Oct. 27, 1999 (Cleveland) — Canada guarantees access to health care to all its citizens, but a new study suggests that the care isn’t always doled out in an equal fashion. Richer Canadians were more likely to undergo a procedure to open clogged blood vessels after a heart attack than were poorer Canadians, and money also played a role in survival, according to a study in the Oct. 28th issue of TheNew England Journal of Medicine.
Study author Jack V. Tu, MD, PhD, a scientist with the Institute for Clinical Evaluative Sciences in Toronto, says that patients from higher income neighborhoods also had shorter waits for heart catheterization. Most striking was the link between income and mortality: each $10,000 increase in neighborhood median income was associated with a 10% decrease in the risk of death at one year.
Tu, who also teaches at the University of Toronto, tells WebMD that he can only guess at reasons for the differences, but he says it is likely that poorer patients have an overall worse health status before the heart attack than do wealthier patients. “They are more likely to smoke, have diabetes, [or] hypertension, and their pre-heart-attack treatment is perhaps less good than those from wealthier neighborhoods,” he says.
Tu and his co-authors studied more than 51,000 patients admitted to Ontario hospitals for heart attacks from April 1994 through March 1997. The average age of the patients was 69. The patients were categorized by neighborhood, and the neighborhoods were divided into five categories based on median personal income. The lowest group had personal yearly incomes in the range of $8,505 to $12,192 in U.S. dollars, while the highest tier had incomes ranging from $17,884 to $30,198, U.S. dollars.
“In total, 15.7% of patients in the lowest income [group] and 20.3% of those in the highest income [group] underwent [heart bypass or balloon angioplasty]. ? Higher neighborhood median income consistently predicted greater use of [catheterization],” Tu and colleagues write. Additionally, this income effect held even for the elderly: wealthier persons 70 or older were more likely to get a heart catheterization than were poorer elderly patients.
Tu says he doesn’t think the study can be interpreted as saying that universal health insurance is not good. “I think it illustrates that universal health insurance doesn’t solve all the problems in terms of socioeconomic influences on health.” Other studies have demonstrated that socioeconomic differences affect care in the U.S. as well, and “I think the differences may be even worse in the U.S.”
Ida Hellander, MD, executive director of Physicians for a National Health Program, a Chicago-based physician group that advocates for the U.S. to adopt a Canadian-style health system, says it’s not news that universal access doesn’t mean equality of care. She says that studies from the National Health Service in the U.K. have already illustrated economic differences persisting even with national health insurance. Hellander tells WebMD that “a cross-border study would probably have shown much worse differences in the U.S.”
Hellander says that, in Canada, inequities in care are more likely to be found at the level of specialized care — such as balloon angioplasty — but in the U.S. “we find disparities in simple things like prenatal care and control of [high blood pressure].”
Tu says that he and his co-authors are planning a number of studies to pursue the theme of socioeconomic differences. “We are going to expand to look at congestive heart failure and stroke,” he says.