Analysis of Multinational Trial Finds Patients with STEMI Who Complete Less than 8 Years of Schooling Less Likely to Receive Certain Treatments, More Likely to Die
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Health care providers may want to gauge patients’ level of education during routine medical histories and spend more time teaching lesser educated patients about coronary disease and the importance of secondary prevention and compliance with evidence-based treatments, according to researchers. New data published in the January 11, 2011, issue of the Journal of the American College of Cardiology (JACC) suggest years of (completed) education is a powerful predictor of mortality in older patients with acute ST-segment elevation myocardial infarction (STEMI).
In particular, early mortality (at 24 hours and 30 days) and in-hospital nonfatal stroke were approximately 4- to 13-fold higher in individuals with less than 8 years of education compared to those with more than 16 years of education. Similarly, 1-year mortality was inversely related to number of years of education and was more than 5-fold higher in subjects with less than 8 years of education, compared with those with more than 16 years of education (17.5% vs. 3.5%, p < 0.0001). Years of education remained independently associated with mortality, even after accounting for important baseline variables (e.g., age, factors that indicate poorer prognosis, heart rate) and country of enrollment.
Patients with the least amount of education were more likely to be women with a history of diabetes, previous congestive heart failure and heart attack; but less likely to have had previous percutaneous coronary intervention compared to those with more education. Aspirin therapy and beta blockers were also less frequently used in patients who were not as educated.
According to authors, years of education could also be a surrogate marker of other factors strongly related to mortality in patients with STEMI; for example, social isolation (living alone), life stress, poverty, lack of insurance and inability to afford medications and/or access subsequent care, lack of compliance with strategies of secondary prevention, including lifestyle changes, or limited health literacy.
Unlike previous, smaller studies that have reported an inverse relationship between lower socioeconomic status (SES) – as measured by years of education – and mortality, the present analysis evaluated 11,326 patients with STEMI in the GUSTO-III (Global Use of Strategies to Open Occluded Coronary Arteries) trial from multiple countries that enrolled more than 500 patients.
Based on the study results, authors point out that comparisons of in-hospital mortality in patients with CHD that adjust for baseline variables without accounting for educational status or other SES measures may place institutions that care for large numbers of socially underprivileged patients at a significant and inappropriate disadvantage, given that such comparisons are typically used as part of measuring, publicly reporting, and rewarding quality. “Our study shows educational status/SES to be the most important factor, after age, associated with early mortality. Adjusting for education/SES could help level the playing field for providers by recognizing differences among their patient populations and allow fairer comparisons of outcome measures as a surrogate for quality,” they write.
The American College of Cardiology is transforming cardiovascular care and improving heart health through continuous quality improvement, patient-centered care, payment innovation and professionalism. The College is a 39,000-member nonprofit medical society comprised of physicians, surgeons, nurses, physician assistants, pharmacists and practice managers, and bestows credentials upon cardiovascular specialists who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. More information about the association is available online at http://www.cardiosource.org/ACC.