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Abdel-Qadir H, Akioyamen LE, Fang J, Pang A, Ha AC, Jackevicius CA, Alter DA, Austin PC, Atzema CL, Bhatia RS, Booth GL, Johnston S, Dhalla I, Kapral MK, Krumholz HM, McNaughton CD, Roifman I, Tu K, Udell JA, Wijeysundera HC, Ko DT, Schull MJ, Lee DS. Association of Neighborhood-Level Material Deprivation With Atrial Fibrillation Care in a Single-Payer Health Care System: A Population-Based Cohort Study. Circulation 2022; 146:159-171. [PMID: 35678171 PMCID: PMC9287095 DOI: 10.1161/circulationaha.122.058949] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care. METHODS This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply. RESULTS Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]). CONCLUSIONS Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.
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Affiliation(s)
- Husam Abdel-Qadir
- Women’s College Hospital, Toronto, Canada (H.A.-Q., J.A.U.)
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Leo E. Akioyamen
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Jiming Fang
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
| | - Andrea Pang
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
| | - Andrew C.T. Ha
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Cynthia A. Jackevicius
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Western University of Health Sciences, Pomona, CA (C.A.J.)
| | - David A. Alter
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Peter C. Austin
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Clare L. Atzema
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - R. Sacha Bhatia
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Gillian L. Booth
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Canada (G.L.B., I.D.)
| | - Sharon Johnston
- Departments of Family Medicine, University of Ottawa, Ottawa, Canada (S.J.)
- Institu du Savoir, Hôpital Montfort‚ Ottawa, Canada (S.J.)
| | - Irfan Dhalla
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Canada (G.L.B., I.D.)
| | - Moira K. Kapral
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.)
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Candace D. McNaughton
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - Idan Roifman
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - Karen Tu
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Family and Community Medicine (K.T.), University of Toronto, Toronto‚ Canada
- North York General Hospital, Toronto, Canada (K.T.)
| | - Jacob A. Udell
- Women’s College Hospital, Toronto, Canada (H.A.-Q., J.A.U.)
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Harindra C. Wijeysundera
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - Dennis T. Ko
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - Michael J. Schull
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - Douglas S. Lee
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
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