Summary

Influence of income on in-hospital mortality in older adults during the first wave of the COVID-19 pandemic: results from the EDEN-33 study

Lourdes Artajona1, Ana García-Martínez1, Sira Aguiló1, Guillermo Burillo-Putze2, Aitor Alquézar-Arbé3, Cesáreo Fernández4, Amparo Fernández-Simón5, María Fernández Cardona6, María Teresa Maza Vera7, Marta Iglesias Vela8, Patricia Trenc Español9, Manuel Salido Mota10, Ángel García García12, Carmen Lucena Aguilera13, Ferran Llopis13, Pablo Herrero14, Adriana Laura Doi Grande15, Leticia Serrano Lázaro16, Ana Chacon García17, José J. Noceda Bermejo18, Amanda Ibisate Cubillas19, María José Hernández Martínez20, Francesc Xavier Alemany González21, Susana Sánchez Ramón22, Begoña Espinosa Fernández23, Juan González del Castillo4, Òscar Miró1, en representación de los investigadores de la red SIESTA (Spanish Investigators in Emergency Situations TEam)

Affiliation of the authors

1Área de Urgencias, Hospital Clínico, IDIBAPS, Universidad de Barcelona, Barcelona, Spain. 2Servicio de Urgencias, Hospital Universitario de Canarias, Tenerife, Spain. 3Servicio de Urgencias, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain. 4Servicio de Urgencias, Hospital Clínico San Carlos, IDISSC, Universidad Complutense, Madrid, Spain. 5Servicio de Urgencias, Hospital Virgen Rocio, Sevilla, Spain. 6Servicio de Urgencias, Hospital Universitario Gregorio Marañón, Madrid, Spain. 7Servicio de Urgencias, Hospital Álvaro Cunqueiro de Vigo, Spain. 8Servicio de Urgencias, Complejo Asistencial Universitario de León, Spain. 9Servicio de Urgencias, Hospital Universitario Miguel Servet, Zaragoza, Spain. 10Servicio de Urgencias, Hospital Regional Universitario de Málaga, Spain. 11Servicio de Urgencias, Hospital Universitario de Salamanca, Spain. 12Servicio de Urgencias, Hospital Universitario Reina Sofía de Córdoba, Spain. 13Servicio de Urgencias, Hospital Universitario de Bellvitge, Barcelona, Spain. 14Servicio de Urgencias, Hospital Universitario Central Asturias, Oviedo, Spain. 15Servicio de Urgencias, Hospital Sant Pau, Barcelona, Spain. 16Servicio de Urgencias, Hospital Universitario y Politécnico La Fe de Valencia, Spain. 17Servicio de Admisión, Hospital Clínico San Carlos, Madrid, Spain. 18Servicio de Urgencias, Hospital Universitario Clínico de Valencia, Spain. 19Servicio de Urgencias, Hospital Universitario de Burgos, Burgos, Spain. 20Servicio de Urgencias, Hospital Universitario Severo Ochoa, Madrid, Spain. 21Servicio de Urgencias, Hospital Clínic, Barcelona, Spain. 22Servicio de Urgencias, Hospital Universitario Río Hortega, Valladolid, Spain. 23Servicio de Urgencias, Hospital Dr. Balmis de Alicante, Spain.

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Artajona L, García-Martínez A, Aguiló S, Burillo-Putze G, Alquézar-Arbé A, Fernández C, et al. Influence of income on in-hospital mortality in older adults during the first wave of the COVID-19 pandemic: results from the EDEN-33 study. Emergencias. 2023;35:423-31

Summary

Objective.

To determine whether income was associated with unexpected in-hospital mortality in older patients treated in Spanish public health system hospital emergency departments.

Methods.

Fifty-one public health system hospital emergency departments in Spain voluntarily participated in the study. Together the hospitals covered 25% of the population aged 65 years or older included in all patient registers during a week in the pre-pandemic period (April 1-7, 2019) and a week during the COVID-19 pandemic (March 30 to April 5, 2020). We estimated a patient’s gross income as the amount published for the postal code of the patient’s address. We then calculated the standardized gross income (SGI) by dividing the patient’s estimated income by the mean for the corresponding territory (Spanish autonomous community). The existence and strength of an association between the SGI and in-hospital mortality was evaluated by means of restricted cubic spline (RCS) curves adjusted for 10 patient characteristics at baseline. Odds ratios (ORs) for each income level were expressed in relation to a reference SGI of 1 (the mean income for the corresponding autonomous community). We compared the COVID-19 and pre-pandemic periods by means of first-order interactions.

Results.

Of the 35 280 patients attended in the 2 periods, gross income could be ascertained for 21 180 (60%), 15 437 in the pre-pandemic period and 5746 during the COVID-19 period. SGIs were slightly higher for patients included before the pandemic (1.006 vs 0.994; P = .012). In-hospital mortality was 5.6% overall and higher during the pandemic (2.8% pre-pandemic vs 13.1% during COVID-19; P < .001). The adjusted RCS curves showed that associations between income and mortality differed between the 2 periods (interaction P = .004). Whereas there were no significant income-influenced differences in mortality before the pandemic, mortality increased during the pandemic in the lowest-income population (SGI 0.5 OR, 1.82; 95% CI, 1.32-3.37) and in higher-income populations (SGI 1.5 OR, 1.32; 95% CI, 1.04-1.68, and SGI 2 OR, 1.92; 95% CI, 1.14-3.23). We found no significant differences between patients with COVID-19 and those with other diagnoses (interaction P = .667).

Conclusions.

The gross income of patients attended in Spanish public health system hospital emergency departments, estimated according to a patient’s address and postal code, was associated with in-hospital mortality, which was higher for patients with the lowest and 2 higher income levels. The reasons for these associations might be different for each income level and should be investigated in the future.

 

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