Socioeconomic status and severity of illness on admission in acute myocardial infarction patients.

The objective of this research is to test the hypothesis of the existence of an association between socioeconomic status and severity of illness of the patients admitted to the hospital with acute myocardial infarction. The design was a retrospective cohort study of consecutive patients admitted to the coronary care unit with the diagnosis of acute myocardial infarction in six public hospitals from the Spanish region of Valenciá. A total of 369 patients admitted to the intensive care units of the participating hospitals were studied. The socioeconomic status was measured using an ad hoc index based upon the occupational level, income and educational level of the patient. The patients below the 20% percentile were considered as disadvantaged, and the patients whose Killip class on admission was 3 or 4 were considered as complicated. The effect of potential confounders was controlled using unconditional logistic regression analysis. The results were validated in an independent but comparable population of 331 patients. The disadvantaged patients showed a higher prevalence of open cardiac failure on admission (Killip classes 3 or 4) than the remainder (crude odds ratio = 3.1, 95% confidence interval between 1.57 and 6.1). The association between socioeconomic status and severity of illness persisted after controlling for important covariates (age, diabetes mellitus, gender and marital status): adjusted odds ratio = 2.4, 95% confidence interval between 1.1 and 5.2. These results were highly consistent with those in the validation group. Our results suggest that socioeconomic status is an independent predictor of the severity of illness on admission to coronary care units in acute myocardial infarction patients. These results are consistent with the existence of a low accessibility of patients in the lower socioeconomic levels.

[Differences in therapeutic effort because of the socioeconomic level of patients with acute myocardial infarction]. / Diferencias de esfuerzo terapéutico en razón del nivel socioeconómico en pacientes con infarto agudo de miocardio.

OBJECTIVES: To assess the hypothesis of the existence of differential therapeutic effort according to the socioeconomic status of the patients admitted to the hospital by acute myocardial infarction. PATIENTS AND METHODS: We study retrospectively 592 patients admitted to the intensive care units from six public hospitals from the Spanish region of Valencia, using data from two cohort studies focused on the study of in-hospital inequalities in health. The socioeconomic status was measured using the British occupational classification. The therapeutic effort predicted for the severity of illness was determined using a regression model that included the logarithm of Therapeutic Intervention Scoring System (TISS) score as the dependent variable and Simplified Acute Physiology Score (SAPS) score and Killip group as predictors. The patients whose observed TISS was 3 or more pointless than predicted were considered as infra-treated. The effect of potential confounders was controlled using unconditional logistic regression analysis. RESULTS: The proportion of infra-treated patients was inversely related to socioeconomic status chi 2 for tendency = 4.31, P = 0.0378). The logistic regression analysis showed a negative association between age and therapeutic effort (p < 0.0001) but not between therapeutic effort and socioeconomic status, after controlling the effect of age (p = 0.2150). DISCUSSION: Our results suggest that older patients receive less relative therapeutic effort, measured by TISS score, than younger patients. The differential therapeutic effort observed in the crude analysis seem attributable to the higher age of the patients in the lower socioeconomic strata.

[Effect of social factors on quality of life of survivors of myocardial infarction]. / Efecto de los factores sociales sobre la calidad de vida de los supervivientes de un infarto de miocardio.

BACKGROUND: The aim of this study was to analyze the effect of the social environment on the quality of life of the survivors of an acute myocardial infarction. METHODS: A prospective cohort study was carried out with telephone follow up of patients admitted in the Intensive Care Units of six public hospitals in the region of Valencia (Spain). Three hundred eighty consecutive patients admitted for acute myocardial infarction were studied being followed a median of 3.4 years. Follow up was complete in 91.6% of the cases. RESULTS: The global quality of life was good. The component most affected was that of physical activity. Following control of the effect of the biologic and health care covariables, the quality of life was inversely and independently associated with age, female sex, low educative level and foreigness. CONCLUSIONS: Unequality was found in regard to the quality of life based on the socioeconomic level of survivors of acute myocardial infarction.

[Construction and validation of an index of psychosocial adjustment in intensive care without interviewing the patient. Group of Researchers of the ASCI (social support in intensive care) Project]. / Construcción y validación de un índice de ajuste psicosocial en cuidados intensivos sin entrevista del paciente. Grupo de Investigadores del Proyecto ASCI.

BACKGROUND: Psycho-social support factors play an important role in the health status of the community. Their effect on the clinical course of critically ill patients is poorly known. One of the main obstacles for their study is the difficulty of the measurement of psychosocial factors in the critical care environment. The objective of this study is to build-up and validate an instrument to assess the psycho-social adjustment in critical care patients. METHODS: We have studied 214 adult patients admitted to the intensive care unit (ICU) in a public hospital with 420 beds. None of them was in coma or showed signs of encephalopathy or acute psychosis. Each patient was independently evaluated by two nurses that rated 15 variables related to the patient's psychosocial environment, without direct interview of the patient. The inter-observer concordance was assessed using the weighted kappa index. The internal consistency of the selected items was assessed by the Cronbach's index. RESULTS: The inter-observer concordance in the assessment of the different items was always higher than 0.4. The classical analysis of the internal consistency selected 7 items (environmental confidence, perceived family-support, refusal of the critical situation, irritation, affliction, empathy and liking) which showed an alpha coefficient of 0.77. The psychosocial adjustment scale built upon these 7 items showed a good inter-observer concordance (kappa = 0.71). CONCLUSIONS: Critical care nurses can reliably assess some psychosocial variables in critical care patients. These assessments allows the building of a scale of psychosocial adjustment in the ICU applicable to a wide variety of critical patients and that does not requires direct interview of the patient.