Open Access Open Badges Research article

Individual education, area income, and mortality and recurrence of myocardial infarction in a Medicare cohort: the National Longitudinal Mortality Study

Sean A Coady1*, Norman J Johnson2, Jahn K Hakes2 and Paul D Sorlie1

Author Affiliations

1 Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, 2 Rockledge Ctr, 6701 Rockledge Dr., Rm10200 MSC 7936, Bethesda 20817 MD, USA

2 Center for Administrative Records and Research Applications, United States Bureau of the Census, 4600 Silver Hill Road, Suitland 20233 MD, USA

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BMC Public Health 2014, 14:705  doi:10.1186/1471-2458-14-705

Published: 9 July 2014



The Medicare program provides universal access to hospital care for the elderly; however, mortality disparities may still persist in this population. The association of individual education and area income with survival and recurrence post Myocardial Infarction (MI) was assessed in a national sample.


Individual level education from the National Longitudinal Mortality Study was linked to Medicare and National Death Index records over the period of 1991-2001 to test the association of individual education and zip code tabulation area median income with survival and recurrence post-MI. Survival was partitioned into 3 periods: in-hospital, discharge to 1 year, and 1 year to 5 years and recurrence was partitioned into two periods: 28 day to 1 year, and 1 year to 5 years.


First MIs were found in 8,043 women and 7,929 men. In women and men 66-79 years of age, less than a high school education compared with a college degree or more was associated with 1-5 year mortality in both women (HRR 1.61, 95% confidence interval 1.03-2.50) and men (HRR 1.37, 1.06-1.76). Education was also associated with 1-5 year recurrence in men (HRR 1.68, 1.18-2.41, < High School compared with college degree or more), but not women. Across the spectrum of survival and recurrence periods median zip code level income was inconsistently associated with outcomes. Associations were limited to discharge-1 year survival (RR lowest versus highest quintile 1.31, 95% confidence interval 1.03-1.67) and 28 day-1 year recurrence (RR lowest versus highest quintile 1.72, 95% confidence interval 1.14-2.57) in older men.


Despite the Medicare entitlement program, disparities related to individual socioeconomic status remain. Additional research is needed to elucidate the barriers and mechanisms to eliminating health disparities among the elderly.

Myocardial infarction; Epidemiology; Mortality; Socio-economic; Elderly