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Nadarajah R, Farooq M, Raveendra K, Nakao YM, Nakao K, Wilkinson C, Wu J, Gale CP. Inequalities in care delivery and outcomes for myocardial infarction, heart failure, atrial fibrillation, and aortic stenosis in the United Kingdom. THE LANCET REGIONAL HEALTH. EUROPE 2023; 33:100719. [PMID: 37953996 PMCID: PMC10636273 DOI: 10.1016/j.lanepe.2023.100719] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/19/2023] [Accepted: 08/02/2023] [Indexed: 11/14/2023]
Abstract
Cardiovascular diseases are a leading cause of death and disability globally, with inequalities in burden and care delivery evident in Europe. To address this challenge, The Lancet Regional Health-Europe convened experts from a range of countries to summarise the current state of knowledge on cardiovascular disease inequalities across Europe. This Series paper presents evidence from nationwide secondary care registries and primary care healthcare records regarding inequalities in care delivery and outcomes for myocardial infarction, heart failure, atrial fibrillation, and aortic stenosis in the National Health Service (NHS) across the United Kingdom (UK) by age, sex, ethnicity and geographical location. Data suggest that women and older people less frequently receive guideline-recommended treatment than men and younger people. There are limited publications about ethnicity in the UK for the studied disease areas. Finally, there is inter-healthcare provider variation in cardiovascular care provision, especially for transcatheter aortic valve implantation, which is associated with differing outcomes for patients with the same disease. Providing equitable care is a founding principle of the UK NHS, which is well positioned to deliver innovative policy responses to reverse observed inequalities. Understanding differences in care may enable the implementation of appropriate strategies to mitigate differences in outcomes.
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Affiliation(s)
- Ramesh Nadarajah
- Leeds Institute of Data Analytics, University of Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Maryum Farooq
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Yoko M. Nakao
- Leeds Institute of Data Analytics, University of Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | - Kazuhiro Nakao
- Leeds Institute of Data Analytics, University of Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, UK
| | - Chris Wilkinson
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, UK
- Hull York Medical School, University of York, York, UK
| | - Jianhua Wu
- Wolfson Institute of Population Health, Queen Mary University of London, UK
| | - Chris P. Gale
- Leeds Institute of Data Analytics, University of Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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2
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Masoli JAH, Mensah E, Rajkumar C. Age and ageing cardiovascular collection: blood pressure, coronary heart disease and heart failure. Age Ageing 2022; 51:6657798. [PMID: 35934320 DOI: 10.1093/ageing/afac179] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Indexed: 01/25/2023] Open
Abstract
As people age they are at increased risk of cardiovascular disease, the leading cause of mortality and morbidity worldwide. Understanding cardiovascular ageing is essential to preserving healthy ageing and preventing serious health outcomes. This collection of papers published in Age and Ageing since 2011 cover key themes in cardiovascular ageing, with a separate collection on stroke and atrial fibrillation planned. Treating high blood pressure remains important as people age and reduces strokes and heart attacks. That said, a more personalised approach to blood pressure may be even more important as people age to lower blood pressure to tight targets where appropriate but avoid overtreatment in vulnerable groups. As people age, more people experience blood pressure drops on standing (orthostatic hypotension), particularly as they become frail. This can predispose them to falls. The papers in this collection provide an insight into blood pressure and orthostatic hypotension. They highlight areas for further research to understand blood pressure changes and management in the ageing population. Inpatient clinical care of older people with heart attacks differs from younger people in UK national audit data. People aged over 80 had improved outcomes in survival after heart attack over time, but had lower rates of specialist input from cardiology compared with younger people. This may partly reflect different clinical presentations, with heart attacks occurring in the context of other health conditions, frailty and multimorbidity. The care and outcomes of acute and chronic cardiovascular disease are impacted by the frailty and health status of an individual at baseline. The research included in this collection reinforces the wide variations in the ageing population and the necessity to focus on the individual needs and priorities, and provide a person-centred multidisciplinary approach to care.
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Affiliation(s)
- Jane A H Masoli
- Healthcare for Older People, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK.,Institute of Biomedical and Clinical Science, University of Exeter, Exeter UK
| | - Ekow Mensah
- Department of Elderly Care and Stroke Medicine, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Chakravarthi Rajkumar
- Department of Elderly Care and Stroke Medicine, Brighton and Sussex University Hospitals Trust, Brighton, UK.,Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
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3
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Werner RM, Templeton Z, Apathy N, Skira MM, Konetzka RT. Trends in Post-Acute Care in US Nursing Homes: 2001-2017. J Am Med Dir Assoc 2021; 22:2491-2495.e2. [PMID: 34823855 PMCID: PMC8654135 DOI: 10.1016/j.jamda.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe recent trends in post-acute care provision within nursing homes, focusing specifically on nursing homes' degree of specialization in post-acute care. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS All US nursing homes between 2001 and 2017 and all fee-for-service Medicare admissions to nursing homes for post-acute care during that time. METHODS We measured post-acute care specialization as annual Medicare admissions per bed for each nursing home and examined changes in the distribution of specialization across nursing homes over the study period. We described the characteristics of nursing homes and the patients they serve based on degree of specialization. RESULTS The average number of Medicare admissions per bed increased from 1.2 in 2001 to 1.6 in 2017, a relative increase of 41%. This upward trend in the number of Medicare admissions per bed was largest among new nursing homes (those established after 2001), increasing 68% from 2001 to 2017. In contrast, nursing homes that eventually closed during the study period experienced no meaningful growth in the number of admissions per bed. Over time, the number of Medicare admissions per bed increased among highly specialized nursing homes. The number of Medicare admissions per bed grew by 66% at the 95th percentile and by 25% at the 99th percentile. Nursing homes delivering the most post-acute care were more likely to be for-profit or part of a chain, had higher staffing levels, and were less likely to admit patients who were Black, Hispanic, or dually enrolled in Medicare and Medicaid. CONCLUSIONS AND IMPLICATIONS Over the last 2 decades, post-acute care has become increasingly concentrated in a subset of nursing homes, which tend to be for-profit, part of a chain, and less likely to serve racial and ethnic minorities and persons on Medicaid. Although these nursing homes may benefit financially from higher Medicare payment, it may come at the expense of equitable access and patient care.
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Affiliation(s)
- Rachel M Werner
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
| | - Zachary Templeton
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nate Apathy
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Meghan M Skira
- Department of Economics, Terry College of Business, University of Georgia, Athens, GA, USA
| | - R Tamara Konetzka
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
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4
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Tegn N, Abdelnoor M, Aaberge L, Hylen Ranhoff A, Endresen K, Gjertsen E, Skårdal R, Gullestad L, Bendz B. Health-related quality of life in older patients with acute coronary syndrome randomised to an invasive or conservative strategy. The After Eighty randomised controlled trial. Age Ageing 2018; 47:42-47. [PMID: 28985265 DOI: 10.1093/ageing/afx121] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 06/21/2017] [Indexed: 11/13/2022] Open
Abstract
Objective in the After Eighty study (ClinicalTrials.gov.number, NCT01255540), patients aged 80 years or more, with non-ST-elevation myocardial infarction (NSTEMI), and unstable angina pectoris (UAP), were randomised to either an invasive or conservative management approach. We sought to compare the effects of these management strategies on health related quality of life (HRQOL) after 1 year. Methods the After Eighty study was a prospective randomised controlled multicenter trial. In total, 457 patients aged 80 or over, with NSTEMI or UAP, were randomised to either an invasive strategy (n = 229, mean age: 84.7 years), involving early coronary angiography, with immediate evaluation for percutaneous coronary intervention, coronary artery bypass graft, optimal medical therapy, or to a conservative strategy (n = 228, mean age: 84.9 years). The Short Form 36 health survey (SF-36) was used to assess HRQOL at baseline, and at the 1-year follow-up. Results baseline SF-36 completion was achieved for 208 and 216 patients in the invasive and conservative groups, respectively. A total of 137 in the invasive group and 136 patients in the conservative group completed the SF-36 form at follow-up. When comparing the changes from follow-up to baseline (delta) no significant changes in quality-of-life scores were observed between the two strategies in any of the domains, expect for a small but statistically significant difference in bodily pain. This difference in only one of the SF-36 subscales may not necessarily be clinically significant. Conclusion from baseline to the 1 year follow-up, only minor differences in change of HRQOL as measured by SF-36 were seen by comparing an invasive and conservative strategy. ClinicalTrials.gov identifier NCT01255540.
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Affiliation(s)
- Nicolai Tegn
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Faculty of Medicine, University of Oslo, Norway
| | - Michael Abdelnoor
- Centre for Biostatistics and Epidemiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Anette Hylen Ranhoff
- Diakonhjemmet Hospital and Department of Clinical Science, University of Bergen, University of Bergen, Bergen, Norway
| | - Knut Endresen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Erik Gjertsen
- Department of Cardiology, Drammen Hospital, Drammen, Norway
| | - Rita Skårdal
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Faculty of Medicine, University of Oslo, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Faculty of Medicine, University of Oslo, Norway
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5
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Soiza RL. Management of acute coronary syndromes in older people. Age Ageing 2018; 47:2-3. [PMID: 29036394 DOI: 10.1093/ageing/afx160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 09/14/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Roy L Soiza
- Deparment of Geriatric Medicine, Aberdeen Royal Infirmary, NHS Grampian, UK
- Ageing Clinical and Experimental Research, School of Medicine, University of Aberdeen, UK
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6
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Zaman MJ, Kwok CS, Bachmann MO, Mamas MA, Myint PK. Explaining inequalities in receipt of care in the older patient with acute coronary syndrome. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 2:59-61. [PMID: 29474631 DOI: 10.1093/ehjqcco/qcw011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- M Justin Zaman
- Norwich Medical School, University of East Anglia, Norfolk, UK.,Department of Medicine, James Paget University Hospital, Gorleston-on-Sea, Norfolk, UK
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, Staffordshire, UK.,Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, Staffordshire, UK
| | - Max O Bachmann
- Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, Staffordshire, UK
| | - Phyo Kyaw Myint
- Epidemiology Group, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK
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