Disparities in Health Care Delivery and Hospital Outcomes between Non-Saudis and Saudi Nationals Presenting with Acute Coronary Syndromes in Saudi Arabia

Abstract

BackgroundSaudi Arabia has a non-Saudi workers population. We investigated the differences and similarities of expatriate non-Saudi patients (NS) and Saudi nationals (SN) presenting with acute coronary syndromes (ACS) with respect to therapies and clinical outcomes.MethodsThe study evaluated 2031 of the 5055 ACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) from 2005 to 2007. Propensity score matching and logistic regression analysis were performed to account for major imbalances in age and sex in the two groups.ResultsThe mean patient age was 56.2±9.8, and 83.5% of the study cohort were male. SN were more likely to have risk factors of atherosclerosis. ST-elevation MI (STEMI) was the most common ACS presentation in NS, while non-ST ACS was more common in SN. The median symptom-to-door time was significantly greater in NS patients (Median 175 min (197) vs. 130 min (167), p=0.027). The only difference in pharmacological therapies between the two groups was that NS were more likely to receive fibrinolytic therapy. NS were less likely than SN to undergo percutaneous coronary interventions (PCI; 32.6% vs. 42.8%, p=0.0001) or primary PCI (7.8% vs. 22.8%, p<0.001). Hospital mortality, cardiogenic shock, and heart failure were significantly higher in NS compared to SN. After adjusting for baseline variables and therapies, the odds ratios for hospital mortality and cardiogenic shock in NS were 2.9 (95% CI 1.5–6.2, p=0.004) and 2.8 (95% CI 1.5–4.9, p<0.001), respectively.ConclusionOur findings indicate disparities in hospital care between NS and SN ACS patients. NS patients had worse hospital outcomes, which may reflect unequal health coverage and access-to-care issues.

ST‐elevation myocardial infarction in a migrant population: a registry‐based study of patient treatment and outcomes

“…Our finding of a longer S2DT within the Australian migrant population has not previously been reported but is consistent with international reports of pre‐hospital delays in migrants and minority ethnic groups . Compared to studies by Al‐Faleh (median S2DT difference of 45 min), Lee (median difference 54 min) and Ting (median difference 60 min), our difference of 11 min is modest at best and of questionable clinical relevance. Over the past decade, the National Heart Foundation of Australia has undertaken sustained and ongoing public health campaigns targeting public awareness of cardiovascular symptoms, and these efforts have likely helped to minimise pre‐hospital delays and should be continued.…”

“…Recent studies conducted in Europe, Singapore and the Middle East have also documented significantly higher rates of complications and mortality between migrant patients and those from a minority background . These findings contrast large studies conducted in the United States, which observed no significant differences in length of hospital stay, adverse events or in‐hospital mortality between patients of different ethnic backgrounds …”

“…Internationally, a growing number of studies has identified race‐related variation in the characteristics, management and outcomes of patients with STEMI. These observational studies demonstrate a strong association between migrant status, reduced use of ambulance services and increased symptom‐to‐balloon time …”

“…These observational studies demonstrate a strong association between migrant status, reduced use of ambulance services and increased symptom-to-balloon time. [2][3][4][5][6] While results vary between countries, recent multinational studies report significantly longer door-to-balloon time (D2BT) and reduced likelihood of timely reperfusion for patients from a minority ethnic background. 3,[7][8][9][10][11][12] Studies have also found that patients from a migrant background are significantly less likely to receive reperfusion compared to the dominant ethnic group.…”

“…[13][14][15][16][17] When they do receive reperfusion, migrant patients are more likely to require coronary artery bypass grafting (CABG), which may reflect more advanced disease at time of presentation. 5,15,18 These disparities in treatment appear to persist despite adjustment for clinical, demographic, insurance and hospital characteristics. 16 migrant patients and those from a minority background.…”