Excess years of life lost to COVID-19 and other causes of death by sex, neighbourhood deprivation, and region in England and Wales during 2020: A registry-based study.

BACKGROUND: Deaths in the first year of the Coronavirus Disease 2019 (COVID-19) pandemic in England and Wales were unevenly distributed socioeconomically and geographically. However, the full scale of inequalities may have been underestimated to date, as most measures of excess mortality do not adequately account for varying age profiles of deaths between social groups. We measured years of life lost (YLL) attributable to the pandemic, directly or indirectly, comparing mortality across geographic and socioeconomic groups. METHODS AND FINDINGS: We used national mortality registers in England and Wales, from 27 December 2014 until 25 December 2020, covering 3,265,937 deaths. YLLs (main outcome) were calculated using 2019 single year sex-specific life tables for England and Wales. Interrupted time-series analyses, with panel time-series models, were used to estimate expected YLL by sex, geographical region, and deprivation quintile between 7 March 2020 and 25 December 2020 by cause: direct deaths (COVID-19 and other respiratory diseases), cardiovascular disease and diabetes, cancer, and other indirect deaths (all other causes). Excess YLL during the pandemic period were calculated by subtracting observed from expected values. Additional analyses focused on excess deaths for region and deprivation strata, by age-group. Between 7 March 2020 and 25 December 2020, there were an estimated 763,550 (95% CI: 696,826 to 830,273) excess YLL in England and Wales, equivalent to a 15% (95% CI: 14 to 16) increase in YLL compared to the equivalent time period in 2019. There was a strong deprivation gradient in all-cause excess YLL, with rates per 100,000 population ranging from 916 (95% CI: 820 to 1,012) for the least deprived quintile to 1,645 (95% CI: 1,472 to 1,819) for the most deprived. The differences in excess YLL between deprivation quintiles were greatest in younger age groups; for all-cause deaths, a mean of 9.1 years per death (95% CI: 8.2 to 10.0) were lost in the least deprived quintile, compared to 10.8 (95% CI: 10.0 to 11.6) in the most deprived; for COVID-19 and other respiratory deaths, a mean of 8.9 years per death (95% CI: 8.7 to 9.1) were lost in the least deprived quintile, compared to 11.2 (95% CI: 11.0 to 11.5) in the most deprived. For all-cause mortality, estimated deaths in the most deprived compared to the most affluent areas were much higher in younger age groups, but similar for those aged 85 or over. There was marked variability in both all-cause and direct excess YLL by region, with the highest rates in the North West. Limitations include the quasi-experimental nature of the research design and the requirement for accurate and timely recording. CONCLUSIONS: In this study, we observed strong socioeconomic and geographical health inequalities in YLL, during the first calendar year of the COVID-19 pandemic. These were in line with long-standing existing inequalities in England and Wales, with the most deprived areas reporting the largest numbers in potential YLL.

Racial Disparities in Management and Outcomes of Out-of-Hospital Cardiac Arrest Complicating Myocardial Infarction: A National Study From England and Wales.

BACKGROUND: Studies of racial disparities in care of patients admitted with an out-of-hospital cardiac arrest (OHCA) in the setting of acute myocardial infarction (AMI) have shown inconsistent results. Whether these differences in care exist in the universal healthcare system in United Kingdom is unknown. METHODS: Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. All patients were stratified based on ethnicity into a Black, Asian, or minority ethnicity (BAME) group vs a White group. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy. RESULTS: From 14,287 patients admitted with AMI complicated by OHCA, BAME patients constituted a minority of patients (1185 [8.3%]), compared with a White group (13,102 [91.7%]). BAME patients were younger (median age [interquartile range]) for BAME group, 58 [50-70] years; for White group, 65 [55-74] years). Cardiogenic shock (BAME group, 33%; White group, 20.7%; P < 0.001) and severe left ventricular impairment (BAME group, 21%; White group, 16.5%; P < 0.003) were more frequent among BAME patients. BAME patients were more likely to be seen by a cardiologist (BAME group, 95.9%; White group, 92.5%; P < 0.001) and were more likely to receive coronary angiography than the White group (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-1.88). The BAME group had significantly higher in-hospital mortality (OR 1.26, 95% CI 1.04-1.52) and re-infarction (OR 1.52, 95% CI 1.06-2.18) than the White group. CONCLUSIONS: BAME patients were more likely to be seen by a cardiologist and receive coronary angiography than White patients. Despite this difference, the in-hospital mortality of BAME patients, particularly in the Asian population, was significantly higher.

INTRODUCTION: Les études sur les inégalités raciales en matière de soins aux patients admis en raison d'un arrêt cardiaque hors de l'hôpital (ACHO) dans le cadre d'un infarctus aigu du myocarde (IAM) ont montré des résultats contradictoires. On ignore si ces différences en matière de soins existent dans le système de soins de santé universel de l'Angleterre. MÉTHODES: Les patients admis en raison d'un diagnostic d'IAM et d'ACHO entre 2010 et 2017 du Myocardial Ischaemia National Audit Project (MINAP) ont fait l'objet de l'étude. Nous avons réparti tous les patients selon l'origine ethnique dans le groupe BAME (de l'anglais Black, Asian and minority ethnic, c.-à-d. Noirs, Asiatiques ou d'une minorité ethnique) vs le groupe des Blancs. Nous avons utilisé les modèles multivariés de régression logistique pour évaluer les prédicteurs des résultats cliniques et la stratégie de traitement. RÉSULTATS: Parmi les 14 287 patients admis en raison d'un IAM compliqué par l'ACHO, les patients du BAME constituaient une minorité de patients (1 185 [8,3 %]) par rapport au groupe des Blancs (13 102 [91,7 %]). Les patients du groupe BAME étaient plus jeunes (âge médian [écart interquartile]), 58 [50-70] ans que le groupe des Blancs, 65 [55-74] ans). Le choc cardiogénique (groupe BAME, 33 %; groupe des Blancs, 20,7 %; P < 0,001) et l'insuffisance ventriculaire gauche grave (groupe BAME, 21 %; groupe des Blancs, 16,5 %; P < 0,003) étaient plus fréquents au sein des patients du BAME. Il était plus probable que les patients du BAME soient vus par un cardiologue (groupe du BAME, 95,9 %; groupe des Blancs, 92,5 %; P < 0,001) et qu'ils passent une angiographie coronarienne que le groupe des Blancs (ratio d'incidence approché [RIA] 1,5, intervalle de confiance [IC] à 95 % 1,2-1,88). Le groupe BAME avait une mortalité intrahospitalière (RIA 1,26, IC à 95 % 1,04-1,52) et une récidive d'infarctus (RIA 1,52, IC à 95 % 1,06-2,18) plus élevées que le groupe des Blancs. CONCLUSIONS: Il était plus probable que les patients du BAME soient vus par un cardiologue et qu'ils passent une angiographie coronarienne que les patients blancs. Malgré cette différence, la mortalité intrahospitalière des patients du BAME, particulièrement de la population asiatique, était significativement plus élevée.

Sex, Gender, and Equity in Cardiovascular Medicine, Surgery, and Science in Canada: Challenges, Successes, and Opportunities for Change.

BACKGROUND: A previous review of sex, gender, and equity within cardiovascular (CV) medicine, surgery, and science in Canada has revealed parity during medical and graduate school training. The purpose of this study was to explore sex and gendered experiences within the Canadian CV landscape, and their impact on career training and progression. METHODS: An environmental scan was conducted of the Canadian CV landscape, which included an equity survey using Qualtrics software. RESULTS: The environmental scan revealed that women remain underrepresented within CV training programs as trainees (12%-30%), program directors (33%), in leadership roles at the divisional level (21%), and in other professional or career-related activities (< 30%). Our analysis also showed improvements of career engagement at these levels of women at over time. The thematic analysis of the equity survey responses (n = 71 respondents; 83% female; 9.7% response rate among female Canadian Cardiovascular Society members) identified the following themes reported within the socio-ecological framework: desire to report inequities vs staying the course (individual level); desire for social support and mentorship and challenges of dual responsibilities (interpersonal level); concerns over exclusionary cliques and desire for respect and opportunity (organizational level); and increasing awareness and actions to overcome institutional barriers and accountability (societal level). CONCLUSIONS: Although women face challenges and remain underrepresented in CV medicine, surgery, and science, this study highlights potential opportunities for improving access of female medical, surgical, and research trainees and professionals to specialized cardiovascular training, career advancement, leadership, and research.

CONTEXTE: Une étude antérieure portant sur le sexe, le genre et l'équité en médecine, chirurgie et sciences cardiovasculaires (CV) au Canada a révélé une parité au cours de la formation médicale et des études supérieures. L'objectif de cette étude était d'évaluer les expériences liées au sexe et au genre dans le paysage canadien du domaine CV, et leur impact sur la formation et la progression de carrière. MÉTHODES: Une analyse de l'environnement du paysage canadien dans le domaine CV a été réalisée, incluant une étude sur l'équité en utilisant le logiciel Qualtrics. RÉSULTATS: L'analyse de l'environnement a révélé que les femmes restent sous-représentées dans les programmes de formation du domaine CV que ce soit en tant que stagiaires (12 à 30 %), directrices de programme (33 %), dans les rôles de direction au niveau divisionnaire (21 %) et dans d'autres activités professionnelles ou associées à la carrière (< 30 %). Notre analyse a également montré une amélioration de l'engagement professionnel des femmes à ces niveaux au fil du temps. L'analyse thématique des réponses à l'enquête sur l'équité (n = 71 répondants; 83 % de femmes ; 9,7 % de taux de réponse parmi les membres féminins de la Société canadienne de cardiologie) a permis de dégager les thèmes suivants au sein du système socioécologique : désir de signaler les inégalités par rapport à la volonté de maintenir cap précis (au niveau individuel); désir de soutien social et de mentorat et défis liés à la double responsabilité (au niveau interpersonnel); préoccupations concernant les cliques exclusives et désir de respect et d'opportunité (au niveau organisationnel); et sensibilisation et actions accrues pour surmonter les obstacles institutionnels et les niveaux de responsabilité (au niveau sociétal). CONCLUSIONS: Bien que les femmes soient confrontées à des défis et restent sous-représentées dans les domaines de la médecine, de la chirurgie et des sciences CV, cette étude met en évidence les possibilités d'améliorer l'accès des stagiaires féminines et des professionnelles de la médecine, de la chirurgie et de la recherche à la formation spécialisée en cardiologie, à l'avancement de carrière, au rôle de direction et à la recherche.

Clinical Decision Support to Reduce Contrast-Induced Kidney Injury During Cardiac Catheterization: Design of a Randomized Stepped-Wedge Trial.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is a common and serious complication of invasive cardiac procedures. Quality improvement programs have been associated with a lower incidence of CI-AKI over time, but there is a lack of high-quality evidence on clinical decision support for prevention of CI-AKI and its impact on processes of care and clinical outcomes. METHODS: The Contrast-Reducing Injury Sustained by Kidneys (Contrast RISK) study will implement an evidence-based multifaceted intervention designed to reduce the incidence of CI-AKI, encompassing automated identification of patients at increased risk for CI-AKI, point-of-care information on safe contrast volume targets, personalized recommendations for hemodynamic optimization of intravenous fluids, and follow-up information for patients at risk. Implementation will use cardiologist academic detailing, computerized clinical decision support, and audit and feedback. All 31 physicians practicing in all 3 of Alberta's cardiac catheterization laboratories will participate using a cluster-randomized stepped-wedge design. The order in which they are introduced to this intervention will be randomized within 8 clusters. The primary outcome is CI-AKI incidence, with secondary outcomes of CI-AKI avoidance strategies and downstream adverse major kidney and cardiovascular events. An economic evaluation will accompany the main trial. CONCLUSIONS: The Contrast RISK study leverages information technology systems to identify patient risk combined with evidence-based protocols, audit, and feedback to reduce CI-AKI in cardiac catheterization laboratories across Alberta. If effective, this intervention can be broadly scaled and sustained to improve the safety of cardiac catheterization.

Do stable non-ST-segment elevation acute coronary syndromes require admission to coronary care units?

BACKGROUND: Clinical practice guidelines recommend admitting patients with stable non-ST-segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two-thirds of patients are admitted to higher-acuity critical care units (CCUs). The outcomes of patients with stable NSTE ACS initially admitted to a CCU vs a cardiology ward with telemetry have not been described. METHODS: We used population-based data of 7,869 patients hospitalized with NSTE ACS admitted to hospitals in Alberta, Canada, between April 1, 2007, and March 31, 2013. We compared outcomes among patients initially admitted to a CCU (n=5,141) with those admitted to cardiology telemetry wards (n=2,728). RESULTS: Patients admitted to cardiology telemetry wards were older (median 69 vs 65years, P<.001) and more likely to be female (37.2% vs 32.1%, P<.001) and have a prior myocardial infarction (14.3% vs 11.5%, P<.001) compared with patients admitted to a CCU. Patients admitted directly to cardiology telemetry wards had similar hospital stays (6.2 vs 5.7days, P=.29) and fewer cardiac procedures (40.3% vs 48.5%, P<.001) compared with patients initially admitted to CCUs. There were no differences in the frequency of in-hospital mortality (1.3% vs 1.2%, adjusted odds ratio [aOR] 1.57, 95% CI 0.98-2.52), cardiac arrest (0.7% vs 0.9%, aOR 1.37, 95% CI 0.94-2.00), 30-day all-cause mortality (1.6% vs 1.5%, aOR 1.50, 95% CI 0.82-2.75), or 30-day all-cause postdischarge readmission (10.6% vs 10.8%, aOR 1.07, 95% CI 0.90-1.28) between cardiology telemetry ward and CCU patients. Results were similar across low-, intermediate-, and high-risk Duke Jeopardy Scores, and in patients with non-ST-segment myocardial infarction or unstable angina. CONCLUSIONS: There were no differences in clinical outcomes observed between patients with NSTE ACS initially admitted to a ward or a CCU. These findings suggest that stable NSTE ACS may be managed appropriately on telemetry wards and presents an opportunity to reduce hospital costs and critical care capacity strain.

Symptomatic graft failure and impact on clinical outcome after coronary artery bypass grafting surgery: Results from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry.

BACKGROUND: In contemporary coronary artery bypass graft (CABG) surgery, the association between symptomatic graft failure (GF) and long-term clinical outcome remains unclear. We sought to identify the clinical characteristics and outcomes of GF in symptomatic patients requiring cardiac catheterization within 1 year of CABG surgery. METHODS: Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease registry, 5,276 patients undergoing CABG surgery from September 2002 to August 2011 were identified. Clinical outcomes in patients with symptomatic GF were observed. Predictors of GF were analyzed at a graft level, whereas long-term survival was assessed at a patient level. A propensity score matching technique was used to adjust for baseline characteristics. RESULTS: Of our CABG cohort, 5.3% (281 patients [285 arterial and 653 vein grafts]) required symptom based coronary angiography within 1 year of CABG surgery. Acute coronary syndrome was the most common presentation (64.4%). At angiography, 27.0% (77/285) of arterial and 34.5% (225/653) of vein grafts were occluded. Respectively, arterial and vein GFs were treated as follows: percutaneous coronary intervention 61.0% versus 41.8%, re-do CABG 9.1% versus 0%, and medically without intervention 29.9% versus 58.2%. A strong trend toward reduced patient survival was noted with "arterial graft failure" (arterial ± vein GF) compared to "vein graft failure only" (no arterial GF) (adjusted hazard ratio 2.2, 95% CI 0.98-5.0, P = .056). CONCLUSION: Although the rate of cardiac catheterization within 1 year of CABG is infrequent, these patients exhibit high GF rates and commonly present with an acute coronary syndrome. In addition, "arterial graft failure" compared to "vein graft failure only" confers a higher risk of adverse long-term survival.

Temporal Trends in Percutaneous Coronary Intervention Appropriateness: Insights From the Clinical Outcomes Assessment Program.

BACKGROUND: It is unknown whether the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the use of PCI. METHODS AND RESULTS: We applied appropriate use criteria to determine the appropriateness of all 51 872 PCI performed in Washington State from 2010 through 2013. We evaluated the number of PCIs performed from 2006 through 2013 to provide a comparator period that preceded statewide appropriateness assessment beginning in 2010. Between 2010 and 2013, the overall number of PCI decreased by 6.8% (13 267 PCIs in 2010 to 12 193 in 2013) with a 43% decline in the number of PCIs for elective indications (3818 PCIs in 2010 to 2193 PCIs in 2013). The decline in the use of elective PCI was significantly larger after the onset of statewide PCI appropriateness assessment in 2010 (P=0.03). The proportion of elective PCIs classified as appropriate increased from 26% in 2010 to 38% in 2013, whereas the proportion of inappropriate PCIs decreased from 16% to 13% (P<0.001 for trends). Significant improvements in the proportion of inappropriate PCI were limited to the tertile of hospitals with the largest decline in PCIs classified as inappropriate (25% in 2010 to 12% in 2013; P=0.03). CONCLUSIONS: In Washington State, the use of PCI for elective indications has decreased over time with concurrent improvements in PCI appropriateness. However, improvements in PCI appropriateness were limited to a minority of hospitals. Understanding processes at these high-performing hospitals may inform efforts to improve PCI appropriateness.

Predicting cardiovascular intensive care unit readmission after cardiac surgery: derivation and validation of the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) cardiovascular intensive care unit clinical prediction model from a registry cohort of 10,799 surgical cases.

INTRODUCTION: In medical and surgical intensive care units, clinical risk prediction models for readmission have been developed; however, studies reporting the risks for cardiovascular intensive care unit (CVICU) readmission have been methodologically limited by small numbers of outcomes, unreported measures of calibration or discrimination, or a lack of information spanning the entire perioperative period. The purpose of this study was to derive and validate a clinical prediction model for CVICU readmission in cardiac surgical patients. METHODS: A total of 10,799 patients more than or equal to 18 years in the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry who underwent cardiac surgery (coronary artery bypass or valvular surgery) between 2004 and 2012 and were discharged alive from the first CVICU admission were included. The full cohort was used to derive the clinical prediction model and the model was internally validated with bootstrapping. Discrimination and calibration were assessed using the AUC c index and the Hosmer-Lemeshow tests, respectively. RESULTS: A total of 479 (4.4%) patients required CVICU readmission. The mean CVICU length of stay (19.9 versus 3.3 days, P <0.001) and in-hospital mortality (14.4% versus 2.2%, P <0.001) were higher among patients readmitted to the CVICU. In the derivation cohort, a total of three preoperative (age ≥ 70, ejection fraction, chronic lung disease), two intraoperative (single valve repair or replacement plus non-CABG surgery, multivalve repair or replacement), and seven postoperative variables (cardiac arrest, pneumonia, pleural effusion, deep sternal wound infection, leg graft harvest site infection, gastrointestinal bleed, neurologic complications) were independently associated with CVICU readmission. The clinical prediction model had robust discrimination and calibration in the derivation cohort (AUC c index = 0.799; Hosmer-Lemeshow P = 0.192). The validation point estimates and confidence intervals were similar to derivation model. CONCLUSIONS: In a large population-based dataset incorporating a comprehensive set of perioperative variables, we have derived a clinical prediction model with excellent discrimination and calibration. This model identifies opportunities for targeted therapeutic interventions aimed at reducing CVICU readmissions in high-risk patients.

Long-term survival with revascularization in South Asians admitted with an acute coronary syndrome (from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease Registry).

People of South Asian (SA) descent are particularly susceptible to acute coronary syndromes (ACS). Yet, little information exists regarding their overall prognosis. The purpose of this study was to compare short- and long-term clinical outcomes of SA and European Canadians admitted with an ACS. Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease registry, 63,393 patients with ACS were reviewed (January 1999 to March 2012). After excluding Chinese patients, 1,825 SAs were compared with 60,791 European Canadians. Both groups were propensity matched, and outcomes were compared. Adjustment was performed using a 3:1 propensity matching technique. Adjusted 30-day and 1-year mortality rates were similar between SA and European patients with ACS (2.6% vs 2.7%, p = 0.93; 5.0% vs 4.8%, respectively, p = 0.75). Repeat angiography did not differ (9.9% vs 9.2%, p = 0.35), yet repeat revascularization within 1 year was greater in SA patients (9.8% vs 7.6%, p <0.01). Improved long-term survival (median 64 months, interquartile range 66 months) was noted with SA patients (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.71 to 0.95). In particular, long-term survival was observed in SA patients receiving coronary artery bypass grafting (HR 0.75, 95% CI 0.52 to 1.08) and percutaneous coronary intervention (HR 0.75, 95% CI 0.59 to 0.96). In conclusion, SA patients treated with revascularization appear to have improved long-term survival after ACS, compared with European Canadians. As such, clinicians should be cognitive of ethnic-based outcomes when determining therapeutic strategies in patient management.

A multi-region assessment of population rates of cardiac catheterization and yield of high-risk coronary artery disease.

BACKGROUND: There is variation in cardiac catheterization utilization across jurisdictions. Previous work from Alberta, Canada, showed no evidence of a plateau in the yield of high-risk disease at cardiac catheterization rates as high as 600 per 100,000 population suggesting that the optimal rate is higher. This work aims 1) To determine if a previously demonstrated linear relationship between the yield of high-risk coronary disease and cardiac catheterization rates persists with contemporary data and 2) to explore whether the linear relationship exists in other jurisdictions. METHODS: Detailed clinical information on all patients undergoing cardiac catheterization in 3 Canadian provinces was available through the Alberta Provincial Project for Outcomes Assessment in Coronary Heart (APPROACH) disease and partner initiatives in British Columbia and Nova Scotia. Population rates of catheterization and high-risk coronary disease detection for each health region in these three provinces, and age-adjusted rates produced using direct standardization. A mixed effects regression analysis was performed to assess the relationship between catheterization rate and high-risk coronary disease detection. RESULTS: In the contemporary Alberta data, we found a linear relationship between the population catheterization rate and the high-risk yield. Although the yield was slightly less in time period 2 (2002-2006) than in time period 1(1995-2001), there was no statistical evidence of a plateau. The linear relationship between catheterization rate and high-risk yield was similarly demonstrated in British Columbia and Nova Scotia and appears to extend, without a plateau in yield, to rates over 800 procedures per 100,000 population. CONCLUSIONS: Our study demonstrates a consistent finding, over time and across jurisdictions, of linearly increasing detection of high-risk CAD as population rates of cardiac catheterization increase. This internationally-relevant finding can inform country-level planning of invasive cardiac care services.

Association of median household income with burden of coronary artery disease among individuals with diabetes.

BACKGROUND: Low income is associated with adverse cardiovascular outcomes. Diabetes is more prevalent among low income groups, and low income patients with diabetes have been shown to have a greater burden of cardiovascular risk factors and worse cardiovascular outcomes. The objective of this study was to determine whether income status was associated with burden of coronary atherosclerosis in patients with diabetes. METHODS AND RESULTS: All patients with diabetes presenting for cardiac catheterization between January 1, 2000, and December 31, 2002, in Calgary, Canada, were identified through the use of the Alberta Provincial Project for Assessing Outcomes in Coronary Heart Disease (APPROACH) database. This clinical database was merged with Canadian 2001 Census data on median household income per dissemination area using patient postal code data, and income quintiles were derived. Clinical profiles, severity of coronary atherosclerosis, and myocardial jeopardy were compared across income quintiles. Mean scores for severity and jeopardy were compared across income quintiles using analysis of variance. Multivariate linear regression was used to control for baseline differences across income groups. A total of 4596 patients were eligible for inclusion in this study. Clinical profiles differed significantly across income quintiles, with the highest income quintile being younger (P<0.0005), more likely to be male (P=0.029), and having a lower prevalence of smoking (P=0. 039). Low income groups were more likely to report a history of myocardial infarction (P<0.0005) or congestive heart failure (P<0.0005). The highest income groups has significantly less coronary atherosclerosis as measured by the weighted Duke index (6.67 versus 7.38, P<0.002), but there were no differences in lesion severity as measured by the Duke severity scale (2.31 versus 2.41, P=0.334). High income patients has significantly less myocardial jeopardy compared with the lowest income group as measured by the Duke and APPROACH scores (36.44 versus 46.23, P=0.0187, and 39.96 versus 45.36, P=0.0182, respectively). These differences remained significant even after controlling for baseline clinical differences in cardiovascular risk factor burden. CONCLUSIONS: Low income is associated with a greater degree of atherosclerosis and greater myocardial jeopardy in patients with diabetes. More needs to be done to reduce cardiovascular risk factor burden in this vulnerable population.

Effects of socioeconomic status on mortality after acute myocardial infarction.

PURPOSE: To assess the effects of socioeconomic status on mortality in patients with acute myocardial infarction. MATERIAL AND METHODS: We studied a retrospective cohort of 5622 patients who presented to a hospital emergency department with an initial episode of acute myocardial infarction between April 1998 and March 2002 in the Province of Alberta, Canada. Our main outcome measure was 1-year all-cause mortality following the index emergency department visit; we used socioeconomic status (measured by neighborhood median household income) as our main predictor after controlling for patient and hospital characteristics and revascularization. RESULTS: Socioeconomic status profoundly affected the rate of emergency department presentation and the process and outcome of acute myocardial infarction care. In patients belonging to the lowest versus the highest socioeconomic status quartile, the risk of presenting to the emergency department was 72% higher (P <.001); at 1 year, revascularization was lower (36% vs 48%, P <.001), and mortality higher (19.1% vs 9.1%, P <.001). Socioeconomic status was independently associated with 1-year mortality after adjustment for baseline characteristics and 1-year revascularization, and socioeconomic status was especially influential in non-revascularized patients. CONCLUSIONS: Given the influence of socioeconomic status on mortality after acute myocardial infarction and the key role of revascularization in modulating this relationship, our study has important implications for access to and process of cardiac care.

Effect of a prior authorization process on antiplatelet therapy and outcomes in patients prescribed clopidogrel following coronary stenting.

BACKGROUND: Alberta Blue Cross (ABC) provides copayment-based coverage for residents older than 65 years. A prior authorization (PA) process for patients prescribed clopidogrel following stent insertion was changed to an authorized prescriber (AP) list process in March 2002. OBJECTIVE: To determine the effect of a policy change in medication coverage for clopidogrel on patients' filling of prescriptions and outcomes following stent insertion. METHODS: Consecutive patients who received a coronary stent between September 1, 2001, and August 31, 2002, at the University of Alberta Hospital and were eligible for ABC coverage were identified. Data were obtained from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and ABC databases. RESULTS: One hundred twelve patients (45 in the PA period and 67 in the AP period) who received a coronary stent were eligible for ABC coverage during the study period. The two cohorts of patients were similar with respect to demographics. Fewer patients in the PA period than in the AP period had their prescription filled on the day of discharge (31% versus 54%; P=0.02), and the median time to fill was four days versus zero days in the PA and AP periods, respectively (Wilcoxon P=0.04). There was no significant difference in the proportion of patients filling their prescriptions after 28 days from discharge (67% versus 75%, P = not significant) or in the overall comparison of time to fill (log rank P=0.22). Two repeat revascularization procedures were necessary within six weeks after stent placement; both were in PA period patients who delayed or failed to fill their prescription. CONCLUSIONS: The PA process may have delayed patients filling clopidogrel prescriptions following hospital discharge and has the potential to contribute to negative clinical consequences.

Misclassification of income quintiles derived from area-based measures. A comparison of enumeration area and forward sortation area.

BACKGROUND: Census-based methods are often used to estimate socioeconomic status. We assessed the agreement between Forward Sortation Area (FSA) and Enumeration Area (EA) derived income levels for all patients undergoing cardiac catheterization in Alberta, Canada, from 1995-1998. METHODS: Income quintiles were calculated from census data for FSA and EA level. FSA- and EA-derived income measures were compared for misclassification. Both methods were then applied to the data to determine 4-year survival by income grouping in 21,446 patients following catheterization. RESULTS: The variability in EA-derived incomes for any given FSA-derived income is large. Only 40% of income quintiles are in agreement between the methods. For EA-based analyses, there is a linear relationship between higher income and lower mortality across all quintiles, while for FSA-based analyses, only the lowest income quintile had significantly higher mortality. DISCUSSION: Assuming that FSA-based methods are more likely to misclassify income compared to EA-based measures, the results for the FSA-based analyses are more likely to be erroneous. EA-derived measures should therefore be used when individual data are not available.