Neighbourhood Socioeconomics Status Predicts Non- Cardiovascular Mortality in Cardiac Patients with Access to Universal Health Care Claire L. Heslop1*, Gregory E. Miller2, John S. Hill1 1 Atherosclerosis Specialty Laboratory, James Hogg iCAPTURE Centre for Cardiovascular and Pulmonary Research, Providence Heart+Lung Institute, Department of Pathology and Laboratory Medicine, University of British Columbia-St. Paul’s Hospital, Vancouver, Canada, 2 Department of Psychology, Faculty of Arts, University of British Columbia, Vancouver, Canada Abstract Background: Although the Canadian health care system provides essential services to all residents, evidence suggests that socioeconomic gradients in disease outcomes still persist. The main objective of our study was to investigate whether mortality, from cardiovascular disease or other causes, varies by neighbourhood socioeconomic gradients in patients accessing the healthcare system for cardiovascular disease management. Methods and Findings: A cohort of 485 patients with angiographic evidence of coronary artery disease (CAD) and neighbourhood socioeconomic status information was followed for 13.3 years. Survival analyses were completed with adjustment for potentially confounding risk factors. There were 64 cases of cardiovascular mortality and 66 deaths from non-cardiovascular chronic diseases. No socioeconomic differentials in cardiovascular mortality were observed. However, lower neighbourhood employment, education, and median family income did predict an increased risk of mortality from non-cardiovascular chronic diseases. For each quintile decrease in neighbourhood socioeconomic status, non- cardiovascular mortality risk rose by 21–30%. Covariate-adjusted hazard ratios (95% confidence interval) for non- cardiovascular mortality were 1.21 (1.02–1.42), 1.21 (1.01–1.46), and 1.30 (1.06–1.60), for each quintile decrease in neighbourhood education, employment, and income, respectively. These patterns were primarily attributable to mortality from cancer. Estimated risks for mortality from cancer rose by 42% and 62% for each one quintile decrease in neighbourhood median income and employment rate, respectively. Although only baseline clinical information was collected and patient-level socioeconomic data were not available, our results suggest that environmental socioeconomic factors have a significant impact on CAD patient survival. Conclusions: Despite public health care access, CAD patients who reside in lower-socioeconomic neighbourhoods show increased vulnerability to non-cardiovascular chronic disease mortality, particularly in the domain of cancer. These findings prompt further research exploring mechanisms of neighbourhood effects on health, and ways they may be ameliorated. Citation: Heslop CL, Miller GE, Hill JS (2009) Neighbourhood Socioeconomics Status Predicts Non-Cardiovascular Mortality in Cardiac Patients with Access to Universal Health Care. PLoS ONE 4(1): e4120. doi:10.1371/journal.pone.0004120 Editor: Landon Myer, University of Cape Town, South Africa Received October 2, 2008; Accepted December 4, 2008; Published January 7, 2009 Copyright: 2009 Heslop et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The recruitment of study patients in 1993–1995 was funded by a research grant from the Canadian Institutes of Health Research, and subsequent analyses were funded by the Heart and Stroke Foundation of British Columbia and Yukon. GEM is supported by a McDonald Scholarship Award from the Heart and Stroke Foundation of Canada. CLH is supported by a Canadian Institutes of Health Research and Providence Health Care Research Institute MD/PhD Studentship Award, and a senior graduate studentship from the Michael Smith Foundation for Health Research. The authors received no specific funding for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: clheslop@interchange.ubc.ca Introduction Personal socioeconomic status (SES) is an influential determi- nant of prognosis in coronary artery disease (CAD). Patients who have lower family incomes, limited education, and work in lower- prestige occupations are 1.5–2.0 times more likely to die in the years following diagnosis of angina pectoris and myocardial infarction [1–7]. Recently, it has become evident that the SES of the neighbor- hood in which a patient resides also contributes to CAD outcomes, and does so above and beyond the effects of his/her personal SES [8,9]. For example, in a sample of more than 51,000 Canadian patients hospitalized for acute myocardial infarction, Alter et al. found that each $10,000 decrease in median neighborhood income was associated with a 10% increase in all-cause mortality over one year [10]. Tonne and colleagues studied 3423 patients hospitalized for myocardial infarction in Worcester, Massachusetts, and reported a 1.5-fold increase in mortality among those living in educationally disadvantaged neighborhoods [11]. These studies focused on the outcome of all-cause mortality. Thus, it remains unclear whether patients from economically disadvantaged neighborhoods are dying from CAD versus other conditions. Additionally, although neighbourhood unemployment is associated with presence of CAD [12], effects of neighbourhood unemployment on survival in CAD patients have not yet been adequately characterized. PLoS ONE | www.plosone.org 1 January 2009 | Volume 4 | Issue 1 | e4120