Lower Socioeconomic Status Is Associated with Worse Outcomes in Pulmonary Arterial Hypertension

Abstract

Rationale: Lower socioeconomic status (SES) confers a heightened risk of common cardiovascular and pulmonary diseases and increased mortality. The association of SES with outcomes in patients with pulmonary arterial hypertension (PAH) is less clear. Objectives: To determine the association between SES and outcomes in patients with PAH. Methods: We performed a prospective cohort study at a national referral center for patients with PAH in China. Two hundred sixty-two consecutive incident patients aged 18 to 65 years with a diagnosis of idiopathic PAH were recruited between January 2007 and June 2011 and followed up until November 2011. The primary endpoint was all-cause mortality. An SES score for each patient was derived from their educational level, annual household income, occupation, and medical reimbursement rate. Measurements and Main Results: Patients with a lower SES had higher unadjusted mortality rates, with 3-year survival estimates of 50.1, 70.8, and 86.0% in increasing tertiles of SES (P for trend , 0.001). After adjustment for clinical features, hemodynamics, and type of PAH treatment, the hazard ratios for death were 2.98 (95% confidence interval, 1.51-5.89) in the lowest tertile of SES and 1.80 (95% confidence interval, 0.89-3.63) in the middle tertile of SES compared with the upper tertile (P for trend ¼ 0.006).Conclusions: A lower SES is strongly associated with a higher risk of death in idiopathic PAH. This association was independent of clinical characteristics, hemodynamics, and treatment. Addressing the health disparities associated with a lower SES may improve the outcomes of patients with PAH.Keywords: pulmonary arterial hypertension; socioeconomic status; survival Pulmonary arterial hypertension (PAH) is a disease of the small muscular pulmonary arteries characterized by a progressive rise in pulmonary artery pressure and pulmonary vascular resistance (PVR), ultimately resulting in right heart failure and death (1-3). Treatment for PAH includes anticoagulants, diuretics, prostanoids, phosphodiesterase 5 inhibitors, and endothelin receptor antagonists (ERAs) (3-5). Although survival may have improved, patients with PAH still have a greatly increased risk of death, even with approved treatments. Socioeconomic status (SES) is defined by education, income, occupation, and social status and refers to an individual's social standing relative to other members of a society (6). A low SES is associated with increased risks of cardiovascular and pulmonary disease and mortality (7-11). However, the association of SES with outcomes in PAH has not been well studied.Socioeconomic-related inequalities in health and healthcare have increased over recent decades in . Approximately 75 to 80% of individuals with low annual household incomes do not carry medical insurance (15), potentially greatly increasing the economic burden of PAH on patients. Wilkens and colleagues reported that each patient with PAH in Germany spends €47,400 per year on average, primarily due to drug costs (16,17). In the United States...

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