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Geography and service supply do not explain socioeconomic gradients in angiography use after acute myocardial infarction

From the Institute for Clinical Evaluative Sciences (all authors); the University of Toronto Clinical Epidemiology and Health Care Research Program, Sunnybrook & Women's College site (Naylor and Tu); the Divisions of Cardiology, Schulich Heart Centre (Alter), and General Internal Medicine (Naylor and Tu), Sunnybrook & Women's College Health Sciences Centre and the University of Toronto; the Departments of Public Health Sciences (Naylor, Austin, Chan and Tu), Health Policy, Management and Evaluation (Naylor, Chan and Tu), Family and Community Medicine (Chan) and the Dean's Office (Naylor), University of Toronto, Toronto, Ont.

Background: Socioeconomic status appears to be an important predictor of coronary angiography use after acute myocardial infarction. One potential explanation for this is that patients with lower socioeconomic status live in neighbourhoods near nonteaching hospitals that have no catheterization capacity, few specialists and lower volumes of patients with acute myocardial infarction. This study was conducted to determine whether the impact of socioeconomic status on angiography use would be lessened by considering variations in the supply of services.

Methods: We examined payment claims for physician services, hospital discharge abstracts and vital status data for 47 036 patients with acute myocardial infarction admitted to hospitals in Ontario between April 1994 and March 1997. Neighbourhood income of each patient was obtained from Canada's 1996 census. Using multivariate hierarchical logistic regression and adjusting for baseline patient and physician factors, we examined the interaction among hospital and regional characteristics, socioeconomic status and angiography use in the first 90 days after admission to hospital for acute myocardial infarction.

Results: Within each hospital and geographic subgroup, crude rates of angiography rose progressively with increases in neighbourhood income. After adjusting for sociodemographic, clinical and physician characteristics, hospitals with on-site angiography capacity (adjusted odds ratio [OR] 1.88, 95% confidence interval [CI] 1.52–2.33), those with university affiliations (adjusted OR 1.60, 95% CI 1.27–2.01) and those closest to tertiary institutions (adjusted OR 1.57, 95% CI 1.32–1.87) were all associated with higher 90-day angiography use after acute myocardial infarction. However, the relative impact of socioeconomic status on 90-day angiography use was similar whether or not hospitals had on-site procedural capacity (interaction term p = 0.68), had university affiliations (interaction term p = 0.99), were near tertiary facilities (interaction term p = 0.67) or were in rural or urban regions (interaction term p = 0.90).

Interpretation: Socioeconomic status was as important a predictor of angiography use in hospitals with ready access to cardiac catheterization facilities as it was in those without. The socioeconomic gradient in the use of angiography after acute myocardial infarction cannot be explained by the distribution of specialists or tertiary hospitals.

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