title: Sex, socioeconomic status, access to cardiac catheterization, and outcomes for acute coronary syndromes in the context of universal healthcare coverage.
abstract: BACKGROUND
  Sex and neighborhood socioeconomic status (nSES) may independently affect the care and outcomes of acute coronary syndrome, partly through barriers in timely access to cardiac catheterization. We sought to determine whether sex modifies the association between nSES and the receipt of cardiac catheterization and mortality after an acute coronary syndrome in a universal healthcare system.
  
  
  RESULTS
  We studied 14 012 patients with acute coronary syndrome admitted to cardiology services between April 18, 2004, and December 31, 2011, in Southern Alberta, Canada. We used multivariable logistic regression to compare the odds of cardiac catheterization within 2 and 30 days of admission and the odds of 30-day and 1-year mortality for men and women by quintile of neighborhood median household income. Significant relationships between nSES and the receipt of cardiac catheterization and mortality after acute coronary syndrome were detected for women but not men. When examined by nSES, each incremental decrease in neighborhood income quintile for women was associated with a 6% lower odds of receiving cardiac catheterization within 30 days (P=0.01) and a 14% higher odds of 30-day mortality (P=0.03). For men, each decrease in neighborhood income quintile was associated with a 2% lower odds of receiving catheterization within 30 days (P=0.10) and a 5% higher odds of 30-day mortality (P=0.36).
  
  
  CONCLUSIONS
  Associations between nSES and receipt of cardiac catheterization and 30-day mortality were noted for women but not men in a universal healthcare system. Care protocols designed to improve equity of access to care and outcomes are required, especially for low-income women.
authors.affiliation: From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.). gef821@mail.harvard.edu.
authors.forename: Gabriel E
authors.initials: GE
authors.lastname: Fabreau
authors.affiliation: From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.).
authors.forename: Alexander A
authors.initials: AA
authors.lastname: Leung
authors.affiliation: From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.).
authors.forename: Danielle A
authors.initials: DA
authors.lastname: Southern
authors.affiliation: From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.).
authors.forename: Merrill L
authors.initials: ML
authors.lastname: Knudtson
authors.affiliation: From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.).
authors.forename: J Michael
authors.initials: JM
authors.lastname: McWilliams
authors.affiliation: From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.).
authors.forename: John Z
authors.initials: JZ
authors.lastname: Ayanian
authors.affiliation: From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.).
authors.forename: William A
authors.initials: WA
authors.lastname: Ghali
mesh_terms: D054058:Acute Coronary Syndrome / Q000191:economics / Q000453:epidemiology / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000416:Alberta / Q000453:epidemiology; D006328:Cardiac Catheterization / Q000191:economics*; D005260:Female; D005500:Follow-Up Studies; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000191:economics / Q000379:methods*; D015995:Prevalence; D012737:Sex Factors; D012959:Socioeconomic Factors; D019472:Universal Health Insurance / Q000191:economics*; D055815:Young Adult
keywords: angiography; gender identity; mortality; myocardial infarction; neighborhood; sex; social class