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Socioeconomic status, service patterns, and perceptions of care among survivors of acute myocardial infarction in Canada


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 healthcare is unknown.

Objectives — To explore how patients with acute myocardial infarction from different socioeconomic backgrounds perceive their care in Canada's universal healthcare 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 dollars or higher vs less than Can 30 000 dollars, 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 healthcare system yet remain more likely to favor supplemental coverage or direct purchase of services.



Alter DA, Iron K, Austin PC, Naylor CD; SESAMI Study Group. JAMA. 2004; 291(9):1100-7.

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