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Sex, socioeconomic status, access to cardiac catheterization, and outcomes for acute coronary syndromes in the context of universal healthcare coverage.

ABSTRACT: Sex and neighborhood socioeconomic status (nSES) may independently affect the care and outcomes of acute coronary syndrome, partly through barriers in timely access to cardiac catheterization. We sought to determine whether sex modifies the association between nSES and the receipt of cardiac catheterization and mortality after an acute coronary syndrome in a universal healthcare system.We studied 14 012 patients with acute coronary syndrome admitted to cardiology services between April 18, 2004, and December 31, 2011, in Southern Alberta, Canada. We used multivariable logistic regression to compare the odds of cardiac catheterization within 2 and 30 days of admission and the odds of 30-day and 1-year mortality for men and women by quintile of neighborhood median household income. Significant relationships between nSES and the receipt of cardiac catheterization and mortality after acute coronary syndrome were detected for women but not men. When examined by nSES, each incremental decrease in neighborhood income quintile for women was associated with a 6% lower odds of receiving cardiac catheterization within 30 days (P=0.01) and a 14% higher odds of 30-day mortality (P=0.03). For men, each decrease in neighborhood income quintile was associated with a 2% lower odds of receiving catheterization within 30 days (P=0.10) and a 5% higher odds of 30-day mortality (P=0.36).Associations between nSES and receipt of cardiac catheterization and 30-day mortality were noted for women but not men in a universal healthcare system. Care protocols designed to improve equity of access to care and outcomes are required, especially for low-income women.

SUBMITTER: Fabreau GE

PROVIDER: S-EPMC4411180 | biostudies-literature | 2014 Jul

REPOSITORIES: biostudies-literature

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Sex, socioeconomic status, access to cardiac catheterization, and outcomes for acute coronary syndromes in the context of universal healthcare coverage.

Fabreau Gabriel E GE Leung Alexander A AA Southern Danielle A DA Knudtson Merrill L ML McWilliams J Michael JM Ayanian John Z JZ Ghali William A WA

Circulation. Cardiovascular quality and outcomes 20140603 4

<h4>Background</h4>Sex and neighborhood socioeconomic status (nSES) may independently affect the care and outcomes of acute coronary syndrome, partly through barriers in timely access to cardiac catheterization. We sought to determine whether sex modifies the association between nSES and the receipt of cardiac catheterization and mortality after an acute coronary syndrome in a universal healthcare system.<h4>Methods and results</h4>We studied 14 012 patients with acute coronary syndrome admitted ...[more]

PMID: 24895450

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Project description:Monitoring universal health coverage (UHC) focuses on information on health intervention coverage and financial protection. This paper addresses monitoring intervention coverage, related to the full spectrum of UHC, including health promotion and disease prevention, treatment, rehabilitation, and palliation. A comprehensive core set of indicators most relevant to the country situation should be monitored on a regular basis as part of health progress and systems performance assessment for all countries. UHC monitoring should be embedded in a broad results framework for the country health system, but focus on indicators related to the coverage of interventions that most directly reflect the results of UHC investments and strategies in each country. A set of tracer coverage indicators can be selected, divided into two groups-promotion/prevention, and treatment/care-as illustrated in this paper. Disaggregation of the indicators by the main equity stratifiers is critical to monitor progress in all population groups. Targets need to be set in accordance with baselines, historical rate of progress, and measurement considerations. Critical measurement gaps also exist, especially for treatment indicators, covering issues such as mental health, injuries, chronic conditions, surgical interventions, rehabilitation, and palliation. Consequently, further research and proxy indicators need to be used in the interim. Ideally, indicators should include a quality of intervention dimension. For some interventions, use of a single indicator is feasible, such as management of hypertension; but in many areas additional indicators are needed to capture quality of service provision. The monitoring of UHC has significant implications for health information systems. Major data gaps will need to be filled. At a minimum, countries will need to administer regular household health surveys with biological and clinical data collection. Countries will also need to improve the production of reliable, comprehensive, and timely health facility data. Please see later in the article for the Editors' Summary.

Project description:ObjectivesCountries with universal health coverage (UHC) strive for equal access for equal needs without users getting into financial distress. However, differences in healthcare utilisation (HCU) between socioeconomic groups have been reported in countries with UHC. This systematic review provides an overview individual-level, community-level, and system-level factors contributing to socioeconomic status-related differences in HCU (SES differences in HCU).DesignSystematic review following the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. The review protocol was published in advance.Data sourcesEmbase, PubMed, Web of Science, Scopus, Econlit, and PsycInfo were searched on 9 March 2021 and 9 November 2022.Eligibility criteriaStudies that quantified the contribution of one or more factors to SES difference in HCU in OECD countries with UHC.Data extraction and synthesisStudies were screened for eligibility by two independent reviewers. Data were extracted using a predeveloped data-extraction form. Risk of bias (ROB) was assessed using a tailored version of Hoy's ROB-tool. Findings were categorised according to level and a framework describing the pathway of HCU.ResultsOf the 7172 articles screened, 314 were included in the review. 64% of the studies adjusted for differences in health needs between socioeconomic groups. The contribution of sex (53%), age (48%), financial situation (25%), and education (22%) to SES differences in HCU were studied most frequently. For most factors, mixed results were found regarding the direction of the contribution to SES differences in HCU.ConclusionsSES differences in HCU extensively correlated to factors besides health needs, suggesting that equal access for equal needs is not consistently accomplished. The contribution of factors seemed highly context dependent as no unequivocal patterns were found of how they contributed to SES differences in HCU. Most studies examined the contribution of individual-level factors to SES differences in HCU, leaving the influence of healthcare system-level characteristics relatively unexplored.

Project description:ContextConflicting information exists about whether sex differences modulate short-term mortality following acute coronary syndromes (ACS).ObjectivesTo investigate the relationship between sex and 30-day mortality in ACS, and to determine whether this relationship was modified by clinical syndrome or coronary anatomy using a large database across the spectrum of ACS and adjusting for potentially confounding clinical covariates.Design, setting, and participantsA convenience sample of patients pooled from 11 independent, international, randomized ACS clinical trials between 1993 and 2006 whose databases are maintained at the Duke Clinical Research Institute, Durham, North Carolina. Of 136 247 patients, 38 048 (28%) were women; 102 004 (26% women) with ST-segment elevation myocardial infarction (STEMI), 14 466 (29% women) with non-STEMI (NSTEMI), and 19 777 (40% women) with unstable angina.Main outcome measureThirty-day mortality following ACS.ResultsThirty-day mortality was 9.6% in women and 5.3% in men (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.83-2.00). After multivariable adjustment, mortality was not significantly different between women and men (adjusted OR, 1.06; 95% CI, 0.99-1.15). A significant sex by type of ACS interaction was demonstrated (P < .001). In STEMI, 30-day mortality was higher among women (adjusted OR, 1.15; 95% CI, 1.06-1.24), whereas in NSTEMI (adjusted OR, 0.77; 95% CI, 0.63-0.95) and unstable angina, mortality was lower among women (adjusted OR, 0.55; 95% CI, 0.43-0.70). In a cohort of 35 128 patients with angiographic data, women more often had nonobstructive (15% vs 8%) and less often had 2-vessel (25% vs 28%) and 3-vessel (23% vs 26%) coronary disease, regardless of ACS type. After additional adjustment for angiographic disease severity, 30-day mortality among women was not significantly different than men, regardless of ACS type. The relationship between sex and 30-day mortality was similar across the levels of angiographic disease severity (P for interaction = .70).ConclusionsSex-based differences existed in 30-day mortality among patients with ACS and vary depending on clinical presentation. However, these differences appear to be largely explained by clinical differences at presentation and severity of angiographically documented disease.

Project description:Background: Universal Health Coverage (UHC) is achieved in a health system when all residents of a country are able to obtain access to adequate healthcare and financial protection. Achieving this goal requires adequate healthcare and healthcare financing systems that ensure financial access to adequate care. In Africa, accessibility and coverage of essential health services are very low. Many African countries have therefore initiated reforms of their health systems to achieve universal health coverage and are advanced in this goal. The aim of this paper is to examine the effects of UHC on equitable access to care in Africa. Methods: A systematic review guided by the Cochrane Handbook was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria (PRISMA). Studies were eligible for inclusion if 1- they clearly mention studying the effect of UHC on equitable access to care, and 2- they mention facilitating factors and barriers to access to care for vulnerable populations. To be included, studies had to be in English or French. In accordance with PRISMA guidelines, our systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on April 24, 2018 (registration number CRD42018092793). Results: In all 271 citations reviewed, 12 studies were eligible for inclusion. Although universal health coverage seems to increase the use of health services, shortages in human resources and medical supplies, socio-cultural barriers, physical inaccessibility, lack of education and information, decision-making power, and gender-based autonomy, prenatal visits, previous experiences, and fear of cesarean delivery were still found to deter access to, and use of, health services. Discussion: Barriers to greater effectiveness of the UHC correspond to various non-financial barriers. There are no specific recommendations for these kinds of barriers. Generally, it is important for each country to research and identify contextual uncertainties in each of the communities of the territory. Afterwards, it will be necessary to put in place adapted strategies to correct these uncertainties, and thus to work toward a more efficient system of UHC, resulting in positive impacts on health outcomes.

Project description:BackgroundCountries in Latin America and the Caribbean (LAC) have substantially improved access to family planning over the past 50 years. Many have also recently adopted explicit declarations of universal rights to health and universal health coverage (UHC) and have begun implementing UHC-oriented health financing schemes. These schemes will have important implications for the sustainability and further growth of family planning programs throughout the region.MethodsWe examined the status of contraceptive methods in major health delivery and financing schemes in 9 LAC countries. Using a set of 37 indicators on family planning coverage, family planning financing, health financing, and family planning inclusion in UHC-oriented schemes, we conducted a desk review of secondary sources, including population surveys, health financing assessments, insurance enrollment reports, and unit cost estimates, and interviewed in-country experts.Findings: Although the modern contraceptive prevalence rate (mCPR) has continued to increase in the majority of LAC countries, substantial disparities in access for marginalized groups remain. On average, mCPR is 20% lower among indigenous women than the general population, 5% lower among uninsured women than insured, and 7% lower among the poorest women than the wealthiest. Among the poorest quintile of women, insured women had an mCPR 16.5 percentage points higher than that of uninsured women, suggesting that expansion of insurance coverage is associated with increased family planning access and use. In the high- and upper-middle-income countries we reviewed, all modern contraceptive methods are typically available through the social health insurance schemes that cover a majority of the population. However, in low- and lower-middle-income countries, despite free provision of most family planning services in public health facilities, stock-outs and implicit rationing present substantial barriers that prevent clients from accessing their preferred method or force them to pay out of pocket.ConclusionLeveraging UHC-oriented schemes to sustain and further increase family planning progress will require that governments take deliberate steps to (1) target poor and informal sector populations, (2) include family planning in benefits packages, (3) ensure sufficient financing for family planning, and (4) reduce nonfinancial barriers to access. Through these steps, countries can increase financial protection for family planning and better ensure the right to health of poor and marginalized populations.

Dataset Information

Sex, socioeconomic status, access to cardiac catheterization, and outcomes for acute coronary syndromes in the context of universal healthcare coverage.

Publications

Sex, socioeconomic status, access to cardiac catheterization, and outcomes for acute coronary syndromes in the context of universal healthcare coverage.

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