Coronary artery bypass graft surgery: socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy

OBJECTIVES—To evaluate whether coronary artery bypass graft (CABG) surgery is equally provided among different socioeconomic status (SES) groups in accordance with need. To estimate the association between SES and mortality occurring 30 days after CABG surgery.
DESIGN—Individual socioeconomic index assigned with respect to the characteristics of the census tract of residence (level I = highest SES; level IV = lowest SES). Comparison of age adjusted hospital admission rates of ischaemic heart disease (IHD) and CABG surgery among four SES groups. Retrospective cohort study of all patients who underwent CABG surgery during 1996-97.
SETTING—Rome (2 685 890 inhabitants) and the seven cardiac surgery units in the city.
PARTICIPANTS—All residents in Rome aged 35 years or more. A cohort of 1875 CABG patients aged 35 years or more.
MAIN OUTCOME MEASURES—Age adjusted hospitalisation rates for CABG and IHD and rate of CABG per 100 IHD hospitalisations by SES group, taking level I as the reference group. Odds ratios of 30 day mortality after CABG surgery, adjusted for age, gender, illness severity at admission, and type of hospital where CABG was performed.
RESULTS—People in the lowest SES level experienced an excess in the age adjusted IHD hospitalisation rates compared with the highest SES level (an excess of 57% among men, and of 94% among women), but the rate of CABG per 100 IHD hospitalisations was lower, among men, in the most socially disadvantaged level (8.9 CABG procedures per 100 IHD hospital admissions in level IV versus 14.1 in level I rate ratio= 0.63; 95% CI 0.44, 0.89). The most socially disadvantaged SES group experienced a higher risk of 30 day mortality after CABG surgery (8.1%) than those in the highest SES group (4.8%); this excess in mortality was confirmed even when initial illness severity was taken into account (odds ratio= 2.89; 95% CI 1.44,( )5.80).
CONCLUSIONS—The universal coverage of the National Health Service in Italy does not guarantee equitable access to CABG surgery for IHD patients. Factors related to SES are likely to influence poor prognosis after CABG surgery.


Keywords: coronary artery bypass graft; ischaemic heart disease; socioeconomic statu

Excess mortality from avoidable and non-avoidable causes in men of low socioeconomic status: a prospective study in Korea

STUDY OBJECTIVE—The objective of this study was to evaluate the magnitude and contributory factors of socioeconomic differentials in mortality in a cohort of Korean male civil servants.
DESIGN—A prospective observational study of male civil servants followed up for five years after baseline measurement.
SETTING—All civil service offices in Korea.
PARTICIPANTS AND MEASUREMENTS—The study was conducted on 759 665 Korean male public servants aged 30-64 at baseline examination in 1992. The grade of monthly salary of these participants divided into four groups, a proxy indicator of socioeconomic status (SES), was the main predictive variable. Mortality of the participants was followed up from 1992( )to 1996. The causes of deaths were categorised into four groups according to the medical amenability: avoidable, partly avoidable, non-avoidable, and external causes of death. The risk of mortality associated with SES was estimated using the Cox proportional hazard model.
MAIN RESULTS—Lowest SES group had significantly higher risk of mortality from most causes compared with the highest SES group in the order of external cause (relative risk (RR): 2.26), avoidable (RR: 1.65), all cause (RR: 1.59), and non-avoidable mortality (RR: 1.54). With the adjustment of known risk factors, significantly higher risks of mortality in lowest SES group were attenuated but persisted. Looking at the deaths from partly avoidable causes, significantly higher risks of mortality in the lowest SES group was observed from cerebrovascular disease but not from coronary heart disease.
CONCLUSIONS—Socioeconomic differentials in non-avoidable as well as avoidable mortality, persisting even under the control of risk factors, suggest that mortality is influenced not only by the quality of health care and different distribution of risk factors but also by other aspects of SES that are yet unknown.