ORIGINAL ARTICLE
Neighborhood Income and Individual Education: Effect on Survival After Myocardial Infarction

https://doi.org/10.4065/83.6.663Get rights and content

OBJECTIVE

To evaluate the association of neighborhood-level income and individual-level education with post-myocardial infarction (MI) mortality in community patients.

PATIENTS AND METHODS

From November 1, 2002, through May 31, 2006, 705 (mean ± SD age, 69±15 years; 44% women) residents of Olmsted County, MN, who experienced an MI meeting standardized criteria were prospectively enrolled and followed up. The neighborhood's median household income was estimated by census tract data; education was self-reported. Demographic and clinical variables were obtained from the medical records.

RESULTS

Living in a less affluent neighborhood and having a low educational level were both associated with older age and more comorbidity. During follow-up (median, 13 months), 155 patients died. Neighborhood income (hazard ratio [HR], 2.10; 95% confidence interval [CI], 1.42-3.12; for lowest [median, $34,205] vs highest [median, $60,652] tertile) and individual education (HR, 2.21; 95% CI, 1.47-3.32; for <12 vs >12 years) were independently associated with mortality risk. Adjustment for demographics and various post-MI prognostic indicators attenuated these estimates, yet excess risk persisted for low neighborhood income (HR, 1.62; 95% CI, 1.08-2.45). Modeled as a continuous variable, each $10,000 increase in annual income was associated with a 10% reduction in mortality risk (adjusted HR, 0.90; 95% CI, 0.82-0.99).

CONCLUSION

In this geographically defined cohort of patients with MI, low individual education and poor neighborhood income were associated with a worse clinical presentation. Poor neighborhood income was a powerful predictor of mortality even after controlling for a variety of potential confounding factors. These data confirm the socioeconomic disparities in health after MI.

Section snippets

PATIENTS AND METHODS

The study was conducted in Olmsted County, MN, where Mayo Clinic and the Olmsted Medical Center provide medical care for all county residents. Each institution uses a unit medical record in which the details of care for a patient, regardless of setting, are available in one place. The records are easily retrievable because Mayo Clinic maintains extensive indices that, through the Rochester Epidemiology Project, are extended to the records of other health care providers in the county, linking

RESULTS

The baseline characteristics across income tertiles and education categories are presented in Table 2. On average, patients living in less affluent areas were older and more likely to be female and of races other than white. They also presented with more comorbidity and included a higher proportion of smokers than their more affluent counterparts. No other differences were observed after adjustment for age and sex. The percentages of patients with fewer than, equal to, and greater than 12 years

DISCUSSION

Measures of SES are well-established determinants of overall health, quality of life, and life expectancy.33, 34 However, because SES is a complex multidimensional construct, the mechanisms by which it affects health are still incompletely understood. Although SES has traditionally been treated as an intrinsic characteristic of individuals, contextual effects of SES on health are theoretically important. Indeed, growing evidence suggests that a person's health can be influenced by the

CONCLUSION

In this community-based cohort of MI, low neighborhood income and lower levels of individual education were associated with a worse clinical presentation. Further, both measures showed a dose-response relationship with mortality. The association between low neighborhood income and increased mortality risk persisted even after controlling for a variety of potential confounders. These findings indicate the importance of SES in determining prognosis after MI.

Acknowledgments

We are indebted to Ellen E. Koepsell, RN, and Susan Stotz, RN, for valuable assistance in study coordination and data collection.

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    This study was funded by grants from the Public Health Service and the National Institutes of Health (AR30582, R01 HL 59205, and R01 HL 72435). Dr Roger is an Established Investigator of the American Heart Association.

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