Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction

N Engl J Med. 1999 Oct 28;341(18):1359-67. doi: 10.1056/NEJM199910283411806.


Background: Universal health care systems seek to ensure access to care on the basis of need rather than income and to improve the health status of all citizens. We examined the performance of the Canadian health system with respect to these goals in the province of Ontario by assessing the effects of neighborhood income on access to invasive cardiac procedures and on mortality one year after acute myocardial infarction.

Methods: We linked claims for payment for physicians' services, hospital-discharge abstracts, and vital-status data for all patients with acute myocardial infarction who were admitted to hospitals in Ontario between April 1994 and March 1997. Patients' income levels were imputed from the median incomes of their residential neighborhoods as determined in Canada's 1996 census. We determined rates of use and waiting times for coronary angiography and revascularization procedures after the index admission for acute myocardial infarction and determined death rates at one year. In multivariate analyses, we controlled for the patient's age, sex, and severity of disease; the specialty of the attending physician; the volume of cases, teaching status, and on-site facilities for cardiac procedures at the admitting hospital; and the geographic proximity of the admitting hospital to tertiary care centers.

Results: The study cohort consisted of 51,591 patients. With respect to coronary angiography, increases in neighborhood income from the lowest to the highest quintile were associated with a 23 percent increase in rates of use and a 45 percent decrease in waiting times. There was a strong inverse relation between income and mortality at one year (P<0.001). Each $10,000 increase in the neighborhood median income was associated with a 10 percent reduction in the risk of death within one year (adjusted hazard ratio, 0.90; 95 percent confidence interval, 0.86 to 0.94).

Conclusions: In the province of Ontario, despite Canada's universal health care system, socioeconomic status had pronounced effects on access to specialized cardiac services as well as on mortality one year after acute myocardial infarction.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Coronary Angiography / statistics & numerical data*
  • Female
  • Health Services Accessibility / economics*
  • Hospitals / classification
  • Hospitals / statistics & numerical data
  • Humans
  • Income
  • Male
  • Multivariate Analysis
  • Myocardial Infarction / diagnostic imaging
  • Myocardial Infarction / mortality*
  • Myocardial Infarction / therapy*
  • Myocardial Revascularization / statistics & numerical data*
  • National Health Programs
  • Ontario / epidemiology
  • Proportional Hazards Models
  • Severity of Illness Index
  • Social Class*
  • Survival Analysis