A recently published Canadian study suggests that our health care system may not be doing enough to direct cardiac care and promotional strategies to poor patients - the people who generally need these services the most (N Engl J Med 1999;341:1359-67).
Researchers with Ontario's Institute for Clinical Evaluative Sciences found that patients living in neighbourhoods with the highest average income received coronary angiography 23% more often and had 45% shorter waiting times for treatment than patients living in the lowest-income neighbourhoods. As well, each $10 000 step up in neighbourhood median income brought with it a 10% drop in the risk that a person would die within 1 year because of acute myocardial infarction (AMI). "Our findings raise the question: Could we as a system be doing a better job in reaching patients of lower socioeconomic status with health care and preventive strategies?" says Dr. David Alter, a cardiologist with Toronto's Sunnybrook and Women's College Health Sciences Centre.
The study followed 51 591 Ontario patients admitted to hospital for an AMI between April 1994 and March 1997. Researchers defined patients' socioeconomic status according to the average incomes of the communities where they lived. All data were adjusted for age, sex, severity of illness, specialty of the attending physician and hospital characteristics.
Alter says the results are evidence of real differences in the health status of patients that appear to be related to socioeconomic status. As such, they lend weight to findings of previous studies that there are disparities between classes in the prevalence of cardiac risk factors. "Why is that? Is it genetic? Or is it related to the way we deliver services and educate the public?" Psychosocial factors such as depression and job stress are also believed to cause worse outcomes for poorer or less educated people with coronary disease, although the precise mechanisms are not fully understood. "What's needed now is a study to address and disentangle all the different factors at play here," says Alter. "I suspect that when we finally do answer the 'why' question, we'll find it's not just diet, or just lifestyle, but rather a whole multitude of factors and how they interplay."