Geographic Variation in Trends and Disparities in Acute Myocardial Infarction Hospitalization and Mortality by Income Levels, 1999-2013

Abstract

Importance Over the last decade, acute myocardial infarction (AMI) incidence and mortality have decreased substantially. Yet it is unknown whether these improvements were consistent across communities of different economic status and geographic regions, for which efforts to improve cardiovascular disease prevention and management may have had variable impact. Objective To determine whether trends in county-level risk-standardized AMI hospitalization and mortality rates varied by county-based median income level. Design Observational study from 1999 to 2013. Setting National study of U.S. counties. Participants County-level risk-standardized (age, sex, race) hospitalization and 1-year mortality rates for AMI from 1999 to 2013 were measured for Medicare beneficiaries ≥65 years. Exposures Counties were stratified by median income percentile using 1999 U.S. Census Bureau data, adjusted for inflation: low (<25th), average (25–75th) or high (>75th) income groups. Main Outcome and Measure We examined the effect of income on the slope of AMI hospitalizations and mortality. We measured differences in rate of change in AMI hospitalizations and mortality by county income and by the 4 U.S. geographic regions. We also tested for a ‘lag’ effect among low-income counties. Results In the 15-year period, AMI risk-standardized hospitalization and mortality rates decreased significantly for all three county income groups. Average hospitalization rates were significantly higher among low-income counties compared with high-income counties, with rates for low-income counties in 2013 lower than for high-income counties in 1999 (853 versus 1,123 per 100,000 person years, respectively). 1-year mortality rates after hospitalization for AMI were similar across county income groups, decreasing from 1999 (31.5%, 31.4%, and 31.1%, for high, average and low income counties, respectively) to 2013 (26.2%, 26.1%, and 25.4%). The rate of decline in AMI hospitalizations was similar for all county income groups; however, low-income counties lagged behind high-income counties by 4.3 (95% CI 3.1 to 5.9) years. There were no differences in trends across geographic regions. Conclusion and Relevance AMI hospitalization and mortality rates declined among counties of all income levels, though hospitalization rates among low-income counties lag behind. These findings lend support for a more targeted community-based approached to AMI prevention.

Comparison of Readmission Rates After Acute Myocardial Infarction in 3 Patient Age Groups (18 to 44, 45 to 64, and ≥65 Years) in the United States

“…Income-related inequalities in AMI outcomes have also been previously suggested, particularly among elderly Medicare beneficiaries. 23,24 However, in the present study, the association between income and outcomes was more prominent in younger patients. Further, despite lower rates of health insurance in the young, observed differences in the income-readmission relation were not explained by differences in insurance status alone.…”

“…Further, despite lower rates of health insurance in the young, observed differences in the income-readmission relation were not explained by differences in insurance status alone. Although diminished access, poorer quality care, 24,25 as well as social challenges after AMI hospitalization may portend higher readmission risk in low-income patients, our study does not capture these elements of care quality. Therefore, future studies are needed to better understand the reason for these differences.…”

Cardiovascular burden and percutaneous interventions in Russian Federation: systematic epidemiological update

“…The socio-economic development in the Russian regions was not directly associated (a M-shaped light correlation) with the rates of CV mortality, but with a weak or moderate correlation with a level of poverty which was relevant to the previous findings (40,41) where the CV mortality was similar in U.S. counties of all income levels. The historic dynamics of the total death rates demonstrates the certain role of the socio-economic disasters for both total and CV mortality, for instance in 90s after the dissolution of the Soviet Union and a default of 1998 (25,28,30), but most probably it makes a sense exceptionally in case of the larger dramatic economic events with the pronounced impoverishment of the population and degradation of the social life with significant changes in a lifestyle which was previously confirmed in both MONICA and HAPIEE studies that observed different populations in the Eastern Europe (1,29,30).…”

“…The cost of MI and cerebrovascular event care in Russia is estimated at 7.6 billion U.S. dollars or 5.6 billion euros over 10 years (6)(7)(8)(9)(10)28,40,41 The small growth resulted in a falling world share in Russia from 3% to 2.1% (in clinical medicine 20% below the score world average of citation impact with a decline from a 0.7% global share or 5,946 papers annually to 0.62% or 6,219 manuscripts a year). Russia's production of highly cited papers over the decade closely resembles the record of India, both in quantity and trend, and like India seems unusually low for a nation with the scientific talent that it possesses most probably due to obvious general poverty of the science and drift of the articles to the Russian-speaking journals which remain uncited (partially cited in the Russian Science Index in cooperation with Thomson Reuters since 2015, but mostly in Russian language; a database of 8.7 million articles from 655 Russian journals published after 2006 which is less than 12.4% of the existing manuscripts) being beyond the international system (43,44).…”

“…It has grown significantly during the decade to a current level of around 25,000 p.a. with a less than 10% in health sciences despite the economic concerns (6)(7)(8)(9)(10)28,40,41).…”