BACKGROUND: Canadian data suggest that patients of lower socioeconomic status with acute myocardial infarction receive less beneficial therapy and have worse clinical outcomes, raising questions regarding care disparities even in universal health care systems. We assessed the contemporary association of marginalization with clinical outcomes and health services use. METHODS: Using clinical and administrative databases in Ontario, Canada, we conducted a population-based study of patients aged ≥65 years hospitalized for their first acute myocardial infarction between April 1, 2010 and March 1, 2019. Patients receiving cardiac catheterization and surviving 7 days postdischarge were included. Our primary exposure was neighborhood-level marginalization, a multidimensional socioeconomic status metric. Neighborhoods were categorized by quintile from Q1 (least marginalized) to Q5 (most marginalized). Our primary outcome was all-cause mortality. A proportional hazards regression model with a robust variance estimator was used to quantify the association of marginalization with outcomes, adjusting for risk factors, comorbidities, disease severity, and regional cardiologist supply. RESULTS: Among 53 841 patients (median age, 75 years; 39.1% female) from 20 640 neighborhoods, crude 1- and 3-year mortality rates were 7.7% and 17.2%, respectively. Patients in Q5 had no significant difference in 1-year mortality (hazard ratio [HR], 1.08 [95% CI, 0.95–1.22]), but greater mortality over 3 years (HR, 1.13 [95% CI, 1.03–1.22]) compared with Q1. Over 1 year, we observed differences between Q1 and Q5 in visits to primary care physicians (Q1, 96.7%; Q5, 93.7%) and cardiologists (Q1, 82.6%; Q5, 72.6%), as well as diagnostic testing. There were no differences in secondary prevention medications dispensed or medication adherence at 1 year. CONCLUSIONS: In older patients with acute myocardial infarction who survived to hospital discharge, those residing in the most marginalized neighborhoods had a greater long-term risk of mortality, less specialist care, and fewer diagnostic tests. Yet, there were no differences across socioeconomic status in prescription medication use and adherence.

中文翻译：

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在单一付款人医疗保健系统中因急性心肌梗塞接受冠状动脉导管插入术的患者出院后社区边缘化与医疗保健使用和临床结果的关系

背景：加拿大的数据表明，社会经济地位较低的急性心肌梗死患者接受的治疗效果较差，临床结果也较差，这引发了即使在全民医疗保健系统中也存在护理差异的问题。我们评估了当代边缘化与临床结果和卫生服务使用的关联。 方法：我们利用加拿大安大略省的临床和管理数据库，对 2010 年 4 月 1 日至 2019 年 3 月 1 日期间因首次急性心肌梗塞住院的年龄≥65 岁的患者进行了一项基于人群的研究。患者接受心导管术并在出院后存活 7 天被包括在内。我们的主要暴露是邻里层面的边缘化，这是一个多维的社会经济地位指标。社区按五分位进行分类，从 Q1（最边缘化程度最低）到 Q5（最边缘化）。我们的主要结局是全因死亡率。使用具有稳健方差估计器的比例风险回归模型来量化边缘化与结果的关联，调整风险因素、合并症、疾病严重程度和区域心脏病专家的供应。 结果：在来自 20 640 个社区的 53 841 名患者（中位年龄 75 岁；39.1% 为女性）中，1 年和 3 年粗死亡率分别为 7.7% 和 17.2%。第 5 季度患者的 1 年死亡率没有显着差异（风险比 [HR]，1.08 [95% CI，0.95–1.22]），但 3 年死亡率更高（HR，1.13 [95% CI，1.03–1.22]） ）与 Q1 相比。在一年多的时间里，我们观察到第一季度和第五季度就诊初级保健医生（第一季度，96.7%；第五季度，93.7%）和心脏病专家（第一季度，82.6%；第五季度，72.6%）以及诊断测试之间存在差异。1 年时二级预防药物的配发或药物依从性没有差异。 结论：在存活出院的老年急性心肌梗死患者中，居住在最边缘化社区的患者长期死亡风险更大，接受的专科护理和诊断测试也更少。然而，不同社会经济地位在处方药使用和依从性方面没有差异。