Transitions and inequalities in acute myocardial infarction mortality in New South Wales, 1969-94

Rural Inequalities in the Australian Burden of Ischaemic Heart Disease: A Systematic Review

OBJECTIVE

To summarise all available evidence on the differences in burden of ischaemic heart disease (IHD) between metropolitan and rural communities of Australia.

METHODS

Systematic review of peer-reviewed literature published between 1990 and 2014. Search terms were derived from the four major topics: (1) rural; (2) ischaemic heart disease; (3) Australia; and (4) burden of disease. Terms were adapted for six databases and two independent researchers screened results. Studies were included if they compared outcomes related to IHD in adults aged 18 years and over, between (at least) two areas of differing remoteness, at the same point in time.

RESULTS

Twenty studies were included and presented data collected between 1969 and 2010. Seventeen studies showed a clear disparity in IHD outcomes between major cities and regional and remote areas, with a consistently higher burden observed outside major cities. Among Aboriginal and Torres Strait Islander populations, fewer differences were observed and some IHD outcomes were not associated with remoteness.

CONCLUSIONS

Populations outside of major cities in Australia bear a disproportionately high burden of ill health due to IHD, yet the majority of the rural populations are yet to be investigated in terms of burden of disease outcomes from IHD.

IMPLICATIONS

Remoteness is a key determinant of IHD burden in Australia. The reasons for increased IHD burden in rural compared to metropolitan communities of Australia are poorly understood, which has implications for the design of targeted interventions to reduce geographical inequalities.

Marital history and survival after a heart attack

Heart disease is the leading cause of death in the United States and nearly one million Americans will have a heart attack this year. Although the risks associated with a heart attack are well established, we know surprisingly little about how marital factors contribute to survival in adults afflicted with heart disease. This study uses a life course perspective and longitudinal data from the Health and Retirement Study to examine how various dimensions of marital life influence survival in U.S. older adults who suffered a heart attack (n = 2197). We found that adults who were never married (odds ratio [OR] = 1.73), currently divorced (OR = 1.70), or widowed (OR = 1.34) were at significantly greater risk of dying after a heart attack than adults who were continuously married; and the risks were not uniform over time. We also found that the risk of dying increased by 12% for every additional marital loss and decreased by 7% for every one-tenth increase in the proportion of years married. After accounting for more than a dozen socioeconomic, psychosocial, behavioral, and physiological factors, we found that current marital status remained the most robust indicator of survival following a heart attack. The implications of the findings are discussed in the context of life course inequalities in chronic disease and directions for future research.

Geographical clustering of incident acute myocardial infarction in Denmark: A spatial analysis approach

OBJECTIVES

To examine the geographical patterns in AMI and characterize individual and neighborhood sociodemographic factors for persons living inside versus outside AMI clusters.

METHODS

The study population comprised 3,515,670 adults out of whom 74,126 persons experienced an incident AMI (2005-2011). Kernel density estimation and global and local clustering methods were used to examine the geographical patterns in AMI. Median differences and frequency distributions of sociodemographic factors were calculated for persons living inside versus outside AMI clusters.

RESULTS

Global clustering of AMI occurred in Denmark. Throughout the country, 112 significant clusters with high risk of incident AMI were identified. The relative risk of AMI in significant clusters ranged from 1.45 to 47.43 (median=4.84). Individual and neighborhood socioeconomic position was markedly lower for persons living inside versus outside AMI clusters.

CONCLUSIONS

AMI is geographically unequally distributed throughout Denmark and determinants of these geographical patterns might include individual- and neighborhood-level sociodemographic factors.

Marital status shows a strong protective effect on long-term mortality among first acute myocardial infarction-survivors with diagnosed hyperlipidemia--findings from the MONICA/KORA myocardial infarction registry

BACKGROUND

Reduction of long term mortality by marital status is well established in general populations. However, effects have been shown to change over time and differ considerably by cause of death. This study examined the effects of marital status on long term mortality after the first acute myocardial infarction.

METHODS

Data were retrieved from the population-based MONICA (Monitoring trends and determinants on cardiovascular diseases)/KORA (Cooperative Health Research in the Region of Augsburg)-myocardial infarction registry which assesses cases from the city of Augsburg and 2 adjacent districts located in southern Bavaria, Germany. A total of 3,766 men and women aged 28 to 74 years who were alive 28 days after their first myocardial infarction were included. Hazard ratios (HR) for the effects of marital status on mortality after one to 10 years of follow-up are presented.

RESULTS

The study population included 2,854 (75.8%) married individuals. During a median follow-up of 5.3 years, with an inter-quartile range of 3.3 to 7.6 years, 533 (14.15%) deaths occurred. Among married and unmarried individuals 388 (13.6%) and 145 (15.9%) deaths occurred, respectively. Overall marital status showed an insignificant protective HR of 0.76 (95% confidence interval (CI) 0.47-1.22). Stratified analyses revealed strong protective effects only among men and women younger than 60 who were diagnosed with hyperlipidemia. HRs ranged from 0.27 (95% CI 0.13-0.59) for a two-year survival to 0.43 (95% CI 0.27-0.68) for a 10-year survival. Substitution of marital status with co-habitation status confirmed the strata-specific effect [HR: 0.52 (95% CI 0.31-0.86)].

CONCLUSIONS

Marital status has a strong protective effect among first myocardial infarction survivors with diagnosed hyperlipidemia, which diminishes with increasing age. Treatments, recommended lifestyle changes or other attributes specific to hyperlipidema may be underlying factors, mediated by the social support of spouses. Underlying causes should be examined in further studies.

Life lost due to premature deaths in New South Wales, Australia

This study attempts to measure premature mortality, in addition to overall death rates, in order to provide more information that can be used to develop and monitor health programmes that are aimed at reducing premature (often preventable) mortality in New South Wales (NSW), Australia. Premature years of potential life lost (PYPLL) and valued years of potential life lost methods are applied for mortality data in NSW from 1990 to 2002. Variations in these measures for 2001 are studied further in terms of age, sex, urban/rural residence, and socio-economic status. PYPLL rates for all leading causes of death have declined. It is shown that the average male to female ratio of PYPLLs is highest for accidents, injury and poisoning (3.4:1) followed by mental disorders (2.7:1) and cardiovascular diseases (2.6:1). Although fewer women than men die of cardiovascular diseases, there is a greater proportionate importance of cerebrovascular mortality among women. In order to further reduce premature deaths, programs are required to improve the health of people living in lower socio-economic status areas, especially in rural NSW. Targeted regional or community level programs are required to reduce avoidable deaths due to accidents, injury and poisoning occasioned by motor vehicle accidents, poisoning and suicide among young adults.

Measuring achievement: changes in risk factors for cardiovascular disease in Australia

A possible measure for evaluating health system performance is the achievement index, which can be calculated using prevalence and distribution of a health measure across different socioeconomic groups. This study extends this approach by examining how achievement can be represented on a two-dimensional plane with the x-axis being the difference in mean ill-health and the y-axis being the difference in an absolute measure of inequality based on the generalised concentration index. The achievement plane is an easily understandable visual aid which provides a method of tracking changes in health and inequality over time, as well as uncertainty around these measures. We also demonstrate how comparisons over time and at different levels of inequality aversion can be undertaken using measures of net achievement. To illustrate the use of the achievement plane, we compared changes in prevalence of various cardiovascular risk factors and absolute inequality in the distribution of these factors, using data from four successive Australian National Health Surveys conducted between 1989 and 2005. While self-reported rates of smoking and high cholesterol have been declining, inequalities have been rising as the greatest reductions in these risk factors have been among higher income groups. Conversely for risk factors where the prevalence has been increasing, health inequalities are either not changing (i.e. diabetes and obesity), or diminishing over time (overweight/obese). All of these changes can be summarized using an achievement plane and graphs of net achievement to examine changes in prevalence and distribution of these risk factors over time.

Socioeconomic disadvantage and acute coronary events: a spatiotemporal analysis

BACKGROUND

The associations between socioeconomic disadvantage and ischemic heart disease are not well understood. We explore the relationship between socioeconomic factors and acute coronary events using spatiotemporal analysis.

METHODS

We studied all deaths from acute myocardial infarction and hospital admissions for acute coronary syndrome and related revascularization procedures for the state of New South Wales, Australia, from 1996 through 2002. We used conditional autoregressive models to describe how characteristics of subjects' place of residence (socioeconomic disadvantage, proportion of the population of indigenous background, and metropolitan versus nonmetropolitan area) influenced admissions and mortality.

RESULTS

There were 32,534 deaths due to acute myocardial infarction and 129,045 admissions for acute coronary syndrome. We found a relationship between increasing socioeconomic disadvantage and mortality (unadjusted relative risk for highest quartile of disadvantage relative to lowest = 1.40; 95% confidence interval = 1.27-1.54) as well as admissions (1.41; 1.28-1.55). After accounting for admission rates, socioeconomic disadvantage was associated with lower rates of angiography (0.75; 0.63-0.88) and interventional angiography (0.70; 0.56-0.85). After adjusting for socioeconomic disadvantage, areas with higher proportions of the population identified as indigenous had higher rates of admission and mortality, while residency in the state capital was associated with higher admission rates and more interventional angiography. After accounting for admission rates, the association of socioeconomic disadvantage with mortality was reduced.

CONCLUSIONS

Socioeconomic disadvantage increases both the risk of acute coronary syndrome and related mortality. A contributing factor appears to be a reduced chance of receiving appropriate care. Regions with a higher proportion of indigenous residents show risk beyond the effects of general socioeconomic disadvantage, while residents of metropolitan communities had increased utilization of more recent interventions.

Inequalities in the transition of cerebrovascular disease mortality in New South Wales, Australia 1969-1996

With reference to epidemiological transition theory, this paper examines change in cerebrovascular disease mortality in Australia's most populous state in the 28 year period, 1969-1996. The hypotheses were that in the context of overall stroke mortality decline over the period, marital status, occupational status and spatial differences decreased. However, while overall mortality declined, differentials increased. The reasons for this are considered, with particular implications for epidemiological transition theory and for the targeting of populations at risk in policy terms.