Differences in access to coronary care unit among patients with acute myocardial infarction in Rome: old, ill, and poor people hold the burden of inefficiency.
BACKGROUND
Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997-2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices.


METHODS
Using discharge data, we analyzed a cohort of 9127 AMI patients. Illness severity on admission was determined using the Deyo's adaptation of the Charlson's comorbidity index, and each patient was assigned to one to four SES groups (level I referring to the highest SES) defined by a socioeconomic index, derived by the characteristics of the census tract of residence. The effect of gender, age, illness severity and SES, on risk of non-admission to CCU was investigated using a logistic regression model (OR, CI 95%).


RESULTS
Only 53.9% of patients were directly admitted to CCU, and access to optimal care was more frequently offered to younger patients (OR = 0.35; 95%CI = 0.25-0.48 when comparing 85+ to >=50 years), those with less severe illness (OR = 0.48; 95%CI = 0.37-0.61 when comparing Charlson index 3+ to 0) and the socially advantaged (OR = 0.81; 95%CI = 0.66-0.99 when comparing low to high SES).


CONCLUSIONS
In Rome, Italy, standard optimal coronary care is underprovided. It seems to be granted preferentially to the better off, even after controversial clinical criteria, such as age and severity of illness, are taken into account.
Ancona
Carla
C
Department of Epidemiology, Local Health Authority RME, Rome, Italy. ancona@asplazio.it
Arcà
Massimo
M
Saitto
Carlo
C
Agabiti
Nera
N
Fusco
Danilo
D
Tancioni
Valeria
V
Perucci
Carlo A
CA
D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D015897:Comorbidity; D003325:Coronary Care Units / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000401:mortality / Q000628:therapy*; D010343:Patient Admission / Q000191:economics / Q000706:statistics & numerical data*; D012384:Rome / Q000453:epidemiology; D012720:Severity of Illness Index; D012959:Socioeconomic Factors; D035862:Vulnerable Populations