Researchers link poverty, death rate

In the first study of its kind, researchers at the Medical Center have found that although less affluent patients receive similar care as those with higher incomes, they still have a higher rate of death and repeat heart attacks.

The study, which examined clinical observations of patients enrolled in a nationwide trial, confirmed previous results that suggested lower-income patients had higher mortality rates than those with higher incomes. However, those studies were based on observational records, where missing data was corrected for using statistical techniques.

"[Those] studies used substitutes for income to define who was poor. For example, they used years of education, occupation or residence in a poor neighborhood," lead investigator Dr. Sunil Rao, chief cardiology fellow at the Duke Clinical Research Institute, wrote in an e-mail. "Our study was in the setting of a clinical trial where data collection is rigorous and complete. We also asked participants directly what their income was rather than rely on income Oproxies' that have the potential to provide inaccurate information."

Despite receiving standardized treatment, patients with an annual household income of less than $10,000 were more than twice as likely to die from severe heart disease or have a repeat heart attack after 30 days and also after six months. "It's not what happens in the hospital but what happens when the patient goes home that really matters," Rao wrote. "For example, poor patients may get prescriptions for medications that they need, but may not be able to afford them. They may go back to a home situation where they have no social support or where it is hard to maintain a healthy lifestyle."

Furthermore, researchers are concerned because this group of lower-income people is expected to rise from 33 million to 77 million by 2030. Also, the majority are female and elderly and, although medications have steadily improved, costs for treatment have simultaneously increased.

"From a research perspective, we have to start understanding issues that affect the continuity of care, such as patient compliance, degree of [physician] follow-up and how to afford medication. From a physician perspective, this should advocate the need for a healthcare system that can provide equity [in care] from a long-term perspective," said senior team member Dr. Eric Peterson, an associate professor in the division of cardiology. "This leads to questions about whether we should be investigating systems to address these problems, either for future research or for potential policy changes."

The study, however, presented at the American College of Cardiology's annual meeting last week, had a relatively small patient size and did not measure post-discharge factors. The researchers plan to consider these issues in subsequent studies, in addition to looking at the potential effects of implementing a comprehensive home health regimen.

"The implications [of this study] are profound. The majority of people in our study were at the age where they are eligible for Medicare. They are the largest consumers of health care and are disproportionately affected by heart disease and poverty. At some point, and we may be there already, something will have to give," Rao wrote. "The answers, unfortunately, are not easy. As a nation we have to make some tough choices about helping the poor."