Socioeconomic inequalities in quality of care and outcomes among patients with acute coronary syndrome in the modern era of drug eluting stents.
BACKGROUND
The rapidly changing landscape of percutaneous coronary intervention provides a unique model for examining disparities over time. Previous studies have not examined socioeconomic inequalities in the current era of drug eluting stents (DES).


RESULTS
We analyzed 835 070 hospitalizations for acute coronary syndrome (ACS) from the Healthcare Cost and Utilization Project across all insurance types from 2008 to 2011, examining whether quality of care and outcomes for patients with ACS differed by income (based on zip code of residence) with adjustment for patient characteristics and clustering by hospital. We found that lower-income patients were less likely to receive an angiogram within 24 hours of a ST elevation myocardial infarction (STEMI) (69.5% for IQ1 versus 73.7% for IQ4, P<0.0001, OR 0.79 [0.68 to 0.91]) or within 48 hours of a Non-STEMI (47.6% for IQ1 versus 51.8% for IQ4, P<0.0001, OR 0.86 [0.75 to 0.99]). Lower income was associated with less use of a DES (64.7% for IQ1 versus 71.2% for IQ4, P<0.0001, OR 0.83 [0.74 to 0.93]). However, no differences were found for coronary artery bypass surgery. Among STEMI patients, lower-income patients also had slightly increased adjusted mortality rates (10.8% for IQ1 versus 9.4% for IQ4, P<0.0001, OR 1.17 [1.11 to 1.25]). After further adjusting for time to reperfusion among STEMI patients, mortality differences across income groups decreased.


CONCLUSIONS
For the most well accepted procedural treatments for ACS, income inequalities have faded. However, such inequalities have persisted for DES use, a relatively expensive and until recently, controversial revascularization procedure. Differences in mortality are significantly associated with differences in time to primary PCI, suggesting an important target for understanding why these inequalities persist.
Stanford University/Stanford Cardiovascular Institute, Palo Alto, CA (C.M.Y., F.A., P.A.H.) VA Palo Alto Health Care System, Palo Alto, CA (C.M.Y., S.M.A., P.A.H.).
Celina M
CM
Yong
Stanford University/Stanford Cardiovascular Institute, Palo Alto, CA (C.M.Y., F.A., P.A.H.).
Freddy
F
Abnousi
VA Palo Alto Health Care System, Palo Alto, CA (C.M.Y., S.M.A., P.A.H.) Division of General Medical Disciplines, Stanford University School of Medicine, Palo Alto, CA (S.M.A.).
Steven M
SM
Asch
Stanford University/Stanford Cardiovascular Institute, Palo Alto, CA (C.M.Y., F.A., P.A.H.) VA Palo Alto Health Care System, Palo Alto, CA (C.M.Y., S.M.A., P.A.H.).
Paul A
PA
Heidenreich
D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D017023:Coronary Angiography; D054855:Drug-Eluting Stents / Q000191:economics / Q000592:standards / Q000639:trends; D005260:Female; D054625:Healthcare Disparities / Q000191:economics / Q000592:standards / Q000639:trends; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000628:therapy*; D010043:Outcome and Process Assessment, Health Care / Q000191:economics / Q000592:standards / Q000639:trends; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation* / Q000401:mortality / Q000592:standards / Q000639:trends; D019984:Quality Indicators, Health Care / Q000191:economics / Q000592:standards / Q000639:trends; D012111:Residence Characteristics; D012959:Socioeconomic Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D014481:United States
acute coronary syndrome; outcomes; quality; socioeconomic status