Elsevier

Annals of Epidemiology

Volume 14, Issue 7, August 2004, Pages 447-452
Annals of Epidemiology

Factors associated with out-of-hospital coronary heart disease death: the national longitudinal mortality study

https://doi.org/10.1016/j.annepidem.2003.10.002Get rights and content

Abstract

Purpose

A significant portion of coronary heart disease deaths occur out of the hospital, prior to access to life saving medical care. Improving the immediacy of care could have important impact on coronary mortality.

Methods

The objective of this research is to identify factors associated with the occurrence of out-of-hospital coronary heart disease death as compared with in-hospital. Identification of these factors could lead to additional strategies for rapid treatment of coronary attack symptoms. A large national cohort study with individually identified characteristics was matched to the National Death Index to identify deaths by cause occurring in up to 11 years of follow-up. Approximately 60,000 deaths occurred in the cohort of approximately 700,000 participants aged 25 years or more. Location of death was defined as either in- or out-of-hospital.

Results

Among deaths classified as coronary heart disease (CHD), multivariate logistic models of the association between selected demographic and socioeconomic characteristics of individuals prior to death and place of death show that black persons are more likely to die out of hospital, as are persons who live alone or are unmarried, persons at the lowest end of the income distribution, and persons who live in rural areas vs. urban areas.

Conclusions

The factors most strongly associated with a CHD death occurring out-of-hospital as compared with in-hospital are race (black persons are 1.23 times more likely to die out of hospital than white persons, net of demographic and socioeconomic differentials) and living status (persons who are not married are 1.60 times more likely to die out of hospital than persons who are married, net of demographic and socioeconomic characteristics). Attention should be paid to these groups to emphasize the need for rapid attention to the signs of a coronary attack so that rapid and potentially life saving intervention can be implemented.

Introduction

With the rapid implementation of effective treatments of acute myocardial infarction in the hospital setting, it is critical that symptoms of a heart attack be recognized early and a medical response be initiated as soon as possible. While death can happen within minutes of the first onset of symptoms, there is often sufficient warning to enable a life-saving response. The overall delay in arrival at the hospital includes the actual travel time, in addition to delays in any of the following: 1) recognition of symptoms, 2) realization of need for medical care, 3) decision to seek medical care, and 4) obtaining transportation (1). Death may occur at any time along this sequence of delay.

There have been many studies which have sought to identify reasons for delay and ways to reduce the time between symptom onset and hospital arrival. The Rapid Early Action for Coronary Treatment (REACT) trial was a large community intervention study designed to apply community-wide education and information to reduce delay, and to investigate reasons why delay occurs (1). A Medicare-based study, the Cooperative Cardiovascular Project, investigated factors affecting delay in over 100,000 hospitalizations for myocardial infarction (2). Other systematic reviews of hospital records have investigated causes and trends in hospital delay 3., 4., 5.. All of these studies investigate factors related to delay times among those who successfully arrived at the hospital, that is, in those who arrived alive at the emergency room. However, these studies miss the substantial portion that dies prior to admittance to the emergency room.

Characterization of the reasons why deaths occur outside of the hospital is difficult, since there need to be extensive interviews with next-of-kin and the death may have been unwitnessed. Information about the decedent is difficult to obtain retrospectively. Using a large national cohort study [National Longitudinal Mortality Study (NLMS)], deaths which occurred over the follow-up period between 1979 and 1989 have been characterized by cause and by place of death. Additionally, and most importantly, decedents can be characterized by their demographic, social, and economic status at the time of their baseline interview. Thus, features which distinguish out-of-hospital CHD death from in-hospital CHD death can be identified, providing an additional resource to identify factors related to delay times and possibly survival.

Section snippets

Methods

The US National Longitudinal Mortality Study is a prospective study of mortality occurring in combined samples of the non-institutionalized United States population drawn from the Current Population Survey (CPS) 6., 7.. Each CPS conducted by the Census Bureau is a complex, national, probability sample of households surveyed monthly to obtain demographic, economic, and social information about the US population. The surveys, which are conducted by personal and telephone interview, have a

Results

The distribution of all deaths in this study categorized by the general place of death is shown in Table 1. In the 11 NLMS cohorts described above, there were 82,679 deaths available for this study. As described in the Methods section, some states did not include information for the more detailed hospital place of death. The second column in Table 1 shows the distribution of deaths excluding those states with missing information, resulting in a remaining total of 59,034 deaths. Since the focus

Discussion

From a sample of the US population followed for mortality outcome (excluding states with missing data) we identified several demographic and socioeconomic characteristics that are significantly associated with an increased risk that a CHD death will occur out of the hospital. While there are weak relationships with geography, income, and education, there is a moderate relationship with race and a strong relationship with living alone or not being married. This strongly suggests that having a

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This study was funded though an interagency agreement between the National Heart, Lung, and Blood Institute and the Bureau of the Census.

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