Education-related variation in coronary procedure rates and the contribution of private health care in Australia: a prospective cohort study

Abstract

Background Contemporary Australian evidence on socioeconomic variation in secondary cardiovascular disease (CVD) care, a possible contributor to inequalities in cardiovascular disease outcomes, is lacking. This study examined the relationship between education, an individual-level indicator of socioeconomic position, and receipt of angiography and revascularisation procedures following incident hospitalisation for acute myocardial infarction (AMI) or angina, and the role of private care in this relationship. Methods Participants aged ≥45 from the New South Wales population-based 45 and Up Study with no history of prior ischaemic heart disease hospitalised for AMI or angina were followed for receipt of angiography or revascularisation within 30 days of hospital admission, ascertained through linked hospital records. Education attainment, measured on baseline survey, was categorised as low (no school certificate/qualifications), intermediate (school certificate/trade/apprenticeship/diploma) and high (university degree). Cox regression estimated the association (hazard ratios [HRs]) between education and coronary procedure receipt, adjusting for demographic and health-related factors, and testing for linear trend. Private health insurance was investigated as a mediating variable. Results Among 4454 patients with AMI, 68.3% received angiography within 30 days of admission (crude rate: 25.8/person-year) and 48.8% received revascularisation (rate: 11.7/person-year); corresponding figures among 4348 angina patients were 59.7% (rate: 17.4/person-year) and 30.8% (rate: 5.3/person-year). Procedure rates decreased with decreasing levels of education. Comparing low to high education, angiography rates were 29% lower among AMI patients (adjusted HR = 0.71, 95% CI: 0.56–0.90) and 40% lower among angina patients (0.60, 0.47–0.76). Patterns were similar for revascularisation among those with angina (0.78, 0.61–0.99) but not AMI (0.93, 0.69–1.25). After adjustment for private health insurance status, the HRs were attenuated and there was little evidence of an association between education and angiography among those admitted for AMI. Conclusions There is a socioeconomic gradient in coronary procedures with the most disadvantaged patients being less likely to receive angiography following hospital admission for AMI or angina, and revascularisation procedures for angina. Unequal access to private health care contributes to these differences. The extent to which the remaining variation is clinically appropriate, or whether angiography is being underused among people with low socioeconomic position or overused among those with higher socioeconomic position, is unclear.

In-hospital outcomes by insurance type among patients undergoing percutaneous coronary interventions for acute myocardial infarction in New South Wales public hospitals

“…education) or insurance status [ 4 ]. Those disparities include increased use of angiography [ 15 ] presenting directly to PCI-capable hospitals and reduced time to reperfusion [ 43 ]. Other studies assessing disparities by indigenous status also highlighted that lack of private health insurance contributed to lower access to angiography and revascularisation procedures, [ 48 , 49 ] including a lower probability of being transferred to metropolitan hospitals for angiography [ 50 ].…”

“…In countries with highly privatised health systems, AMI inpatients with health insurance, compared with uninsured patients, have higher rates of revascularisation [ 12 ] and better outcomes such as shorter length of stay [ 12 ] and 30%-40% lower rates of in-hospital mortality [ 12 – 14 ], even after adjusting for patient demographic, socioeconomic and clinical characteristics. These differences likely reflect disparities in patient access to surveillance, preventive and hospital care, as well as physician preferences and incentives in performing procedures based on patient insurance status [ 7 , 10 , 15 ].…”