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Low-income patients at higher risk of death after heart attack, regardless of what country they live in


Despite vastly different healthcare systems, low-income patients across six different countries have mortality rates that are 10 to 20% greater than their high-income peers, according to a new study from ICES, Harvard Medical School, and the University of Texas Medical Branch, Galveston.

The researchers say that the findings suggest there are income-based disparities present even in countries with universal healthcare and robust social services.

“A country’s healthcare system can impact treatment and outcomes for specific health conditions, like cardiovascular disease,” says Bruce Landon, an internist and professor of medicine at the Beth Israel Deaconess Medical Center, and professor of healthcare policy at Harvard Medical School. “We wanted to explore whether the poorer outcomes that have been observed in lower-income Americans relative to higher-income Americans were reduced in countries with universal health insurance. We found that high-income individuals had better survival rates and were more likely to receive life-saving treatments compared to low-income individuals, regardless of their country of residence or type of health system.”

The authors analyzed medical records of all adults 66 years or older who were hospitalized with a type of heart attack known as ST-elevation myocardial infarction (STEMI, which tends to be more severe) and non-ST-elevation myocardial infarction (NSTEMI). Outcomes for STEMI and NSTEMI patients with low incomes were compared with outcomes among patients with high income in the US, Canada (Ontario and Manitoba), England, Netherlands, Taiwan, and Israel between 2013 and 2018.

Published in the journal JAMA, the study included 289,376 patients hospitalized with STEMI and 843,046 patients hospitalized with NSTEMI. Findings showed that:

  • Thirty-day mortality following hospitalization generally was 1-3 percentage points lower for high-income patients. The largest difference was seen in Canada (14.9% and 17.8% for high versus low-income individuals with STEMI).
  • Differences in one-year mortality were even larger, with the highest difference in Israel (16.2% and 25.3% for high versus low-income individuals with STEMI).
  • Low-income patients in all countries were less likely to receive necessary and aggressive treatments for STEMI, including cardiac catheterization and revascularization, and readmission rates to hospital were higher than for low-income patients.
  • There were more females in the lowest-income group compared to the highest-income group in all countries.

“These results suggest that countries around the world need to redouble their efforts to assure the delivery of equitable care to persons across the spectrum of socioeconomic status,” says Dr. Landon.

Though the researchers accounted for the possible effects of other diseases the patients had, it is still possible that there were other health-related factors that influenced higher rates of death and lower rates of treatment for low-income patients. The authors caution they did not adjust for race and ethnicity because these data were not available for all the countries and populations included in the study. Moreover, all Americans in the study had health insurance, so it is unclear if the results might have been different if uninsured Americans were included.

The researchers say that further efforts are needed to explore the availability and quality of hospital care in these regions, which could affect a patient’s access to treatment.

“Our results challenge the belief that income-based disparities are a uniquely American phenomenon. The truth is that the poverty penalty seems consistent across countries,” says senior author Peter Cram, an adjunct scientist at ICES and The University of Texas Medical Branch, Galveston. “All countries, including Canada, need to address these issues and improve healthcare delivery for older patients who experience severe heart attacks.”

The study “Differences in treatment patterns and outcomes of acute myocardial infarction for low- and high-income patients in 6 countries: an analysis from the International Health Systems Research Collaborative” was published in JAMA.

Author block: Landon BE, Hatfield LA, Bakx P, Banerjee A, Chen Y-C, Fu C, Gordon M, Heine R, Huang N, Ko DT, Lix LM, Novack V, Pasea L, Qiu F, Stukel TA, Uyl-de Groot C, Yan L, Weinreb G, Cram P.

ICES is an independent, non-profit research institute that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. In October 2018, the institute formerly known as the Institute for Clinical Evaluative Sciences formally adopted the initialism ICES as its official name. For the latest ICES news, follow us on Twitter: @ICESOntario


Misty Pratt
Senior Communications Officer, ICES
[email protected]


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