Is geography destiny for patients in new york with myocardial infarction?

doi:10.1016/S0002-9343(03)00446-7

The American Journal of Medicine

Volume 115, Issue 6, 15 October 2003, Pages 448-453

https://doi.org/10.1016/S0002-9343(03)00446-7 Get rights and content

Abstract

Purpose

The use of coronary revascularization among patients with myocardial infarction varies by race/ethnicity and socioeconomic status. The objective of this study was to determine whether local availability of facilities might influence apparent racial disparities in revascularization and health outcomes.

Methods

Using Statewide Planning and Research Cooperative System data (1988–1999) from the New York State Department of Health, we determined revascularization rates among patients hospitalized with myocardial infarction in two socioeconomically disadvantaged communities in New York City (the South Bronx, which has no hospitals that have revascularization facilities, and Harlem, which has three revascularization facilities), as well as in its most advantaged community (mid-Manhattan, which has six such facilities). The rest of New York City served as reference. We measured demographic and clinical characteristics and revascularization rates in each community.

Results

Among patients hospitalized with myocardial infarction, the age-adjusted revascularization rates were 29.2% for whites, 12.5% for blacks, and 19.9% for Hispanics (P <0.01). Rates were 12.0% in the South Bronx, 24.0% in Harlem, 38.4% in mid-Manhattan, and 21.2% in the rest of New York City (P <0.05). Logistic regression analysis, adjusting for age, sex, race, insurance status, comorbidity, clinical complications, and year of admission, revealed that South Bronx patients were about 20% less likely to be revascularized than those in the rest of New York City, whereas patients living in Harlem were twice as likely to receive such treatment as residents in the rest of New York City. Among patients admitted to hospitals with cardiac revascularization facilities, lower use among South Bronx residents persisted, but after adjusting for patient characteristics, Harlem residents were significantly less likely to be revascularized than those from the rest of New York City.

Conclusion

Race and socioeconomic factors influence the likelihood of revascularization after myocardial infarction among residents of New York City. In addition, lack of availability of revascularization further reduces its use by residents of disadvantaged neighborhoods.

Section snippets

Data sources

We used the 1988 to 1999 Statewide Planning and Research Cooperative System (SPARCS) database, created by the New York State Department of Health (12). SPARCS contains discharge data abstracted for at least 95% of all New York State hospital admissions, except for psychiatric and federal hospitals. Data include age, sex, race, admission status, physician and hospital identifiers, principal diagnosis and up to 14 secondary diagnoses, principal procedure code and up to 14 other procedure codes,

Results

Residents of the South Bronx and Harlem were more likely to be younger, living under the poverty line, and unemployed than those in either mid-Manhattan or elsewhere in New York City (Table 1). They also had lower per capita incomes and less education (Table 1). Patients from the South Bronx and Harlem were less likely than those from mid-Manhattan and elsewhere in the city to be white, less likely to have private insurance coverage, and more likely to be on Medicaid.

During the 12 years of

Discussion

Among residents of disadvantaged communities in New York City, local availability of coronary reperfusion significantly increased revascularization for myocardial infarction. Revascularization was more common among Harlem residents than those from the South Bronx, presumably because more Harlem residents with myocardial infarction were admitted to hospitals that had revascularization facilities. Treatment of patients admitted to hospitals performing revascularization was similar, regardless of

Acknowledgements

SPARCS data were provided by the New York State Department of Health.

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Les populations des quartiers défavorisés des pays à revenu élevé portent un fardeau disproportionnellement élevé de maladies cardiovasculaires. Bien que le faible statut socioéconomique des individus ait longtemps été associé à une morbidité et une mortalité plus élevées de maladies cardiovasculaires, il existe de plus en plus de données probantes établissant que le statut socioéconomique des régions peut également avoir des conséquences majeures sur les résultats cardiovasculaires. Le manque de supermarchés, les espaces verts limités et les taux élevés de crimes violents dans les quartiers défavorisés du centre-ville entraînent un apport alimentaire médiocre et de faibles taux d’activité physique chez les résidents. Les environnements physiques et sociaux des quartiers défavorisés du centre-ville peuvent également contribuer à des taux élevés de troubles mentaux cormorbides dans les populations urbaines désavantagées. Les troubles mentaux peuvent mener à l’accumulation des facteurs de risque de maladies cardiovasculaires par ses répercussions sur les comportements en matière de santé, les effets des médicaments psychotropes et les séquelles de la toxicomanie. Les individus qui résident dans des quartiers défavorisés subissent une diminution de l’accès aux soins de prévention primaire et aux soins cardiovasculaires de courte durée dans un hôpital. Les obstacles financiers peuvent dissuader d’offrir des soins aux patients de statut socioéconomique faible, ainsi que les questions de capacité du système dans les quartiers pauvres et les différences concernant la propension des patients à recourir aux soins. Les études à petite échelle sur les interventions pour améliorer les comportements en matière de santé sur le plan individuel et l’accès aux soins dans les quartiers pauvres ont démontré un certain succès dans l’amélioration des résultats cardiovasculaires par l’utilisation de cliniques mobiles, de l’accompagnement en santé et des approches de prise en charge coordonnée. D’autres recherches en intervention communautaire sont nécessaires pour améliorer la santé cardiovasculaire des populations des quartiers défavorisés du centre-ville.
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The degree to which low transplant rates among Asians and Pacific Islanders in the United States are confounded by poverty and reduced access to care is unknown. We examined the relationship between neighborhood poverty and kidney transplant rates among 22 152 patients initiating dialysis during 1995–2003 within 1800 ZIP codes in California, Hawaii and the US‐Pacific Islands. Asians and whites on dialysis were distributed across the spectrum of poverty, while Pacific Islanders were clustered in the poorest areas. Overall, worsening neighborhood poverty was associated with lower relative rates of transplant (adjusted HR [95% CI] for areas with ≥20% vs. <5% residents living in poverty, 0.41 [0.32–0.53], p < 0.001). At every level of poverty, Asians and Pacific Islanders experienced lower transplant rates compared with whites. The degree of disparity increased with worsening neighborhood poverty (adjusted HR [95% CI] for Asians–Pacific Islanders vs. whites, 0.64 [0.51–0.80], p < 0.001 for areas with <5% and 0.30 [0.21–0.44], p < 0.001 for areas with ≥20% residents living in poverty; race–poverty level interaction, p = 0.039). High levels of neighborhood poverty are associated with lower transplant rates among Asians and Pacific Islanders compared with whites. Our findings call for studies to identify cultural and local barriers to transplant among Asians and Pacific Islanders, particularly those residing in resource‐poor neighborhoods.
Health Care for Children and Youth in the United States: Annual Report on Patterns of Coverage, Utilization, Quality, and Expenditures by a County Level of Urban Influence
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To examine child and hospital demographics and children’s health care coverage, use, expenditures, and quality by a county-level measure of urban influence.
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Gender Differences of Revascularization in Patients With Acute Myocardial Infarction
2006, American Journal of Cardiology
Women are less likely to undergo revascularization after acute myocardial infarction (AMI). We assessed whether this was due to patterns of hospital admission or less frequent revascularization even when resources are available. Using New York City hospital discharge records from 1995 to 2002, we determined revascularization rates for patients who were hospitalized for AMI. Rates of admission to hospitals capable of revascularizing and revascularization use were assessed by gender. Odds ratios of admission and procedure use were determined after adjusting for sociodemographic and clinical characteristics and accounting for availability of revascularization in neighborhoods of residence. Of 93,978 patients with AMI (43.7% women), 27% were revascularized (32% and 20% for men and women, respectively, p <0.001). Moreover, women were less likely than men to be admitted to hospitals capable of revascularization (45% vs 52%, p <0.001) and to undergo revascularization (54% vs 60%, p <0.001) when admitted to capable hospitals. These differences were similar for residents of neighborhoods with or without revascularization services. Odds ratios for men versus women were 1.22 (95% confidence interval 1.18 to 1.26) for admission to revascularizing hospitals and 1.28 (95% confidence interval 1.22 to 1.34) for using revascularization among patients in revascularization hospitals. The in-hospital mortality advantage of men over women persisted after revascularization (9.6% vs 14.5%). In conclusion, less revascularization after AMI among women was associated with less frequent admission to hospitals capable of revascularization and less frequent revascularization even when admitted to performing hospitals. However, improving revascularization among women does not eliminate the gender disparity of in-hospital death after AMI.

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^☆: This study was supported by a Health Service Research grant from the Agency for Healthcare Research and Quality (HS11612–01A1).

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Clinical studyIs geography destiny for patients in new york with myocardial infarction?☆

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Data sources

Results

Discussion

Acknowledgements

J Am Coll Cardiol

Am Heart J

Gender and ethnic differences in hospital-based procedure utilization in California

Arch Intern Med

Racial and community factors influencing coronary artery bypass graft surgery rates for all 1986 Medicare patients

JAMA

Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs

JAMA

High-technology cardiac procedures—the impact of service availability on service use in New York State

JAMA

The three leading causes of death in African Americansbarriers to reducing excess disparity and to improving health behaviors

J Health Care Poor Underserved

Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery

Med Care

Clinical study
Is geography destiny for patients in new york with myocardial infarction?☆