Looking Beyond the Hospital to Reduce Acute Myocardial Infarction

Abstract

A large and growing body of evidence suggests that poverty is linked with lower life expectancy and, in particular, with higher mortality rates due to cardiovascular disease (CVD). 1,2 The causes are likely multifactorial: rates of cardiovascular risk factors tend to be higher in lower-income populations, opportunities to engage in healthier lifestyle behaviors are fewer, and access to high-quality cardiac health care is more limited. 3,4 Recognition of these issues has led to a variety of efforts in prevention, access to care, and quality of care to improve cardiovascular health, especially among populations such as the poor, who are at the highest risk for cardiovascular events and their attendant morbidity and mortality. In this issue of JAMA Cardiology, Spatz et al 5 provide encouraging information that these policies have had an impressive effect. In particular, they demonstrate that, over the past 15 years, rates of acute myocardial infarction (AMI) hospitalization and mortality in the Medicare population have decreased significantly and across all income groups. These impressive gains are tempered, however, by the finding that lower-income populations continue to have significantly higher AMI rates than their higher-income counterparts. For individuals who sustained an AMI, there were no significant differences in mortality rates by income at any point in the study period. These findings, although perhaps unexpected at first glance, can provide important insights into our successes in reducing the burden of AMI and its associated mortality and where our attention might next need to focus. The finding that mortality rates after AMI hospitalization declined during the study period confirms prior work 6 and extends this observation across income groups. This finding suggests that efforts to standardize and improve quality of care for AMI, both during the acute hospitalization for the event and after hospitalization, have had their intended effect. Furthermore, as some have posited should happen with quality improvement efforts, 7 it is likely that the increased standardization associated with performance measurement, reporting, and reward has led to a reduction in overall variability of care and its associated disparities in outcomes, such as those seen in lower-income populations. 8 The fact that AMI hospitalization rates, although also declining over time, continue to demonstrate disparities between low-and high-income counties, with rates of AMI hospitalization in this study approximately 20% higher in