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, University of Copenhagen

1. 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

2. Research questions
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?

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

4. Data on CVD
Lack of studies regarding:
• Immigrants’ access to healthcare services
• Whether immigrants with CVD receive adequate treatment

5. Background
Immigrants and descendants comprise 10% of the population
Statistics Denmark 2010
Two-thirds originate from a non-Western country

6. Background

7. Methods
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

8. Definitions
Native Danes were used as the reference group
However, not a gold standard

9. Social inequalities
Health
Differences in
socioeconomic Access to healthcare services
status (SES)
Quality of care

10. Socioeconomic status (SES)
Lower SES among non-Western immigrants compared
with native Danes
• Income
• Education
• Employment
• Housing conditions

11. Data Sources
The Danish National
Patient Registry
The Integrated
The Danish Registry
Database for Labour
The Central of Medical Product
Market Research
Population Statistics
Registry
The Danish The Registry of
Demographic Causes of Death
Registry
Admissions
Redeemed prescriptions
Employment, income
Country of birth
Migrations
Deaths

12. Country of Birth
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

13. Design
Inclusion criteria:
Residence in
Denmark 1997-2000
1997 Baseline 2005
(2001)
Initiation
Persistence

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

15. Methods
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

16. Results – initiation (OR)
Ref.: native Danes

17. Results – persistence (HR)
Ref.: native Danes

18. 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

19. Interpretation of results
Insufficient indicators of SES
Communication obstacles between provider and patient
Lack of social support
Differences in perceived need
Use of cross border healthcare services

20. 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

21. Further reading
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.

22. Thank you for your attention
The Copenhagen Center for Healthy Aging
is supported by the Danish foundation