Quality of care after first acute myocardial

infarction (AMI)

a comparison of native Danes and immigrants from Turkey, Pakistan and the former Yugoslavia

Nana Folmann Hempler, PhD, Post.doc

University of Copenhagen Centre for Healthy Aging

Section for Health Services Research Department of Public Health

Do immigrants receive adequate medical treatment with beta-blockers and statins after acute myocardial infarction, compared with native Danes? Are potential differences partially explained by social inequalities?

Research questions

Increased number of CVD-specific hospital contacts Folmann and Jørgensen 2006, Ingerslev 2000

Increased diabetes Kristensen et al. 2007

CVD risk factors increased Singhammer 2008

Increased incidence of CVD and AMI among Turks and Pakistanis Hempler NF et al. 2011

Data on cardiovascular disease (CVD) among Non-Western immigrants in Denmark

Lack of studies regarding:

• Immigrants’ access to healthcare services

• Whether immigrants with CVD receive adequate treatment

Data on CVD

Immigrants and descendants comprise 10% of the population Statistics Denmark 2010

Two-thirds originate from a non-Western country

Background

Background

Capital Region of Denmark or Central Denmark Region (n=3,107,901)

Study population:

• Native Danes

• Turks, Pakistanis, former Yugoslavians (not including refugees from the civil war)

Non-Western groups with:

• The longest duration of stay in Denmark

• The highest average age

Methods

Native Danes were used as the reference group

However, not a gold standard

Definitions

Social inequalities

Differences in socioeconomic status (SES)

Health Access to healthcare services Quality of care

Socioeconomic status (SES)

Lower SES among non-Western immigrants compared with native Danes

• Income

• Education

• Employment

• Housing conditions

Data Sources

Admissions Redeemed prescriptions

Employment, income Country of birth

Migrations Deaths

The Danish Demographic Registry

The Integrated Database for Labour Market Research

The Danish Registry of Medical Product Statistics

The Registry of Causes of Death

The Danish National Patient Registry

The Central Population Registry

Immigrant:

Born in a foreign country to parents without Danish citizenship also born in a foreign country

Descendant:

Born in Denmark to parents born in a foreign country without Danish citizenship

Native Dane:

Individual with at least one parent, who is a Danish citizen born in Denmark

Country of Birth

Design

1997 2005 Baseline (2001)

Inclusion criteria: Residence in Denmark 1997-2000

Initiation Persistence

Guidelines recommend treatment with statins and beta-blockers after AMI Prescription drugs require co-payment

Facts

No previous history of AMI

Discharged alive after first AMI

22,335 individuals (322 immigrants)

Covariates: age, sex, employment, income

Outcomes: Statins and beta-blockers Initiation: within 14 days after discharge

Persistence: no refill 90 days after the defined daily dose expired

Methods

Results – initiation (OR)

Ref.: native Danes

Results – persistence (HR)

Ref.: native Danes

Conclusions

Pakistanis and Turks were less likely to receive adequate treatment with beta-blockers after AMI

Poorer persistence with statins and, in particular, beta-blockers

A trend of better initiation among immigrant groups

No strong effect of SES was observed

Insufficient indicators of SES

Communication obstacles between provider and patient

Lack of social support

Differences in perceived need

Use of cross border healthcare services

Interpretation of results

Discussion

Strengths:

Follow-up design

Measurement of SES before measurement of outcome

Registry-based data of high quality regarding the outcomes

Country of birth categories

Limitations:

Small sample size of immigrants groups (type II errors)

Cases before 1997 could not be identified

Misclassification of outcome

Broad categories (SES indicators)

Poor validity of education

Country of birth does not take ethnic identity, culture and

language into account

Hempler NF, Diderichsen F, Larsen FB, Ladelund S, Jorgensen T.

Do immigrants from Turkey, Pakistan and Yugoslavia receive adequate medical treatment with beta-blockers and statins after acute myocardial infarction compared with Danish-born residents? A register-based follow-up study.

Eur J Clin Pharmacol 2010; 66(7): 735-42.

Further reading

Thank you for your attention

The Copenhagen Center for Healthy Aging

is supported by the Danish foundation