title: Area Median Income and Metropolitan Versus Nonmetropolitan Location of Care for Acute Coronary Syndromes: A Complex Interaction of Social Determinants.
abstract: BACKGROUND
  Metropolitan versus nonmetropolitan status and area median income may independently affect care for and outcomes of acute coronary syndromes. We sought to determine whether location of care modifies the association among area income, receipt of cardiac catheterization, and mortality following an acute coronary syndrome in a universal health care system.
  
  
  RESULTS
  We studied a cohort of 14 012 acute coronary syndrome patients admitted to cardiology services between April 18, 2004, and December 31, 2011, in southern Alberta, Canada. We used multivariable logistic regression to determine the odds of cardiac catheterization within 1 day and 7 days of admission and the odds of 30-day and 1-year mortality according to area median household income quintile for patients presenting at metropolitan and nonmetropolitan hospitals. In models adjusting for area income, patients who presented at nonmetropolitan facilities had lower adjusted odds of receiving cardiac catheterization within 1 day of admission (odds ratio 0.22, 95% CI 0.11-0.46, P<0.001). Among nonmetropolitan patients, when examined by socioeconomic status, each incremental decrease in income quintile was associated with 10% lower adjusted odds of receiving cardiac catheterization within 7 days (P<0.001) and 24% higher adjusted odds of 30-day mortality (P=0.008) but no significant difference for 1-year mortality (P=0.12). There were no differences in adjusted mortality among metropolitan patients.
  
  
  CONCLUSIONS
  Within a universal health care system, the association among area income and receipt of cardiac catheterization and 30-day mortality differed depending on the location of initial medical care for acute coronary syndromes. Care protocols are required to improve access to care and outcomes in patients from low-income nonmetropolitan communities.
authors.affiliation: Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA O'Brien Institute for Public Health, University of Calgary, Alberta, Canada Department of Health Care Policy, Harvard Medical School, Boston, MA gefabrea@ucalgary.ca.
authors.forename: Gabriel E
authors.initials: GE
authors.lastname: Fabreau
authors.affiliation: O'Brien Institute for Public Health, University of Calgary, Alberta, Canada.
authors.forename: Alexander A
authors.initials: AA
authors.lastname: Leung
authors.affiliation: O'Brien Institute for Public Health, University of Calgary, Alberta, Canada.
authors.forename: Danielle A
authors.initials: DA
authors.lastname: Southern
authors.affiliation: O'Brien Institute for Public Health, University of Calgary, Alberta, Canada.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: James
authors.affiliation: Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada.
authors.forename: Merrill L
authors.initials: ML
authors.lastname: Knudtson
authors.affiliation: O'Brien Institute for Public Health, University of Calgary, Alberta, Canada.
authors.forename: William A
authors.initials: WA
authors.lastname: Ghali
authors.affiliation: Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA Department of Health Care Policy, Harvard Medical School, Boston, MA Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
authors.forename: John Z
authors.initials: JZ
authors.lastname: Ayanian
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000628:therapy*; D000368:Aged; D000416:Alberta / Q000453:epidemiology; D006328:Cardiac Catheterization / Q000191:economics / Q000401:mortality; D016009:Chi-Square Distribution; D015331:Cohort Studies; D003695:Delivery of Health Care / Q000191:economics / Q000458:organization & administration*; D005260:Female; D017048:Health Care Costs; D054625:Healthcare Disparities / Q000191:economics; D006801:Humans; D007182:Income; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D017064:Process Assessment, Health Care / Q000191:economics; D012111:Residence Characteristics; D012307:Risk Factors; D019035:Rural Health Services / Q000191:economics / Q000458:organization & administration*; D013997:Time Factors; D016896:Treatment Outcome; D019472:Universal Health Insurance; D019037:Urban Health Services / Q000191:economics / Q000458:organization & administration*
keywords: acute coronary syndromes; angiography; geography; median income; mortality/survival; quality and outcomes; rural/urban