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Alter DA, Iron K, Austin PC, Naylor CD, for the SESAMI Study Group. Socioeconomic Status, Service Patterns, and Perceptions of Care Among Survivors of Acute Myocardial Infarction in Canada. JAMA. 2004;291(9):1100–1107. doi:10.1001/jama.291.9.1100
Author Affiliations: Institute for Clinical Evaluative Sciences (Drs Alter, Austin, and Naylor and Ms Iron); the Division of Cardiology, Schulich Heart Centre and Department of Medicine, Sunnybrook and Women's College Health Sciences Centre, University of Toronto (Dr Alter); Departments of Public Health Sciences and Health Policy, Management, and Evaluation (Dr Austin); and the Department of Medicine and the Dean's Office, University of Toronto (Dr Naylor), Toronto, Ontario.
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
health care is unknown.
Objectives To explore how patients with acute myocardial infarction from different
socioeconomic backgrounds perceive their care in Canada's universal health
care system and to correlate patients' backgrounds and perceptions with actual
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
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 or higher vs less than
Can $30 000, respectively; P<.001). After
adjusting for baseline characteristics, socioeconomic status was not significantly
associated with mortality at 1 year following hospitalization for myocardial
Conclusions Compared with those with lower incomes or less education, upper middle-class
Canadians gain preferential access to services within the publicly funded
health care system yet remain more likely to favor supplemental coverage or
direct purchase of services.
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