What is the clinical evidence from this study?

Study design: Cohort. Population: Patients undergoing a first isolated coronary artery bypass grafting (CABG) (n=72333). Intervention: Foreign-born status vs. Sweden-born status. Primary outcome: All-cause mortality (overall period, men) (HR 1.03, 95% CI 0.96-1.09).

May 22, 2013Open Access

Short and Long Term Mortality after Coronary Artery Bypass Grafting (CABG) Is Influenced by Socioeconomic Position but Not by Migration Status in Sweden, 1995–2007

DDD. DzayeeKarolinska Institutet TITorbjörn IvertCardiac Surgery OBOmid BeikiKarolinska Institutet

Key Result

Low socioeconomic position was associated with higher mortality after coronary artery bypass grafting, while overall mortality did not differ significantly between foreign-born and Sweden-born patients.

Study Design

Type

Cohort (n=72,333)

Multicenter

Yes

Structured PICO

Does socioeconomic position or migration status influence short and long term mortality after CABG?

Population

72,333 patients undergoing a first isolated CABG in Sweden during 1995-2007, of whom 12.7% were foreign-born.

Intervention

Foreign-born status and low socioeconomic position (low educational level)

Comparator

Sweden-born status and higher socioeconomic position (>12 years of education)

Outcome

Short and long term mortality (all-cause mortality)hard clinical

Lower socioeconomic position, but not migration status overall, is associated with higher short- and long-term mortality after isolated CABG in Sweden.

Main Result

Effect estimate: HR 1.03 (95% CI 0.96-1.09)

Limitations

Insufficient number of observations for valid analyses regarding important life style factors such as smoking and body mass index
Missing information on left ventricular function, number of diseased vessels, completeness of revascularization, indication for surgery and repeat revascularization
Medical management after hospital discharge was not known
Did not classify the foreign-born as refugees or labor immigrants

Abstract

BACKGROUND: There are no nationwide studies on mortality after coronary artery bypass grafting (CABG) among foreign-born populations that include detailed information about country of birth and information about socioeconomic position. The objective was to investigate the risk of mortality after CABG considering socioeconomic position, sex and country of birth. MATERIAL AND METHODS: We included all 72 333 patients undergoing a first isolated CABG in Sweden, during 1995 - 2007 of whom 12.7% were foreign-born. The patients were classified according to educational level, sex, and country of birth and were followed up to December 2007. We estimated the risk of short and long term mortality after CABG in a multivariable model adjusted for age, calendar year of surgery, diabetes, educational level, and waiting time for surgery. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated based on the Cox proportional hazard model. FINDINGS: There were 15,284 deaths during the follow-up, 10.4% of whom were foreign-born. The foreign-born patients were 3 to 4 years younger than Sweden-born patients at the time of CABG surgery. There were no significant differences in overall early or late mortality between foreign-born and Sweden-born men and women after CABG. All-cause mortality differed in between regions and was highest in foreign-born men from Eastern Africa (HR 3.80, 95% CI 1.58-9.17), China (HR 3.61, 95% CI 1.50-8.69), and in Chile (HR 2.12, 95% CI 1.01-4.47). Patients with low level of education had worse survival compared to those with longer than 12 years of education irrespective of sex and country of birth. This difference was more pronounced among foreign-born women (HR 1.50, 95% CI 1.00-2.33). CONCLUSION: This national study showed higher CABG mortality in patients from lower socioeconomic position. Early and late mortality did not differ after isolated CABG in foreign-born and Sweden-born patients.

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