Low-income people have an increased risk of death from heart attack in six health systems around the world

Low-income people have an increased risk of death from heart attack in six health systems around the world

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Despite vastly different health care systems, low-income patients in six different countries have 10-20% higher death rates than their high-income peers, according to a new study by Harvard researchers Medical School, University of Texas Medical Branch, Galveston, ICES (formerly Institute for Clinical Evaluative Sciences) and other international collaborators.

The results suggest that income-based disparities are present even in countries health care and strong social services, the researchers said. The article, published in the journal JAMAwas a project of the International Health System Research Collaborative, an effort dedicated to understanding the trade-offs inherent in different countries’ approaches to health care delivery.

“A country’s healthcare system can impact treatment and outcomes for specific health conditions, such as heart disease“said Bruce Landon, professor of health care policy at Harvard Medical School’s Blavatnik Institute.

“We wanted to determine whether the poorer outcomes seen among low-income Americans compared to high-income Americans were reduced in countries with universal health insurance. We found that higher-income people had better rates survival and were more likely to receive life-saving treatment compared to low-income people, regardless of country of residence or type of healthcare system.”

The authors analyzed population-based healthcare billing and claims data to study all adults aged 66 or older who were hospitalized for a type of heart attack called ST-segment elevation myocardial infarction (STEMI), which tends to be more severe and not ST-elevation myocardial infarction (NSTEMI).

Outcomes for low-income STEMI and NSTEMI patients were compared to outcomes for high-income patients in the United States, Canada (Ontario and Manitoba), England, the Netherlands, Taiwan and Israel between 2013 and 2018. The study included 289,376 patients hospitalized with STEMI and 843,046 patients hospitalized with NSTEMI.

The results showed that:

  • Mortality at 30 days after hospitalization was generally 1 to 3 percentage points lower in high-income patients. The greatest difference was observed in Canada (14.9% and 17.8% for high-income people compared to low-income people with STEMI)
  • One-year mortality differences were even larger, with the highest difference in Israel (16.2% and 25.3% for high-income versus low-income people with STEMI)
  • Low-income patients in all countries were less likely to receive necessary and aggressive treatments for STEMI, such as heart catheterization and revascularization, and hospital readmission rates were higher than for low-income patients
  • There were more women in the lowest income group than in the highest income group in all countries

Social risk factors and health care disparities

“These findings suggest that countries around the world need to redouble their efforts to ensure equitable care delivery for people of all socioeconomic statuses,” Landon said.

The authors noted that previous research has drawn attention to the relatively poor performance of the US healthcare system in delivering equitable care.

“Our analysis puts these past results in a different context by highlighting the consistency of these results across multiple developed countries with very different health care systems and contexts,” Landon said.

Although some of the differences in outcomes may be related to the cumulative consequences of social risk factors related to low income and other factors outside the health care system, the researchers noted that policy makers and providers in each of these countries also need to examine why low-income people are less likely to receive aggressive treatment than their peers.

For example, they suggest that additional efforts are needed to explore the availability and quality of hospital care in areas that serve low-income populations, which could affect a patient’s access to treatment.

Although the researchers took into account the possible effects of other diseases that the patients suffered from, it is still possible that other health-related factors influenced higher death rates and lower treatment rates for the patients. low income.

The authors caution that they did not adjust for race and ethnicity because these data were not available for all countries and populations included in the study. Additionally, all of the Americans in the study had health insurance, so it’s unclear whether the results might have been different if uninsured Americans had been included.

“Our results challenge the belief that income-based disparities are a uniquely American phenomenon. The truth is that the poverty penalty appears consistent across countries,” says lead author Peter Cram, associate researcher at the ‘ICES and the University of Texas. “All countries, including Canada, must address these issues and improve the delivery of health care to elderly patients who suffer severe heart attacks.”

More information:
Bruce E. Landon et al, Differences in treatment regimens and outcomes of acute myocardial infarction for low- and high-income patients in 6 countries, JAMA (2023). DOI: 10.1001/jama.2023.1699

Journal information:
Journal of the American Medical Association

Provided by Harvard Medical School

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