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Socioeconomic Status, Service Patterns, and Perceptions of Care Among Survivors of Acute Myocardial Infarction in Canada
David A. Alter, MD, PhD;
Karey Iron, MHSc;
Peter C. Austin, PhD;
C. David Naylor, MD, DPhil; for the SESAMI Study Group
JAMA. 2004;291:1100-1107.
Context Some have argued that Canada's uniquely restrictive approach to private health insurance keeps the socioeconomic elite inside the public system so that their demands and influence elevate the standard of service for all Canadian citizens. The extent to which this theory is a valid representation of Canadian health care is unknown.
Objectives To explore how patients with acute myocardial infarction from different socioeconomic backgrounds perceive their care in Canada's universal health care system and to correlate patients' backgrounds and perceptions with actual care received.
Design, Setting, and Patients Prospective observational cohort study with follow-up telephone interviews of 2256 patients 30 days following acute myocardial infarction discharged from 53 hospitals across Ontario, Canada, between December 1999 and June 2002.
Main Outcome Measures Postdischarge use of cardiac specialty services; satisfaction with care; willingness to pay directly for faster service or more choice; and mortality according to income and education, adjusted for age, sex, ethnicity, clinical factors, onsite angiography capacity at the admitting hospital, and rural-urban residence.
Results Compared with patients in lower socioeconomic strata, more affluent or better educated patients were more likely to undergo coronary angiography (67.8% vs 52.8%; P<.001), receive cardiac rehabilitation (43.9% vs 25.6%; P<.001), or be followed up by a cardiologist (56.7% vs 47.8%; P<.001). Socioeconomic differences in cardiac care persisted after adjustment for confounders. Despite receiving more specialized services, patients with higher socioeconomic status were more likely to be dissatisfied with their access to specialty care (adjusted RR, 2.02; 95% confidence interval, 1.20-3.32) and to favor out-of-pocket payments for quicker access to a wider selection of treatment options (30% vs 15% for patients with household incomes of Can $60 000 or higher vs less than Can $30 000, respectively; P<.001). After adjusting for baseline characteristics, socioeconomic status was not significantly associated with mortality at 1 year following hospitalization for myocardial infarction.
Conclusions Compared with those with lower incomes or less education, upper middle-class Canadians gain preferential access to services within the publicly funded health care system yet remain more likely to favor supplemental coverage or direct purchase of services.
Author Affiliations: Institute for Clinical Evaluative Sciences (Drs Alter, Austin, and Naylor and Ms Iron); the Division of Cardiology, Schulich Heart Centre and Department of Medicine, Sunnybrook and Women's College Health Sciences Centre, University of Toronto (Dr Alter); Departments of Public Health Sciences and Health Policy, Management, and Evaluation (Dr Austin); and the Department of Medicine and the Dean's Office, University of Toronto (Dr Naylor), Toronto, Ontario.
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