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Background: Gradients that link socioeconomic status and cardiovascular mortality have been observed in many populations, including those of countries that provide publicly funded comprehensive medical coverage. The intermediary causes of such gradients remain poorly elucidated.Objective: To examine the relationships among socioeconomic status, other health factors, and 2-year mortality rates after acute myocardial infarction (MI).Design: Prospective cohort study.Setting: Ontario, Canada.Patients: 3407 patients who were hospitalized for acute MI in 53 large-volume hospitals in Canada from December 1999 to February 2003.Measurements: The authors obtained self-reported measures of income and education and developed profiles of the patients' prehospitalization cardiac risks and comorbid conditions. To create these profiles, the authors used the patients' self-reports and retrospectively linked no less than 12 years' worth of previous hospitalization data. Mortality rates 2 years after acute MI were examined with and without sequential risk adjustment for age, sex, ethnicity, social support, cardiovascular history and risk, comorbid conditions, and selected in-hospital process factors.Results: Income was strongly and inversely correlated with 2-year mortality rate (crude hazard ratio for high-income vs. low-income tertile, 0.45 [95% CI, 0.35 to 0.57]; P < 0.001). However, after adjustment for age and preexisting cardiovascular events or conventional vascular risk factors, the effect of income was greatly attenuated (adjusted hazard ratio for high-income vs. low-income tertile, 0.77 [CI, 0.54 to 1.10]; P = 0.150). Noncardiovascular comorbid conditions and in-hospital process factors had negligible explanatory effect.Limitations: Previous cardiovascular risks were ascertained through self-report or retrospectively through the longitudinal tracking of the hospitals' administrative databases. The study began with a cohort of patients who had an index cardiac event rather than with asymptomatic individuals.Conclusions: Age, past cardiovascular events, and current vascular risk factors accounted for most of the income-mortality gradient after acute MI. This observation suggests that the "wealth-health gradient" in cardiovascular mortality may be partially ameliorated by more rigorous management of known risk factors among less affluent persons. *For a list of members of the SESAMI Study Group, see the Appendix. [ABSTRACT FROM AUTHOR]

Background: A relationship between higher patient volume and both better quality of care and better outcomes has been shown for many acute care conditions. Whether a volume-quality relationship exists for the outpatient management of chronic diseases is uncertain., Objective: To explore the association between primary care physician volume and quality of diabetes care., Design: Cohort study., Setting: The study was conducted using linked population-based health care administrative data in Ontario, Canada., Patients: 1 018 647 adults with diabetes in 2011 who received care from 9014 primary care physicians. Two measures of volume were ascertained for each physician: overall ambulatory volume (representing time available to devote to chronic disease management during patient encounters) and diabetes-specific volume (representing disease-specific expertise)., Measurements: Quality of care was measured over a 2-year period using 6 indicators: disease monitoring (eye examination, hemoglobin A1c testing, and low-density lipoprotein cholesterol testing), prescribing appropriate medications (angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers and statins), and adverse clinical outcomes (emergency department visits for hypoglycemia or hyperglycemia)., Results: Higher overall ambulatory volume was associated with lower rates of appropriate disease monitoring and medication prescription. In contrast, higher diabetes-specific volume was associated with better quality of care across all 6 indicators., Limitation: Only a select set of quality indicators and potential confounders could be ascertained from available data., Conclusion: Primary care physicians with busier ambulatory patient practices delivered lower-quality diabetes care, but those with greater diabetes-specific experience delivered higher-quality care. These findings show that relationships between physician volume and quality can be extended from acute care to outpatient chronic disease care. Health policies or programs to support physicians with a low volume of patients with diabetes may improve care., Primary Funding Source: Canadian Institutes of Health Research.

Background: The magnitude, consistency, and manner of association between sedentary time and outcomes independent of physical activity remain unclear., Purpose: To quantify the association between sedentary time and hospitalizations, all-cause mortality, cardiovascular disease, diabetes, and cancer in adults independent of physical activity., Data Sources: English-language studies in MEDLINE, PubMed, EMBASE, CINAHL, Cochrane Library, Web of Knowledge, and Google Scholar databases were searched through August 2014 with hand-searching of in-text citations and no publication date limitations., Study Selection: Studies assessing sedentary behavior in adults, adjusted for physical activity and correlated to at least 1 outcome., Data Extraction: Two independent reviewers performed data abstraction and quality assessment, and a third reviewer resolved inconsistencies., Data Synthesis: Forty-seven articles met our eligibility criteria. Meta-analyses were performed on outcomes for cardiovascular disease and diabetes (14 studies), cancer (14 studies), and all-cause mortality (13 studies). Prospective cohort designs were used in all but 3 studies; sedentary times were quantified using self-report in all but 1 study. Significant hazard ratio (HR) associations were found with all-cause mortality (HR, 1.240 [95% CI, 1.090 to 1.410]), cardiovascular disease mortality (HR, 1.179 [CI, 1.106 to 1.257]), cardiovascular disease incidence (HR, 1.143 [CI, 1.002 to 1.729]), cancer mortality (HR, 1.173 [CI, 1.108 to 1.242]), cancer incidence (HR, 1.130 [CI, 1.053 to 1.213]), and type 2 diabetes incidence (HR, 1.910 [CI, 1.642 to 2.222]). Hazard ratios associated with sedentary time and outcomes were generally more pronounced at lower levels of physical activity than at higher levels., Limitation: There was marked heterogeneity in research designs and the assessment of sedentary time and physical activity., Conclusion: Prolonged sedentary time was independently associated with deleterious health outcomes regardless of physical activity., Primary Funding Source: None.

Background: The public health insurance system in Canada is predicated on equal access to care for persons in need., Objective: To determine the views and experiences of Ontario physicians and hospital administrators in providing patients with preferential access to specialized cardiovascular care on the basis of nonclinical factors., Design: Survey with self-administered questionnaire., Setting: Ontario, Canada., Participants: All Ontario cardiologists (n = 268), cardiac surgeons (n = 68), and hospital chief executives (n = 218) and random samples of internists (n = 300) and family physicians (n = 300)., Measurements: Elicited responses (yes or no) to questions on whether and why preferential access occurred and whether the respondents had been personally involved in such a situation., Results: After undeliverable surveys and respondents no longer involved with acute care were excluded, the eligible response rate was 71.3% (788 of 1105 respondents). More than 80% of physicians and 53% of hospital chief executives had been personally involved in managing a patient who had received preferential access on the basis of factors other than medical need. Patients deemed most likely to receive such treatment were those with personal ties to the treating physicians (93% [95% CI, 91% to 95%]), high-profile public figures (85% [CI, 82% to 87%]), and politicians (83% [CI, 80% to 86%]). Physicians were significantly more likely than chief executives to indicate that hospital board members (81% and 68%; P < 0.001) and donors to hospital foundations (63% and 42%; P < 0.001) would receive preferential access. Most respondents indicated that preferential access was more likely to be provided if patients or families were well informed, aggressive, or potentially litigious. The survey did not permit estimation of the frequency of episodes of preferential access., Conclusions: Although equality of access is a cornerstone principle of Canada's universal health care system, some access to specialized cardiovascular services occurs preferentially on the basis of factors other than clinical need. The actual magnitude and consequences of this phenomenon remain unknown.