Educational level and 30-day outcomes after hospitalization for acute myocardial infarction in Italy

Abstract

Background: There is a growing interest in the factors that influence short-term mortality and readmission after hospitalization for acute myocardial infarction (AMI) since such outcomes are commonly considered as hospital performance measures. Socioeconomic status (SES) is one of the factors contributing to healthcare outcomes after hospitalization for AMI. However, no study has been published on education and 30-day readmission in Europe. The objective of this study is to examine the association between educational level and 30-day mortality and readmission among patients hospitalized for AMI in Tuscany (Italy).

Methods: A retrospective cohort study using data from hospital discharge records was conducted. The analysis included all patients discharged with a principal diagnosis of AMI between January 1, 2011, and November 30, 2014, from all hospitals in Tuscany. Educational level was categorized as low (no middle school diploma), mid (middle school diploma) and high (high school diploma or more). Three multilevel models were developed, sequentially controlling for patient-level socio-demographic and clinical variables and hospital-level variables. Patients were stratified by age (≤75 and >75 years).

Results: Mortality analysis included 23,402 patients, readmission analysis included 22,181 patients. In both unadjusted and full-adjusted models, patients with a high education had lower odds of 30-day mortality compared to those patients with low education (OR age ≤ 75 years 0.67, 95% CI:0.47-0.94; OR age > 75 years 0.72, 95% CI:0.54-0.95). With regard to 30-day readmission, only patients aged over 75 years with a high education had lower odds of short-term readmission compared to those patients with low education (OR age > 75 0.73, 95% CI:0.58-0.93).

Conclusions: Among patients hospitalized in Tuscany for AMI, low levels of education were associated with increased odds of 30-day mortality for both age groups and increased odds of 30-day readmission only for patients aged over 75 years. Our findings suggest that the educational component should not be underestimated in order to improve short-term outcomes, which are considered as performance measures at the hospital level. Hospital managers might consider strategies that are sensitive to patients with low SES, such as providing post-hospitalization support to less-educated patients and promoting a healthier lifestyle, to improve both health equity and performance outcomes.

Keywords: Acute myocardial infarction; Education; Health care outcomes; Health equity; Health services research; Hospital performance; Italy; Short-term mortality; Short-term readmission; Socioeconomic status.

Fig. 1

AMI Cohort exclusions in the January 2012-November 2014 Dataset

Fig. 2

Odds ratios (95% CIs) for 30-day mortality. Legend: Odds ratios and 95% confidence intervals reported from multilevel logistic regressions for 30-day mortality. Low education is the reference category, which is compared with mid education and high education. Model 3 = model adjusted for patients’ age, sex, and clinical characteristics, and for hospital characteristics. Results are reported for patients aged both under and over 75 years

Fig. 3

Odds ratios (95% CIs) for 30-day readmission. Legend: Odds ratios and 95% confidence intervals reported from multilevel logistic regressions for 30-day readmission. Low education is the reference category, which is compared with mid education and high education. Model 3 = model adjusted for patients’ age, sex, and clinical characteristics, and for hospital characteristics. Results are reported for patients aged both under and over 75 year