the 15 comparisons). Hospital charges were 1 to 18 percent higher for the patients of lowest socioeconomic status than for those of higher status (P less than or equal to 0.05 for 9 of 15 comparisons). When we adjusted for age, severity of illness, and DRG, the patients of lowest socioeconomic status had longer stays than those of higher status in 14 of 15 comparisons (P less than 0.05 for 7 of the 15) and higher charges in 13 of 15 comparisons (P less than 0.05 for 6 of the 15). The differences between patients of high and low status ranged up to 21 percent for length of stay and 13 percent for charges. Our findings suggest that hospitalized patients of lower socioeconomic status have longer stays and probably require more resources. Supplementary payments to hospitals for the treatment of poor patients merit further consideration.

The role of socio-economic status and place of residence in total hip replacement.

The influence of socio-economic status and place of residence on walking ability, performance of daily activities and the aid required in these activities were evaluated among 539 total hip replacement (THR) patients. The walking ability of patients of higher socioeconomic status and of urban origin was better than that of patients of lower socio-economic status and of rural origin, both before and after THR. There were no significant interclass differences in the improvement in walking ability. The same pattern was valid as regards preoperative and postoperative performance of daily activities and the need for assistance. Neither socio-economic status nor place of residence had any significant influence on the improvement in the performance of daily activities or on the decrease in use of an aid. Earlier total hip replacement is recommended for patients of lower socio-economic status and for those living in rural areas.

ACQUISITION OF ANTIBODY TO HEPATITIS B ANTIGEN IN THREE SOCIOECONOMICALLY DIFFERENT MEDICAL POPULATIONS

Sera from three socioeconomically distinct, age-stratified, patient populations were tested for antibody to hepatitis B antigen (anti-HBAg) by a sensitive radioimmunoassay procedure. Patients who were drug users or had overt liver disease were excluded from the sample. The populations studied were: admissions to Harlem Hospital, a municipal hospital serving a low socioeconomic status Black population; admissions to Staten Island Hospital, a voluntary hospital, serving a middle socioeconomic class White population; and consecutive patients of high socioeconomic status seen in a Park Avenue internist's practice. A population of former drug addicts was also studied. The frequency of anti-HBAg was, in general, directly related to the age and inversely related to the socioeconomic status of the individuals studied. Little antibody was acquired before 20 years of age; between 20 and 50 years there was a striking rise, with no increase thereafter. By the age of 50, antibody was present in 43% of patients from Harlem, in 22% of patients from Staten Island, and 15% of the Park Avenue patients. Antibody was found in 52% of former drug addicts. Exposure to HBAg seemed to be widespread in the Harlem population, less so on Staten Island, and even less so in affluent predominantly White patients. The antibody-acquisition curve differed from that of most fæcal/ orally transmitted viral diseases. These findings suggest that the virus of hepatitis B is endemic in low socioeconomic populations and that it is probably spread, in part, by non-parenteral (or inapparent parenteral) means.

Private practice among general practitioners in the English National Health Service.

Data are presented on correlates of “some private practice” among a national sample of general practitioners working in the National Health Service in England and Wales. Doctors more likely to have private patients entered practice prior to the National Health Service, have patients of higher socioeconomic status, and are most likely to practice in smaller communities and in the Southern Region of the country. Doctors with private patients are likely to have higher social status origins, to have a smaller number of patients to care for, to have greater access to hospital facilities, and to adopt more modern procedures in their practices. The data suggest that the modest extent of private practice that presently exists is, in all likelihood, a product of limited consumer demand rather than an unwillingness on the part of younger general practitioners to take on private patients.