The impact of socioeconomic status on secondary prevention of the acute coronary syndrome

Background

Although socioeconomic status (SES) has been reported to be associated with health inequities, there are limited studies exploring the association between SES and secondary prevention of acute coronary syndrome (ACS) in countries with universal health cover.

Purpose

The aim is to examine whether SES has an impact on the secondary prevention of ACS in Australia.

Methods

Australian SNAPSHOT ACS data (2012) and its 18-month follow-up data were linked to admissions data from 6 jurisdictions covering all states and territories, national death index and Medicare Pharmaceutical Benefits Scheme data covering up to 3 years post-discharge. The five SES groups (lowest in Group 1 and highest in Group 5) were derived from the Australian Bureau of Statistics Socio-Economic Indexes for Areas (SEIFA) using the residential postcode at baseline. Outcomes were cardiac rehabilitation (CR) participation and smoking rate at 18 months post discharge as well as the use of ≥3 of the 4 indicated medications, all-cause death and cardiovascular disease (CVD) rates by 36 months of discharge. Outcomes were compared between the groups using the multilevel logistic regression with covariates of SES (5 groups), sex, GRACE risk score (4 groups), ACS diagnosis (STEMI/NSTEMI/UA) and the jurisdictions where the admissions data were linked.

Results

Of 1655 patients with ACS (mean age 68±13.5 yrs, 65% were male), who were discharged from hospital alive and had linked data available, 353 (21%) were in SES Group 1 (lowest SES), 369 (22%) in Group 2, 382 (23%) in Group 3, 296 (18%) in Group 4 and 255 (15%) in Group 5 (highest SES). Baseline clinical characteristics were comparable across the five SES groups. At 18-month after discharge, 1014 (61%) patients were followed-up with comparable loss to follow-up in each group. After adjustment, fewer patients in the lower SES groups (Groups 1 and 2) had participated in CR than those in the highest SES group (Group 5) (OR (95% CI): 0.60 (0.36, 0.99) and 0.56 (0.35, 0.91), respectively). Moreover, the odds of smoking was greater in Group 3 than Group 5 (2.60 (1.15, 5.89)) but no trend was found across the groups. By 36 months of discharge after adjustment, there was no difference in the odds of using ≥3 out of 4 medications between the SES groups. Despite this, patients in Groups 1 and 2 were significantly more likely to die than those in the highest SES group (1.96 (1.19, 3.21) and 1.91 (1.19, 3.07), respectively). The odds of CVD readmission did not differ across SES groups.

Conclusion

This study suggests that patients with low SES were less likely to participate in CR programs and more likely to die than those with high SES. Smoking rates varied between patients with intermediate and high SES but no trend was found across the groups. Despite the universal health cover available, inequity between the SES groups still exist. Future research is needed to further explore strategies to help close the evidence-practice gaps.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Australian National Heart Foundation Postdoctoral Fellowship

The Self-Help Clearinghouse of Metropolitan Toronto: reflections on seven years of survival and beyond

In May of 1987, Health and Welfare Canada awarded the Self-Help Clearinghouse of Metropolitan Toronto a three-year demonstration grant. Today, the Toronto Clearinghouse remains the only free-standing self-help resource of its kind in Canada and is a registered charitable organization whose mandate is to facilitate the growth and development of self-help/mutual-aid groups, networks, and resources. This paper describes the unique Toronto Clearinghouse model which from its earliest beginnings has been a partnership between the self-help community and interested and supportive professionals. The success of this model stems from its strong grassroots origins, respect for a community empowerment approach, and focused goals and objectives. Using information gleaned from the archival history of the Toronto Clearinghouse and through a series of interviews with past and current members of the Clearinghouse board of directors, program staff, and local self-help group members, the paper explains the "roller coaster ride" which has characterized the history of the Clearinghouse to date. Finally, the paper illustrates that while the achievement of financial stability has been an ongoing challenge in the face of variable community and political support, the Toronto Clearinghouse is, today, a strong centre of self-help activity and promotion, involved in a unique exercise to determine the role that self-help can play as a strategic component of an overall health and social services system-and with every reason to be optimistic about its future.