Using socioeconomic disparities in ACS mortality to identify opportunities for better cardiac care

BACKGROUND: Though cardiac care in acute coronary syndrome (ACS) should be equitable, socioeconomic disparities in associated mortality persist. In this study we ask if problems in provision of cardiac care could be pinpointed by examining these disparities in mortality between different time-points of ACS care. Thus, we assessed how socioeconomic disparities in one-year coronary heart disease (CHD) mortality emerged in Finland both outside hospital and in three consecutive time-points after ACS hospitalisation. METHODS: We obtained individual data of incident ACS hospitalisation for those aged ≥40 in 2013-2017 from national hospitalisation registers. Respective data for CHD mortality, education, income, living alone and travel time to hospital were obtained from Statistics Finland and from Digiroad database. Comorbidity was measured with Charlson index. Two-level Poisson multilevel models provided incidence rate ratios (IRRs) separately in total CHD mortality (including prehospital deaths) and by the time of death after ACS hospitalisation (within 1-7 days, 8-28 d and 29-365 d). Variation between hospital districts was adjusted for with random effects. RESULTS: Of 31,902 CHD deaths 74.9% occurred prehospital, 9.0% within 1-7 d, 6.2% within 8-28 d and 9.9% within 29-365 d of ACS hospitalisation. IRRs for living alone were 1.25-fold (CI95% 1.22-1.29) for total CHD mortality but varied between 0.95-1.05-fold after ACS hospitalisation. A clear income gradient emerged favouring higher quintiles. In the highest quintile IRRs were constantly 0.53-0.56-fold (CI95% 0.43-0.73) to those of the lowest quintile. In other quintiles income disparities were fewer, especially within 1-7 d. CONCLUSIONS: Though socioeconomic disparities in CHD mortality persisted throughout cardiac care, more focus should be given especially to subacute care and rehabilitation of vulnerable groups. Improving early identification of ACS in those living alone offers opportunities to decrease excess CHD mortality. KEY MESSAGES: • A detailed analysis of socioeconomic disparities in one-year mortality after acute coronary syndrome event can provide opportunities for improving provision of cardiac care. • More focus should be given especially to subacute cardiac care and rehabilitation of vulnerable populations, as well as to early identification of acute coronary syndrome events in those living alone.