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Multicenter Study
. 2023 Apr 4;329(13):1088-1097.
doi: 10.1001/jama.2023.1699.

Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries

Bruce E Landon  1   2 , Laura A Hatfield  1 , Pieter Bakx  3 , Amitava Banerjee  4   5 , Yu-Chin Chen  6 , Christina Fu  1 , Michal Gordon  7 , Renaud Heine  3 , Nicole Huang  6 , Dennis T Ko  8   9   10 , Lisa M Lix  11   12 , Victor Novack  6 , Laura Pasea  4 , Feng Qiu  2 , Therese A Stukel  9   13 , Carin Uyl-de Groot  3 , Lin Yan  11   12 , Gabe Weinreb  1 , Peter Cram  9   10   14
Affiliations
Multicenter Study

Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries

Bruce E Landon et al. JAMA. .

Abstract

Importance: Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries.

Objective: To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries.

Design, setting, and participants: Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data.

Exposures: Being in the top and bottom quintile of income within and across countries.

Main outcomes and measures: Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates.

Results: We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients.

Conclusions and relevance: High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Landon reported receiving speaking fees from CVS/Aetna for a topic unrelated to the current analysis; grants from the National Institute on Aging (NIA), the National Cancer Institute, and the Agency for Healthcare Research and Quality outside the submitted work and serving on the following boards without compensation: board of managers of Physician Performance LLC, the contracts and payments committee of Physician Performance LLC, the contracts and finance committee of the Beth Israel Lahey Performance Network, and the board of directors of Health Resources in Action. Dr Hatfield reported receiving grants from the National Institutes of Health (NIH) and personal fees from the American Medical Association. Dr Bakx reported receiving grants from the NIA. Dr Lix reported receiving grants from Harvard Medical School and subgrant funding with Harvard from the NIH. Dr Novack reported receiving personal fees from Cardiomed Consultants. Dr Yul-de Groot reported receiving grants from the NIA. Mr Weinreb reported receiving personal fees from McKinsey and Co. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Adjusted 30-Day and 1-Year Mortalitya
aAdjusted for age, sex, and comorbidity. bSee eTable 1 in Supplement 1 for definitions. STEMI indicates ST-elevation myocardial infarction; NSTEMI, non-STEMI.
Figure 2.
Figure 2.. Age- and Sex-Standardized Rates of Cardiac Catheterization, Percutaneous Coronary Intervention, and Coronary Artery Bypass Graft Surgery Within 90 Days of Admission
aSee eTable 1 in Supplement 1 for definitions. STEMI indicates ST-elevation myocardial infarction; NSTEMI, non-STEMI.
Figure 3.
Figure 3.. Age- and Sex-Standardized Rates of Length of Stay and 30-Day Readmissiona,b
aSee eTable 1 in Supplement 1 for definitions. bLength of stay was adjusted for age and sex; readmission rates were adjusted for age, sex, and comorbidity cSee eTable 1 in the Supplement 1 for definitions. STEMI indicates ST-elevation myocardial infarction; NSTEMI, non-STEMI.
See this image and copyright information in PMC

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