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Impact of socioeconomic status on outcome of a Brazilian heart transplant recipients cohort
International Journal of Cardiology 125 (2008) 142 – 143 www.elsevier.com/locate/ijcard
Letter to the Editor
Impact of socioeconomic status on outcome of a Brazilian heart transplant recipients cohort Andrelisa V. Parra a , Vanessa Rodrigues a , Sônia Cancella a , José A. Cordeiro c , Reinaldo B. Bestetti b,⁎ a
Division of Social Worker Service, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, Brazil b Division of Cardiology, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, Brazil c Division of Statistics, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, Brazil Received 30 November 2006; accepted 1 January 2007 Available online 2 April 2007
Abstract We studied the clinical course of 44 cardiac transplant recipients at our institution according to socioeconomic status (socioeconomic class level, educational level, household family income, dwelling, presence of caregiver, and national health insurance) before the procedure. Patients in the low socioeconomic status had a prognosis similar to that seen in patients in the median socioeconomic status. Thus, low socioeconomic status has no unfavorable impact on outcome of cardiac transplant recipients in Brazil. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Chagas' cardiomyopathy; Heart failure; Congestive; Heart transplantation; Socioeconomic status; Socioeconomic aspects
1. Introduction
2. Methods
Patients' selection for heart transplantation is usually based on an extensive assessment protocol, which includes patients' social aspects. In Brazil, about 10% of patients have been not listed for the procedure because of socioeconomic aspects [1]. Chagas' cardiomyopathy is the leading cause of chronic heart failure in areas where the disease is endemic [2]. Furthermore, Chagas' disease patients usually have a low socioeconomic status [3], which might potentially preclude patients with this condition to be listed for heart transplantation. Accordingly, this study was conducted to assess the impact of socioeconomic aspects on outcome of a typical Brazilian cohort of cardiac transplant recipients.
The medical charts of patients listed for heart transplantation from January, 2000 to November, 2005 were reviewed. Data related to 70 consecutive patients form the basis of this report. Fifty-four (77%) patients were male. Mean age was 43 ± 11 years. Thirty-one patients (44%) were diagnosed as having Chagas' cardiomyopathy on the basis of a positive serological test for Chagas' disease, severe left ventricular systolic dysfunction and normal coronary
⁎ Corresponding author. Rua Olavo Bilac, 1102, Ribeirão Preto City, 14025-400, Brazil. Fax: +55 17 32015065. E-mail address: [email protected] (R.B. Bestetti). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.01.038
Table 1 Socioeconomic aspects of patients on the waiting list (n = 70) and after cardiac transplantation (n = 44)
Primary school level Sufficient dwelling Presence of caregiver No health insurance Monthly family income ⁎ Low socioeconomic class
On the waiting list
Transplant recipient
53 (76%) 54 (77%) 66 (94%) 41 (59%) 3 (3.25) 60 (86%)
32 33 41 19 3 37
(73%) (75%) (93%) (43%) (2) (84%)
⁎ Median of the number of minimum salaries (interquartile range).
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19 days for patients in the median socioeconomic class (p N 0.05, Fig. 1). Low educational level, dwelling, lack of national health insurance, and median household income also had no impact on prognosis after transplantation. 4. Discussion
Fig. 1. Survival probability for heart transplant recipients according to socioeconomic class.
arteriogram. The remaining 39 (56%) patients had nonChagas' cardiomyopathy. Socioeconomic evaluation was performed taking into account monthly family income, literacy, dwelling, presence of caregiver, and family members profession. Dwelling was subsequently classified in sufficient or insufficient according to ownership, urban zone placement, substructure, and lodging [4]. 3. Results Forty-four (63%) of the 70 patients listed for heart transplantation underwent the procedure, 21 (30%) died on the waiting list and 5 (7%) were on the waiting list for the procedure at the end of the study period. Table 1 summarizes the socioeconomic status of both patients listed for heart transplantation and cardiac transplant recipients. No difference was observed in the socioeconomic status in Chagas and non-Chagas' disease patients before and after the procedure. Median follow up was 674 (interquartile range = 640) days after heart transplantation. Sixteen (36%) heart transplant recipients had Chagas' disease. No difference was observed in the survival probability between Chagas' and non-Chagas' heart transplant recipients. Thirty-seven (84%) of 44 heart transplant recipients were classified in the low socioeconomic class and 7 (16%) in the median socioeconomic class. Survival probability at 7, 158 and 575 days was 83%, 78%, and 71%, respectively for patients in the low socioeconomic class, and 86%, 69%, and 51%, respectively, at 1, 16 and
The majority of patients listed for heart transplantation in this study had a low socioeconomic status: low socioeconomic class, low educational level, low monthly income, and lack of National Health Insurance. Nevertheless, there was no difference in survival probability in patients in the low and in patients in the median socioeconomic status. The reasons for the success of the heart transplantation program at our institution in spite of an unfavorable socioeconomic profile may be related to 1) the fact that our institution took the responsibility to pay for sufficient dwellings during the sixth months after cardiac transplantation; 2) our patients received financial support from nonnational organizations, relatives and so forth to compensate for the lack of National Health Insurance; 3) all treatment after heart transplantation is freely provided by the Federal Health System, and 4) the presence of the caregiver in the vast majority of cases. As expected, this study shows a low socioeconomic status for Chagas' disease patients listed for heart transplantation. Nevertheless, no difference in outcome following heart transplantation was observed in Chagas and non-Chagas disease patients. In conclusion, low social economic status should not be regarded as a contraindication for heart transplantation. Thus, physicians dealing with heart transplantation should be on the alert for our findings. References [1] Freitas HFG, Nastari L, Mansur AJ, et al. Dinâmica da avaliação de pacientes para transplante cardíaco ou cardiomioplastia. Arq Bras Cardiol 1994;62(4):233–8. [2] Bestetti RB, Muccillo G. Clinical course of Chagas' heart disease: a comparison with dilated cardiomyopathy. Int J Cardiol 1997;58:199–209. [3] Anonymous. Chagas' disease. An epidemic that can no longer be ignored. Lancet 2006;368:619. [4] Lehfeld NAS, Graciano MIG, Neves-Filho A. Critérios de avaliação para a classificação sócio-econômica: elementos de atualização. Parte. Serv Soc Real 1996;5:171–201.
Letter to the Editor
Impact of socioeconomic status on outcome of a Brazilian heart transplant recipients cohort Andrelisa V. Parra a , Vanessa Rodrigues a , Sônia Cancella a , José A. Cordeiro c , Reinaldo B. Bestetti b,⁎ a
Division of Social Worker Service, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, Brazil b Division of Cardiology, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, Brazil c Division of Statistics, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, Brazil Received 30 November 2006; accepted 1 January 2007 Available online 2 April 2007
Abstract We studied the clinical course of 44 cardiac transplant recipients at our institution according to socioeconomic status (socioeconomic class level, educational level, household family income, dwelling, presence of caregiver, and national health insurance) before the procedure. Patients in the low socioeconomic status had a prognosis similar to that seen in patients in the median socioeconomic status. Thus, low socioeconomic status has no unfavorable impact on outcome of cardiac transplant recipients in Brazil. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Chagas' cardiomyopathy; Heart failure; Congestive; Heart transplantation; Socioeconomic status; Socioeconomic aspects
1. Introduction
2. Methods
Patients' selection for heart transplantation is usually based on an extensive assessment protocol, which includes patients' social aspects. In Brazil, about 10% of patients have been not listed for the procedure because of socioeconomic aspects [1]. Chagas' cardiomyopathy is the leading cause of chronic heart failure in areas where the disease is endemic [2]. Furthermore, Chagas' disease patients usually have a low socioeconomic status [3], which might potentially preclude patients with this condition to be listed for heart transplantation. Accordingly, this study was conducted to assess the impact of socioeconomic aspects on outcome of a typical Brazilian cohort of cardiac transplant recipients.
The medical charts of patients listed for heart transplantation from January, 2000 to November, 2005 were reviewed. Data related to 70 consecutive patients form the basis of this report. Fifty-four (77%) patients were male. Mean age was 43 ± 11 years. Thirty-one patients (44%) were diagnosed as having Chagas' cardiomyopathy on the basis of a positive serological test for Chagas' disease, severe left ventricular systolic dysfunction and normal coronary
⁎ Corresponding author. Rua Olavo Bilac, 1102, Ribeirão Preto City, 14025-400, Brazil. Fax: +55 17 32015065. E-mail address: [email protected] (R.B. Bestetti). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.01.038
Table 1 Socioeconomic aspects of patients on the waiting list (n = 70) and after cardiac transplantation (n = 44)
Primary school level Sufficient dwelling Presence of caregiver No health insurance Monthly family income ⁎ Low socioeconomic class
On the waiting list
Transplant recipient
53 (76%) 54 (77%) 66 (94%) 41 (59%) 3 (3.25) 60 (86%)
32 33 41 19 3 37
(73%) (75%) (93%) (43%) (2) (84%)
⁎ Median of the number of minimum salaries (interquartile range).
A.V. Parra et al. / International Journal of Cardiology 125 (2008) 142–143
143
19 days for patients in the median socioeconomic class (p N 0.05, Fig. 1). Low educational level, dwelling, lack of national health insurance, and median household income also had no impact on prognosis after transplantation. 4. Discussion
Fig. 1. Survival probability for heart transplant recipients according to socioeconomic class.
arteriogram. The remaining 39 (56%) patients had nonChagas' cardiomyopathy. Socioeconomic evaluation was performed taking into account monthly family income, literacy, dwelling, presence of caregiver, and family members profession. Dwelling was subsequently classified in sufficient or insufficient according to ownership, urban zone placement, substructure, and lodging [4]. 3. Results Forty-four (63%) of the 70 patients listed for heart transplantation underwent the procedure, 21 (30%) died on the waiting list and 5 (7%) were on the waiting list for the procedure at the end of the study period. Table 1 summarizes the socioeconomic status of both patients listed for heart transplantation and cardiac transplant recipients. No difference was observed in the socioeconomic status in Chagas and non-Chagas' disease patients before and after the procedure. Median follow up was 674 (interquartile range = 640) days after heart transplantation. Sixteen (36%) heart transplant recipients had Chagas' disease. No difference was observed in the survival probability between Chagas' and non-Chagas' heart transplant recipients. Thirty-seven (84%) of 44 heart transplant recipients were classified in the low socioeconomic class and 7 (16%) in the median socioeconomic class. Survival probability at 7, 158 and 575 days was 83%, 78%, and 71%, respectively for patients in the low socioeconomic class, and 86%, 69%, and 51%, respectively, at 1, 16 and
The majority of patients listed for heart transplantation in this study had a low socioeconomic status: low socioeconomic class, low educational level, low monthly income, and lack of National Health Insurance. Nevertheless, there was no difference in survival probability in patients in the low and in patients in the median socioeconomic status. The reasons for the success of the heart transplantation program at our institution in spite of an unfavorable socioeconomic profile may be related to 1) the fact that our institution took the responsibility to pay for sufficient dwellings during the sixth months after cardiac transplantation; 2) our patients received financial support from nonnational organizations, relatives and so forth to compensate for the lack of National Health Insurance; 3) all treatment after heart transplantation is freely provided by the Federal Health System, and 4) the presence of the caregiver in the vast majority of cases. As expected, this study shows a low socioeconomic status for Chagas' disease patients listed for heart transplantation. Nevertheless, no difference in outcome following heart transplantation was observed in Chagas and non-Chagas disease patients. In conclusion, low social economic status should not be regarded as a contraindication for heart transplantation. Thus, physicians dealing with heart transplantation should be on the alert for our findings. References [1] Freitas HFG, Nastari L, Mansur AJ, et al. Dinâmica da avaliação de pacientes para transplante cardíaco ou cardiomioplastia. Arq Bras Cardiol 1994;62(4):233–8. [2] Bestetti RB, Muccillo G. Clinical course of Chagas' heart disease: a comparison with dilated cardiomyopathy. Int J Cardiol 1997;58:199–209. [3] Anonymous. Chagas' disease. An epidemic that can no longer be ignored. Lancet 2006;368:619. [4] Lehfeld NAS, Graciano MIG, Neves-Filho A. Critérios de avaliação para a classificação sócio-econômica: elementos de atualização. Parte. Serv Soc Real 1996;5:171–201.