Low Socio-Economic Status Heart Patients Need More Than Just Aggressive Cardiac Procedures

November 10, 1998

DALLAS -- While aggressive procedures such as angioplasty and coronary bypass procedures improve the health of patients with heart disease, the benefits are less if patients don't have the financial means to protect that "investment" afterwards.

In a study of 800 patients, Duke University Medical Center researchers have found that heart patients of low socio-economic status (SES) have a worse quality of life after these aggressive forms of treatment than better-off and more educated patients.

"If patients don't understand what healthy living is or don't have the means to live healthier, they will not do as well, " said Duke cardiologist Dr. Chen Tung.

The issues facing this group of patients after treatment are complicated and not easily solved, Tung said. Most need to drastically change their lifestyles, may need physical rehabilitation, and need to take heart medications -- aspects of continuing medical care that can be either out of reach or not fully understood by most low SES patients.

Tung, who is on the faculty at the Duke Clinical Research Institute, prepared the results of his study for presentation Tuesday (Nov. 10) at the 71st scientific sessions of the American Heart Association meeting.

The study followed 800 consecutive patients who were referred to Duke for a cardiac catheterization and who then went on to receive either an angioplasty or bypass. Of these patients, 350 were of low SES, which was defined as having less than nine years of education and an annual income of less than $10,000. These patients tended to be older than high SES patients and a higher percentage were women.

The study found that patients from low SES came to the hospital sicker than high SES patients, and while both groups experienced small but marked improvements after either revascularization procedure, the functional status of lower SES patients remained significantly impaired one year after treatment.

"We expected all patients to feel bad at the beginning, but we also expected them to get much better," Tung said. "What is so striking is after revascularization how much worse the low SES people felt compared to the higher SES people. We saw at least a 30 to 40 percent reduction in the functional status and quality of life despite having the aggressive procedures."

For Tung, the results show that heart procedures aren't magic bullets that can cure heart disease by themselves, especially for the poor and less educated.

"Much effort has been placed on providing equal access to care," Tung said. "While this is indeed important, especially for low SES patients, more fundamental changes are needed."

Tung believes that an educational component is critical to the medical care provided low SES patients. To this end, the Duke team is developing a pilot program for lower SES patients that stresses the importance of lifestyle and dietary changes.

Researchers used two different quality-of-life questionnaires to assess the functional status of patients. Each test was given to patients at the beginning of the study and again one year later.

The first, called the Duke Activities Status Index (DASI), is a questionnaire developed by Duke cardiologists in the mid-1980s that measures how much a person can do physically. The second test, called SF-36, is a questionnaire that measures patients' perceptions of their overall health. Taken together, the results of these two tools give researchers an insight into a patient's quality of life, Tung said.

The study was funded by a grant from the National Heart Lung Blood Institute. Dr. Daniel Mark was the senior Duke cardiologist on the study.
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Duke University Medical Center

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