Cardiovascular care following a heart attack influenced by unemployment—and more so in the US than Canada, study suggests

New RI-MUHC study shows that health systems and unemployment influence the quality of care that young adults with acute myocardial infarction receive in Canada and the United States.

The COVID-19 pandemic has highlighted how social factors like poverty can increase vulnerability to infectious diseases and decrease access to care. What about cardiovascular care? Do social factors affect the care people with heart problems receive?

In a study recently published in JAMA Network Open, a team of researchers at the Research Institute of the McGill University Health Centre (RI-MUHC) examined the influence of social determinants of health (SDOH), biological sex and health systems on the quality of care that young adults with acute myocardial infarction (AMI) receive in Canada and the United States. They found that unemployment was the SDOH most importantly associated with the lowest quality of in-hospital care and that women were more affected than men. Furthermore, the study revealed that quality of care was lower in the US than in Canada, where universal coverage potentially decreases inequalities in access to high-quality care. These findings suggest that beyond sex, health care systems and SDOH that depict social vulnerability are associated with quality of AMI care and that initiatives to improve quality of care and reduce readmissions should consider these factors, especially in the US.

“Our study shows that the health care system in which the patients are treated and the social vulnerability factors that affect them are associated with the quality of AMI care that they receive,” says Dr. Louise Pilote, the principal investigator of the study and a senior scientist in the Cardiovascular Health Across the Lifespan Program at the RI-MUHC. “In addition, it appears that women experience lower in-hospital quality of care, not because of their sex, but because they are more affected by gender-related factors, i.e. social determinants of health that impact males and females differently.”

The main goal of the study, which was conducted in collaboration with researchers from Yale University, was to determine if the quality of in-hospital and post-acute care (1-year post-discharge) among young adults with AMI differs between the US and Canada; and if it is influenced by sex and social determinants of health. To answer that question, the researchers used two existing data sets from large multicenter cohorts. They compared baseline clinical characteristics (such as obesity, hypertension, diabetes and alcohol abuse), gendered social determinants of health (such as level of stress, roles, marital status, social support and socio-economic status) and quality of care indicators, by sex within and between countries. For each phase of care—in-hospital and post-acute—they calculated an opportunity-based quality-of-care score (QCS).

Overall, 4048 individuals were included in the study (74 per cent were from the US, 58 per cent were women and 42 per cent were men). In both countries, women had a more adverse cardiac risk factor profile and a greater burden of detrimental social determinants of health, such as low socio-economic status, unemployment and living alone.


The overall analysis showed that for in-hospital care, a low QCS was more prevalent in the US than in Canada (36 per cent vs 13 per cent) and in women than in men (36 per cent vs 24 per cent). Low quality of post-AMI care (25.5 per cent) was similarly observed for both sexes, with a higher prevalence in the US (29 per cent vs 12 per cent).

However, in adjusted analyses, female sex was not associated with low QCS for in-hospital and post-AMI care. Conversely, being treated in the US was associated with low in-hospital and post-AMI QCS, regardless of sex.

Of all social determinants of health, only employment was associated with higher quality of in-hospital care. Of note, being unemployed in the US had a greater impact on quality of care than being unemployed in Canada.

Finally, only in the US, low quality of in-hospital care was associated with a higher 1-year cardiac readmissions rate.

“As political systems attempt to improve access to high quality of care, the most vulnerable populations should be a priority, especially since quality of care is associated with outcomes such as readmission and mortality,” says Dr. Pilote, who is also a professor in the Department of Medicine at McGill University. “Our work should inform health care reforms both in Canada and in the US.”



About the study

The study Variations in Quality of Care by Sex and Social Determinants of Health Among Younger Adults With Acute Myocardial Infarction in the US and Canada was conducted by Valeria Raparelli, Louise Pilote, Brian Dang, Hassan Behlouli, James D. Dziura, Hector Bueno, Gail D’Onofrio, Harlan M. Krumholz and Rachel P. Dreyer



Louise Pilote
Dr. Louise Pilote

About the RI-MUHC

The Research Institute of the McGill University Health Centre (RI-MUHC) is a world-renowned biomedical and healthcare research centre. The institute, which is affiliated with the Faculty of Medicine of McGill University, is the research arm of the McGill University Health Centre (MUHC) – an academic health centre located in Montreal, Canada, that has a mandate to focus on complex care within its community. The RI-MUHC supports over 450 researchers and around 1,200 research trainees devoted to a broad spectrum of fundamental, clinical and health outcomes research at the Glen and the Montreal General Hospital sites of the MUHC. Its research facilities offer a dynamic multidisciplinary environment that fosters collaboration and leverages discovery aimed at improving the health of individual patients across their lifespan. The RI-MUHC is supported in part by the Fonds de recherche du Québec – Santé (FRQS).