J Epidemiol Community Health 2000;54:930-935 ( December )

Public health policy and practice

Coronary artery bypass graft surgery: socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy Carla Ancona, Nera Agabiti, Francesco Forastiere, Massimo Arcà, Danilo Fusco, Salvatore Ferro, Carlo A Perucci

Agency for Public HealthLazio, Italy

Correspondence to: Dr Ancona, Agency for Public HealthLazio, Italy, Via S Costanza,53 00198 Rome, Italy (outcome1{at}asplazio.it)

Accepted for publication 7 June 2000

OBJECTIVESTo evaluate whether coronary artery bypass graft (CABG) surgery is equally provided among different socioeconomic status (SES) groups in accordance with need. To estimate the association between SES and mortality occurring 30 days after CABG surgery.
DESIGNIndividual socioeconomic index assigned with respect to the characteristics of the census tract of residence (level I = highest SES; level IV = lowest SES). Comparison of age adjusted hospital admission rates of ischaemic heart disease (IHD) and CABG surgery among four SES groups. Retrospective cohort study of all patients who underwent CABG surgery during 1996-97.
SETTINGRome (2 685 890 inhabitants) and the seven cardiac surgery units in the city.
PARTICIPANTSAll residents in Rome aged 35 years or more. A cohort of 1875 CABG patients aged 35 years or more.
MAIN OUTCOME MEASURESAge adjusted hospitalisation rates for CABG and IHD and rate of CABG per 100 IHD hospitalisations by SES group, taking level I as the reference group. Odds ratios of 30 day mortality after CABG surgery, adjusted for age, gender, illness severity at admission, and type of hospital where CABG was performed.
RESULTSPeople in the lowest SES level experienced an excess in the age adjusted IHD hospitalisation rates compared with the highest SES level (an excess of 57% among men, and of 94% among women), but the rate of CABG per 100 IHD hospitalisations was lower, among men, in the most socially disadvantaged level (8.9 CABG procedures per 100 IHD hospital admissions in level IV versus 14.1 in level I rate ratio= 0.63; 95% CI 0.44, 0.89). The most socially disadvantaged SES group experienced a higher risk of 30 day mortality after CABG surgery (8.1%) than those in the highest SES group (4.8%); this excess in mortality was confirmed even when initial illness severity was taken into account (odds ratio= 2.89; 95% CI 1.44, 5.80).
CONCLUSIONSThe universal coverage of the National Health Service in Italy does not guarantee equitable access to CABG surgery for IHD patients. Factors related to SES are likely to influence poor prognosis after CABG surgery.


Keywords: coronary artery bypass graft; ischaemic heart disease; socioeconomic status

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© 2000 by Journal of Epidemiology and Community Health
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