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Timmis A, Vardas P, Townsend N, Torbica A, Katus H, De Smedt D, Gale CP, Maggioni AP, Petersen SE, Huculeci R, Kazakiewicz D, de Benito Rubio V, Ignatiuk B, Raisi-Estabragh Z, Pawlak A, Karagiannidis E, Treskes R, Gaita D, Beltrame JF, McConnachie A, Bardinet I, Graham I, Flather M, Elliott P, Mossialos EA, Weidinger F, Achenbach S. European Society of Cardiology: cardiovascular disease statistics 2021. Eur Heart J 2022; 43:716-799. [PMID: 35016208 DOI: 10.1093/eurheartj/ehab892] [Citation(s) in RCA: 324] [Impact Index Per Article: 162.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/07/2021] [Accepted: 12/16/2021] [Indexed: 12/13/2022] Open
Abstract
AIMS This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries. METHODS AND RESULTS Statistics pertaining to 2019, or the latest available year, are presented. Data sources include the World Health Organization, the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards World Health Organization (WHO) 2025 targets for non-communicable diseases. Salient observations in this report: (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high income (81.6 years) compared with middle-income (74.2 years) countries. (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese with similar prevalence in high and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five-member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures. CONCLUSION Risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO NCD targets for 2025 are unlikely to be met across ESC member countries.
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Affiliation(s)
- Adam Timmis
- William Harvey Research Institute, Queen Mary University London, London, UK
| | - Panos Vardas
- Hygeia Hospitals Group, HHG, Athens, Greece
- European Heart Agency, European Society of Cardiology, Brussels, Belgium
| | | | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy
| | - Hugo Katus
- Department of Internal Medicine and Cardiology, University of Heidelberg, Heidelberg, Germany
| | | | - Chris P Gale
- Medical Research Council Bioinformatics Centre, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Aldo P Maggioni
- Research Center of Italian Association of Hospital Cardiologists (ANMCO), Florence, Italy
| | - Steffen E Petersen
- William Harvey Research Institute, Queen Mary University London, London, UK
| | - Radu Huculeci
- European Heart Agency, European Society of Cardiology, Brussels, Belgium
| | | | | | - Barbara Ignatiuk
- Division of Cardiology, Ospedali Riuniti Padova Sud, Monselice, Italy
| | | | - Agnieszka Pawlak
- Mossakowski Medical Research Centre Polish Academy of Sciences, Warsaw, Poland
| | - Efstratios Karagiannidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Roderick Treskes
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dan Gaita
- Universitatea de Medicina si Farmacie Victor Babes, Institutul de Boli Cardiovasculare, Timisoara, Romania
| | - John F Beltrame
- University of Adelaide, Central Adelaide Local Health Network, Basil Hetzel Institute, Adelaide, Australia
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | | | - Ian Graham
- Tallaght University Hospital, Dublin, Ireland
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Perry Elliott
- Institute of Cardiovascular Science, University College London, London, UK
| | | | - Franz Weidinger
- Department of Internal Medicine and Cardiology, Klinik Landstrasse, Vienna, Austria
| | - Stephan Achenbach
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Abstract
Racism and racial bias influence the lives and cardiovascular health of minority individuals. The fact that minority groups tend to have a higher burden of cardiovascular disease risk factors is often a result of racist policies that restrict opportunities to live in healthy neighbourhoods and have access to high-quality education and healthcare. The fact that minorities tend to have the worst outcomes when cardiovascular disease develops is often a result of institutional or individual racial bias encountered when they interact with the healthcare system. In this review, we discuss bias, discrimination, and structural racism from the viewpoints of cardiologists in Canada, the United Kingdom, and the US, and how racial bias impacts cardiovascular care. Finally, we discuss proposals to mitigate the impact of racism in our specialty.
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Hawkes S, Buse K. Socially Constructed Determinants of Health: The Case for Synergies to Arrive at Gendered Global Health Law. Public Health Ethics 2020. [DOI: 10.1093/phe/phaa013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Abstract
Both gender and the law are significant determinants of health and well-being. Here, we put forward evidence to unpack the relationship between gender and outcomes in health and well-being, and explore how legal determinants interact and intersect with gender norms to amplify or reduce health inequities across populations. The paper explores the similarities between legal and health systems in their response to gender—both systems portray gender neutrality but would be better described as gender-blind. We conclude with a set of recommendations to address both law and gender in implementing the work of the Lancet Commission on the legal determinants of health to improve health outcomes for all, irrespective of gender.
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Thomson S, Huygen F, Prangnell S, De Andrés J, Baranidharan G, Belaïd H, Berry N, Billet B, Cooil J, De Carolis G, Demartini L, Eldabe S, Gatzinsky K, Kallewaard JW, Meier K, Paroli M, Stark A, Winkelmüller M, Stoevelaar H. Appropriate referral and selection of patients with chronic pain for spinal cord stimulation: European consensus recommendations and e-health tool. Eur J Pain 2020; 24:1169-1181. [PMID: 32187774 PMCID: PMC7318692 DOI: 10.1002/ejp.1562] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 12/13/2022]
Abstract
Background Spinal cord stimulation (SCS) is an established treatment for chronic neuropathic, neuropathic‐like and ischaemic pain. However, the heterogeneity of patients in daily clinical practice makes it often challenging to determine which patients are eligible for this treatment, resulting in undesirable practice variations. This study aimed to establish patient‐specific recommendations for referral and selection of SCS in chronic pain. Methods A multidisciplinary European panel used the RAND/UCLA Appropriateness Method (RUAM) to assess the appropriateness of (referral for) SCS for 386 clinical scenarios in four pain areas: chronic low back pain and/or leg pain, complex regional pain syndrome, neuropathic pain syndromes and ischaemic pain syndromes. In addition, the panel identified a set of psychosocial factors that are relevant to the decision for SCS treatment. Results Appropriateness of SCS was strongly determined by the neuropathic or neuropathic‐like pain component, location and spread of pain, anatomic abnormalities and previous response to therapies targeting pain processing (e.g. nerve block). Psychosocial factors considered relevant for SCS selection were as follows: lack of engagement, dysfunctional coping, unrealistic expectations, inadequate daily activity level, problematic social support, secondary gain, psychological distress and unwillingness to reduce high‐dose opioids. An educational e‐health tool was developed that combines clinical and psychosocial factors into an advice on referral/selection for SCS. Conclusions The RUAM was useful to establish a consensus on patient‐specific criteria for referral/selection for SCS in chronic pain. The e‐health tool may help physicians learn to apply an integrated approach of clinical and psychosocial factors. Significance Determining the eligibility of SCS in patients with chronic pain requires careful consideration of a variety of clinical and psychosocial factors. Using a systematic approach to combine evidence from clinical studies and expert opinion, a multidisciplinary European expert panel developed detailed recommendations to support appropriate referral and selection for SCS in chronic pain. These recommendations are available as an educational e‐health tool (https://www.scstool.org/).
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Affiliation(s)
- Simon Thomson
- Department of Anaesthesiology, Basildon and Thurrock University Hospitals, Basildon, UK
| | - Frank Huygen
- Department of Anaesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Simon Prangnell
- Clinical Neuropsychology Service, Oxford University Hospitals, Oxford, UK
| | - José De Andrés
- Valencia University Medical School Anesthesia Unit - Surgical Specialties Department, Department of Anaesthesiology, Critical Care and Pain Management, General University Hospital, Valencia, Spain
| | | | - Hayat Belaïd
- Department of Neurosurgery, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Neil Berry
- Neuromodulation Team, Wessex Neurological Centre, Southampton, UK
| | - Bart Billet
- Department of Anaesthesiology, AZ Delta, Roeselare, Belgium
| | - Jan Cooil
- Department of Physiotherapy, Basildon and Thurrock University Hospitals, Basildon, UK
| | - Giuliano De Carolis
- Anaesthesiology & Pain Therapy Unit, Santa Chiara University Hospital, Pisa, Italy
| | - Laura Demartini
- Pain Unit, Clinical Scientific Institutes Maugeri, Pavia, Italy
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Kliment Gatzinsky
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan W Kallewaard
- Department of Anaesthesiology and Pain Management, Rijnstate Hospital, Velp, The Netherlands
| | - Kaare Meier
- Department of Neurosurgery and Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mery Paroli
- Anaesthesiology & Pain Therapy Unit, Santa Chiara University Hospital, Pisa, Italy
| | - Angela Stark
- Pain Management Service, Basildon and Thurrock University Hospitals, Basildon, UK
| | | | - Herman Stoevelaar
- Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium
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Gul B, Lansky A, Budoff MJ, Sharp D, Maniet B, Herman L, Kuo JZ, Huang L, Monane M, Ladapo JA. The Clinical Utility of a Precision Medicine Blood Test Incorporating Age, Sex, and Gene Expression for Evaluating Women with Stable Symptoms Suggestive of Obstructive Coronary Artery Disease: Analysis from the PRESET Registry. J Womens Health (Larchmt) 2019; 28:728-735. [PMID: 30653377 PMCID: PMC6537117 DOI: 10.1089/jwh.2018.7203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Evaluating women with symptoms suggestive of coronary artery disease (CAD) remains challenging. A blood-based precision medicine test yielding an age/sex/gene expression score (ASGES) has shown clinical validity in the diagnosis of obstructive CAD. We assessed the effect of the ASGES on the management of women with suspected obstructive CAD in a community-based registry. Materials and Methods: The prospective PRESET (A Registry to Evaluate Patterns of Care Associated with the Use of Corus® CAD in Real World Clinical Care Settings) Registry (NCT01677156) enrolled 566 patients presenting with symptoms suggestive of stable obstructive CAD from 21 United States primary care practices from 2012 to 2014. Demographics, clinical characteristics, and referrals to cardiology or further functional and/or anatomical cardiac studies after ASGES testing were collected for this subgroup analysis of women from the PRESET Registry. Patients were followed for 1-year post-ASGES testing. Results: This study cohort included 288 women with a median age 57 years. The median body mass index was 29.2, with hyperlipidemia and hypertension present in 48% and 43% of patients, respectively. Median ASGES was 8.5 (range 1–40), with 218 (76%) patients having low (≤15) ASGES. Clinicians referred 9% (20/218) low ASGES versus 44% (31/70) elevated ASGES women for further cardiac evaluation (odds ratio 0.14, p < 0.0001, adjusted for patient demographics and clinical covariates). Across the score range, higher ASGES were associated with a higher likelihood of posttest cardiac referral. At 1-year follow-up, low ASGES women experienced fewer major adverse cardiac events than elevated ASGES women (1.3% vs. 4.2% respectively, p = 0.16). Conclusions: Incorporation of ASGES into the diagnostic workup demonstrated clinical utility by helping clinicians identify women less likely to benefit from further cardiac evaluation.
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Affiliation(s)
- Burcu Gul
- 1 Section of Cardiology, Yale University, New Haven, Connecticut
| | - Alexandra Lansky
- 1 Section of Cardiology, Yale University, New Haven, Connecticut
| | | | | | | | - Lee Herman
- 5 Johns Creek Primary Care, Suwanee, Georgia
| | - Jane Z Kuo
- 6 CardioDx, Inc., Redwood City, California
| | - Lin Huang
- 6 CardioDx, Inc., Redwood City, California
| | | | - Joseph A Ladapo
- 7 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, California
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Hirsch JA, Beall DP, Chambers MR, Andreshak TG, Brook AL, Bruel BM, Deen HG, Gerszten PC, Kreiner DS, Sansur CA, Tutton SM, van der Meer P, Stoevelaar HJ. Management of vertebral fragility fractures: a clinical care pathway developed by a multispecialty panel using the RAND/UCLA Appropriateness Method. Spine J 2018; 18:2152-2161. [PMID: 30096377 DOI: 10.1016/j.spinee.2018.07.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/31/2018] [Accepted: 07/31/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Vertebral fragility fractures (VFFs), mostly due to osteoporosis, are very common and are associated with significant morbidity and mortality. There is a lack of consensus on the appropriate management of patients with or suspected of having a VFF. PURPOSE This work aimed at developing a comprehensive clinical care pathway (CCP) for VFF. STUDY DESIGN/SETTING The RAND/UCLA Appropriateness Method was used to develop patient-specific recommendations for the various components of the CCP. The study included two individual rating rounds and two plenary discussion sessions. METHODS A multispecialty expert panel (orthopedic and neurosurgeons, interventional [neuro]radiologists and pain specialists) assessed the importance of 20 signs and symptoms for the suspicion of VFF, the relevance of 5 diagnostic procedures, the appropriateness of vertebral augmentation versus nonsurgical management for 576 clinical scenarios, and the adequacy of 6 aspects of follow-up care. RESULTS The panel identified 10 signs and symptoms believed to be relatively specific for VFF. In patients suspected of VFF, advanced imaging was considered highly desirable, with MRI being the preferred diagnostic modality. Vertebral augmentation was considered appropriate in patients with positive findings on advanced imaging and in whom symptoms had worsened and in patients with 2 to 4 unfavorable conditions (eg, progression of height loss and severe impact on functioning), dependent on their relative weight. Time since fracture was considered less relevant for treatment choice. Follow-up should include evaluation of bone mineral density and treatment of osteoporosis. CONCLUSIONS Using the RAND/UCLA Appropriateness Method, a multispecialty expert panel established a comprehensive CCP for the management of VFF. The CCP may be helpful to support decision-making in daily clinical practice and to improve quality of care.
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Affiliation(s)
- Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Douglas P Beall
- Department of Radiology, Oklahoma Spine Hospital, 1800 Renaissance Blvd, Suite 110, Edmond, OK 73013, USA
| | - M Renée Chambers
- Department of Neurosurgery, University of Alabama at Birmingham, 1720 2(nd) Avenue South, Birmingham, AL 35294, USA
| | - Thomas G Andreshak
- Consulting Orthopaedic Associates, 7640 W Sylvania Ave Ste B, Sylvania, OH 43560, USA
| | - Allan L Brook
- Department of Radiology, Montefiore Medical Center, 111 East 210(th) Street, Bronx, NY 10467, USA
| | - Brian M Bruel
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Building Tower West - McNair Campus, Houston, TX 77030, USA
| | - H Gordon Deen
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Peter C Gerszten
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - D Scott Kreiner
- Ahwatukee Sports & Spine, 4530 E Muirwood Dr # 110, Phoenix, AZ 85048, USA
| | - Charles A Sansur
- Department of Neurosurgery, University of Maryland Medical Center, 655 W. Baltimore Street, Baltimore, MD 21201, USA
| | - Sean M Tutton
- Department of Radiology, Vascular/Interventional Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Peter van der Meer
- Southern New Hampshire Radiology Consultants, 703 Riverway Place, Bedford, NH 03110, USA
| | - Herman J Stoevelaar
- Centre for Decision Analysis & Support, Ismar Healthcare, Leopoldplein 39, 2500 Lier, Belgium.
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Influences of socioeconomic deprivation on GPs' decisions to refer patients to cardiology: a qualitative study. Br J Gen Pract 2018; 68:e826-e834. [PMID: 30348887 DOI: 10.3399/bjgp18x699785] [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: 04/03/2018] [Accepted: 08/14/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Variation in GP referral practice may be a factor contributing to the lower uptake of cardiology specialist services for people living in socioeconomic deprivation. Cardiology referrals were chosen for this study due to higher rates of premature death and emergency admissions resulting from coronary heart disease for patients living in more deprived areas. AIM To find out how socioeconomic deprivation influences GP referral practice. DESIGN AND SETTING A qualitative study of GPs working in affluent and deprived areas of one large city in the UK. METHOD The authors used purposive and snowball sampling to recruit 17 GP participants to interviews and a focus group. Participants were asked to reflect on their own experience of making referrals. The authors used a framework approach to the analysis, with differences in themes for GPs working in least and most deprived areas being highlighted. RESULTS The authors identified four main themes by which socioeconomic deprivation influenced GP referral practice: identifying problems; making decisions about referral; navigating the healthcare system; and external pressures. Using a published framework of consultation complexity, the authors then examined the data in relation to a fifth theme of complexity. Referrals from areas of high socioeconomic deprivation involved greater complexity in the majority of the domains of this framework. CONCLUSION Socioeconomic deprivation influences GP referral decisions and navigation of the healthcare system in multiple ways. Referral practice for GPs working in deprived areas is more complex than for their peers working in more affluent areas.
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Abstract
OBJECTIVE We aimed to evaluate the impact of the same-day GPs' strike and terrorist attacks on a call centre's activity. METHODS We compared the number of calls received, the number of patient's medical files (PMFs) created and the number of mobile ICU (MICU) dispatched per hour on Friday, 13 November, to the repository established on the five previous Fridays. As previously published, the variation criterion was set to an activity variation above 20% for more than 2 h. RESULTS On Friday, 13 November, 1745 calls were received compared with 1455 calls, on average, for the five previous Fridays. The number of calls received increased after the terrorist attacks (≤90%) and remained above the threshold for 3 h. The number of PMFs exceeded the threshold from 10:00 a.m. to 05:00 p.m., but was not affected by the attacks. The number of MICUs dispatched exceeded the threshold (>500%) in the first hour after the attacks. CONCLUSION The GPs' strike and the terrorist attacks did not impact our call centre's activity in the same manner. The strike increased the number of PMFs without increasing the number of calls received. The attacks increased the number of calls received and MICU dispatched without increasing the number of PMFs. Many markers are at the disposal of call centres to evaluate the impact of healthcare events.
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Asthana S, Moon G, Gibson A, Bailey T, Hewson P, Dibben C. Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:259-272. [PMID: 27747961 DOI: 10.1111/hsc.12384] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 06/06/2023]
Abstract
There is a general understanding that socioeconomically disadvantaged people are also disadvantaged with respect to their access to NHS care. Insofar as considerable NHS funding has been targeted at deprived areas, it is important to better understand whether and why socioeconomic variations in access and utilisation exist. Exploring this question with reference to cardiovascular care, our aims were to synthesise and evaluate evidence relating to access to and/or use of English NHS services around (i) different points on the care pathway (i.e. presentation, primary management and specialist management) and (ii) different dimensions of inequality (socioeconomic, age- and gender-related, ethnic or geographical). Restricting our search period from 2004 to 2016, we were concerned to examine whether, compared to earlier research, there has been a change in the focus of research examining inequalities in cardiac care and whether the pro-rich bias reported in the late 1990s and early 2000s still applies today. We conducted a scoping study drawing on Arksey & O'Malley's framework. A total of 174 studies were included in the review and appraised for methodological quality. Although, in the past decade, there has been a shift in research focus away from gender and age inequalities in access/use and towards socioeconomic status and ethnicity, evidence that deprived people are less likely to access and use cardiovascular care is very contradictory. Patterns of use appear to vary by ethnicity; South Asian populations enjoying higher access, black populations lower. By contrast, female gender and older age are consistently associated with inequity in cardiovascular care. The degree of geographical variation in access/use is also striking. Finally, evidence of inequality increases with stage on the care pathway, which may indicate that barriers to access arise from the way in which health professionals are adjudicating health needs rather than a failure to seek help in the first place.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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Humphries KH, Pilote L. Research in Women's Cardiovascular Health-Progress at Last? Can J Cardiol 2017; 34:349-353. [PMID: 29290365 DOI: 10.1016/j.cjca.2017.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 10/26/2017] [Accepted: 10/27/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- Karin H Humphries
- BC Center for Improved Cardiovascular Health, Vancouver, British Columbia, Canada.
| | - Louise Pilote
- Divisions of General Internal Medicine and Clinical Epidemiology, Department of Medicine, Research Institute, McGill University Health Center, Montréal, Québec, Canada
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Shaw LJ, Pepine CJ, Xie J, Mehta PK, Morris AA, Dickert NW, Ferdinand KC, Gulati M, Reynolds H, Hayes SN, Itchhaporia D, Mieres JH, Ofili E, Wenger NK, Bairey Merz CN. Quality and Equitable Health Care Gaps for Women: Attributions to Sex Differences in Cardiovascular Medicine. J Am Coll Cardiol 2017; 70:373-388. [PMID: 28705320 DOI: 10.1016/j.jacc.2017.05.051] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/17/2017] [Accepted: 05/17/2017] [Indexed: 12/20/2022]
Abstract
The present review synthesizes evidence and discusses issues related to health care quality and equity for women, including minority population subgroups. The principle of "sameness" or women and men receiving equitable, high-quality care is a near-term target, but optimal population health cannot be achieved without consideration of the unique, gendered structural determinants of health and the development of unique care pathways optimized for women. The aim of this review is to promote enhanced awareness, develop critical thinking in sex and gender science, and identify strategic pathways to improve the cardiovascular health of women. Delineation of the components of high-quality health care, including a women-specific research agenda, remains a vital part of strategic planning to improve the lives of women at risk for or living with cardiovascular disease.
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Affiliation(s)
- Leslee J Shaw
- Emory University School of Medicine, Atlanta, Georgia.
| | | | - Joe Xie
- Emory University School of Medicine, Atlanta, Georgia
| | - Puja K Mehta
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | - Martha Gulati
- University of Arizona College of Medicine, Phoenix, Arizona
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12
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Lumme S, Manderbacka K, Keskimäki I. Trends of relative and absolute socioeconomic equity in access to coronary revascularisations in 1995-2010 in Finland: a register study. Int J Equity Health 2017; 16:37. [PMID: 28222730 PMCID: PMC5320656 DOI: 10.1186/s12939-017-0536-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 02/14/2017] [Indexed: 11/30/2022] Open
Abstract
Background Resources for coronary revascularisations have increased substantially since the early 1990s in Finland. At the same time, ischaemic heart disease (IHD) mortality has decreased markedly. This study aims to examine how these changes have influenced trends in absolute and relative differences between socioeconomic groups in revascularisations and age group differences in them using IHD mortality as a proxy for need. Methods Hospital Discharge Register data on revascularisations among Finns aged 45–84 in 1995–2010 were individually linked to population registers to obtain socio-demographic data. We measured absolute and relative income group differences in revascularisation and IHD mortality with slope index of inequality (SII) and concentration index (C), and relative equity taking need for care into account with horizontal inequity index (HII). Results The supply of procedures doubled during the years. Socioeconomic distribution of revascularisations was in absolute and relative terms equal in 1995 (Men: SII = −12, C = −0.00; Women, SII = −30, C = −0.03), but differences favouring low-income groups emerged by 2010 (M: SII = −340, C = −0.08; W: SII = −195, C = −0.14). IHD mortality decreased markedly, but absolute and relative differences favouring the better-off existed throughout study years. Absolute differences decreased somewhat (M: SII = −760 in 1995, SII = −681 in 2010; W: SII = −318 in 1995, SII = −211 in 2010), but relative differences increased significantly (M: C = −0.14 in 1995, C = −0.26 in 2010; W: C = −0.15 in 1995, C = −0.25 in 2010). HII was greater than zero in each year indicating inequity favouring the better-off. HII increased from 0.15 to 0.18 among men and from 0.10 to 0.12 among women. We found significant and increasing age group differences in HII. Conclusions Despite large increase in supply of revascularisations and decrease in IHD mortality, there is still marked socioeconomic inequity in revascularisations in Finland. However, since changes in absolute distributions of both supply and need for coronary care have favoured low-income groups, absolute inequity can be claimed to have decreased although it cannot be quantified numerically.
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Affiliation(s)
- Sonja Lumme
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland.
| | - Kristiina Manderbacka
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland
| | - Ilmo Keskimäki
- Department of Health and Social Care Systems, Social and Health Systems Research Unit, National Institute for Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland.,Faculty of Social Sciences, University of Tampere, Tampere, FI-33014 University of Tampere, Finland
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Asthana S, Gibson A, Bailey T, Moon G, Hewson P, Dibben C. Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BackgroundA strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.ObjectivesTo generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.DesignCross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).ResultsThe utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.ConclusionsWe found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- College of Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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Bierman AS, Brown AD, Levinton CM. Using decision trees for measuring gender equity in the timing of angiography in patients with acute coronary syndrome: a novel approach to equity analysis. Int J Equity Health 2015; 14:155. [PMID: 26698302 PMCID: PMC4689056 DOI: 10.1186/s12939-015-0280-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 12/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Methods to measure or quantify equity in health care remain scarce, if not difficult to interpret. A novel method to measure health equity is presented, applied to gender health equity, and illustrated with an example of timing of angiography in patients following a hospital admission for an acute coronary syndrome. METHODS Linked administrative hospital discharge and survey data was used to identify a retrospective cohort of patients hospitalized with Acute Coronary Syndrome (ACS) between 2002 and 2008 who also responded to the Canadian Community Health Survey (CCHS), was analyzed using decision trees to determine whether gender impacted the delay to angiography following an ACS. RESULTS Defining a delay to angiography as 1 day or more, resulted in a non-significant difference in an equity score of 0.14 for women and 0.12 for men, where 0 and 1 represents perfect equity and inequity respectively. Using 2 and 3 day delays as a secondary outcome resulted in women and men producing scores of 0.19 and 0.17 for a 2 day delay and 0.22 and 0.23 for a 3 day delay. CONCLUSIONS A technique developed expressly for measuring equity suggests that men and women in Ontario receive equitable care in access to angiography with respect to timeliness following an ACS.
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Affiliation(s)
- Arlene S Bierman
- University of Toronto, 155 College Street, 3rd floor, Toronto, Ontario, M5T 3M7, Canada.
| | - Adalsteinn D Brown
- University of Toronto, 155 College Street 4th floor, Toronto, Ontario, M5T 3M7, Canada.
| | - Carey M Levinton
- University of Toronto, 5 Thomas Elgie Dr. #301, Toronto, Ontario, M4G 4J6, Canada.
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Sandhu K, Nadar SK. Percutaneous coronary intervention in the elderly. Int J Cardiol 2015; 199:342-55. [PMID: 26241641 DOI: 10.1016/j.ijcard.2015.05.188] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 05/07/2015] [Accepted: 05/09/2015] [Indexed: 12/20/2022]
Abstract
Our population dynamics are changing. The number of octogenarians and older people in the general population is increasing and therefore the number of older patients presenting with acute coronary syndrome or stable angina is increasing. This group has a larger burden of coronary disease and also a greater number of concomitant comorbidities when compared to younger patients. Many of the studies assessing percutaneous coronary intervention (PCI) to date have actively excluded octogenarians. However, a number of studies, both retrospective and prospective, are now being undertaken to reflect the, "real" population. Despite being a higher risk group for both elective and emergency PCIs, octogenarians have the greatest to gain in terms of prognosis, symptomatic relief, and arguably more importantly, quality of life. Important future development will include assessment of patient frailty, encouraging early presentation, addressing gender differences on treatment strategies, identification of culprit lesion(s) and vascular access to minimise vascular complications. We are now appreciating that the new frontier is perhaps recognising and risk stratifying those elderly patients who have the most to gain from PCI. This review article summarises the most relevant trials and studies.
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Affiliation(s)
- Kully Sandhu
- Royal Stoke Hospital, University Hospitals of North Midlands, Newcastle Road, Stoke on Trent ST46QG, United Kingdom
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16
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The impact of social deprivation on coronary revascularisation treatment outcomes within the National Health Service in England and Wales. Eur J Prev Cardiol 2015; 23:316-27. [DOI: 10.1177/2047487314567000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 12/15/2014] [Indexed: 11/15/2022]
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Bansal N, Fischbacher CM, Bhopal RS, Brown H, Steiner MFC, Capewell S. Myocardial infarction incidence and survival by ethnic group: Scottish Health and Ethnicity Linkage retrospective cohort study. BMJ Open 2013; 3:e003415. [PMID: 24038009 PMCID: PMC3773657 DOI: 10.1136/bmjopen-2013-003415] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 07/26/2013] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Inequalities in coronary heart disease mortality by country of birth are large and poorly understood. However, these data misclassify UK-born minority ethnic groups and provide little detail on whether excess risk is due to increased incidence, poorer survival or both. DESIGN Retrospective cohort study. SETTING General resident population of Scotland. PARTICIPANTS All those residing in Scotland during the 2001 Census were eligible for inclusion: 2 972 120 people were included in the analysis. The number still residing in Scotland at the end of the study in 2008 is not known. PRIMARY AND SECONDARY OUTCOME MEASURES As specified in the analysis plan, the primary outcome measures were first occurrence of admission or death due to myocardial infarction and time to event. There were no secondary outcome measures. RESULTS Acute myocardial infarction (AMI) incidence risk ratios (95% CIs) relative to white Scottish populations (100) were highest among Pakistani men (164.1 (142.2 to 189.2)) and women (153.7 (120.5, 196.1)) and lowest for men and women of Chinese (39.5 (27.1 to 57.6) and 59.1 (38.6 to 90.7)), other white British (77 (74.2 to 79.8) and 72.2 (69.0 to 75.5)) and other white (83.1 (75.9 to 91.0) and 79.9 (71.5 to 89.3)) ethnic groups. Adjustment for educational qualification did not eliminate these differences. Cardiac intervention uptake was similar across most ethnic groups. Compared to white Scottish, 28-day survival did not differ by ethnicity, except in Pakistanis where it was better, particularly in women (0.44 (0.25 to 0.78)), a difference not removed by adjustment for education, travel time to hospital or cardiac intervention uptake. CONCLUSIONS Pakistanis have the highest incidence of AMI in Scotland, a country renowned for internationally high cardiovascular disease rates. In contrast, survival is similar or better in minority ethnic groups. Clinical care and policy should focus on reducing incidence among Pakistanis through more aggressive prevention.
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Affiliation(s)
- Narinder Bansal
- Public Health Sciences, Centre for Population Health Studies, University of Edinburgh,Edinburgh, UK
| | - Colin M Fischbacher
- Information Services Division, NHS National Services Scotland, Edinburgh, UK
| | - Raj S Bhopal
- Public Health Sciences, Centre for Population Health Studies, University of Edinburgh,Edinburgh, UK
| | - Helen Brown
- Public Health Sciences, Centre for Population Health Studies, University of Edinburgh,Edinburgh, UK
| | - Markus FC Steiner
- Public Health Sciences, Centre for Population Health Studies, University of Edinburgh,Edinburgh, UK
| | - Simon Capewell
- Division of Public Health, University of Liverpool, Liverpool, UK
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Zaman MJS, Philipson P, Chen R, Farag A, Shipley M, Marmot MG, Timmis AD, Hemingway H. South Asians and coronary disease: is there discordance between effects on incidence and prognosis? Heart 2013; 99:729-36. [PMID: 23406688 PMCID: PMC3960593 DOI: 10.1136/heartjnl-2012-302925] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objective To determine whether the effect of South Asian ethnicity differs between studies of incidence and prognosis of coronary disease. Design Systematic literature review and meta-analysis, and cohort analysis from a national acute coronary syndrome (ACS) registry linked to mortality (National Institute of Cardiovascular Outcomes Research/Myocardial Infarction National Audit Project). Setting International for the review, and England and Wales for the cohort analysis. Patients The numbers of South Asians included in the meta-analysis were 111 555 (incidence) and 14 531 (prognosis) of whom 8251 were from the ACS cohort. Main outcome measures Incidence studies: non-fatal myocardial infarction or fatal coronary heart disease; prognostic studies: mortality; HRs for 1-year all-cause death in ACS cohort. Results South Asians had higher incidence of coronary disease compared with white subjects (HR 1.35 95% CI 1.30 to 1.40) based on meta-analysis of nine studies. Among 10 studies on prognosis, South Asians had better prognosis compared with white subjects (HR 0.78 95% CI 0.74 to 0.82). In the ACS cohort, the impact of diabetes (42.4% of South Asians, 16.9% of white subjects) on 1-year mortality was stronger in South Asians than white subjects (age-adjusted HR 1.83 95% CI 1.59 to 2.11 vs 1.53 95% CI 1.49 to 1.57). However, prognosis was better in South Asians even among diabetics, older people and those living in areas of the highest social deprivation. Conclusions South Asian ethnicity is associated with higher incidence of coronary disease, but lower mortality once coronary disease is manifest. The dissociation between effects on incidence and prognosis suggests that public health initiatives to reduce inequalities in mortality between South Asian and white populations should focus on primary prevention. This is a CALIBER study with ClinicalTrials.gov Identifier: NCT01163513.
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Affiliation(s)
- M Justin S Zaman
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK.
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Steg PG, Greenlaw N, Tardif JC, Tendera M, Ford I, Kääb S, Abergel H, Fox KM, Ferrari R. Women and men with stable coronary artery disease have similar clinical outcomes: insights from the international prospective CLARIFY registry. Eur Heart J 2012; 33:2831-40. [PMID: 22922505 PMCID: PMC3498005 DOI: 10.1093/eurheartj/ehs289] [Citation(s) in RCA: 406] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aims Men and women differ in terms of presentation and management in coronary artery disease (CAD). Whether these differences translate into different clinical outcomes in stable CAD is unclear. We analysed data from the international prospective CLARIFY registry to compare cardiovascular clinical outcomes in men and women with stable CAD. Methods and results We analysed 1-year outcomes in 30 977 outpatients with stable CAD [23 975 (77.4%) men; 7002 (22.6%) women]. Women were older than men, more likely to have hypertension and diabetes, and less likely to exercise or smoke. They had more frequent angina, but were less likely to have undergone diagnostic non-invasive testing or coronary angiography. Women received less optimized treatment for stable CAD. One-year outcomes were similar for men and women for the composite of cardiovascular death, non-fatal myocardial infarction, or stroke [adjusted rates 1.7 vs. 1.8%, respectively, odds ratio (OR) 0.93, 95% confidence interval (CI) 0.75–1.15]; all-cause death (adjusted 1.5 vs. 1.6%, OR: 0.91, 95% CI: 0.72–1.13); fatal or non-fatal myocardial infarction (adjusted 1.0 vs. 0.9%, OR: 0.81, 95 CI: 0.60–1.08); and cardiovascular death or non-fatal myocardial infarction (adjusted 1.4 vs. 1.4%, OR: 0.89, 95% CI: 0.70–1.12). Fewer women underwent revascularization (2.6 vs. 2.2%, OR: 0.77, 95% CI: 0.64–0.93), although appropriateness was not analysed. Conclusion The risk profiles of women and men with stable CAD differ substantially. However, 1-year outcomes were similar. Fewer women underwent revascularization. Further research is needed to better understand gender determinants of outcome and devise strategies to minimize bias in the management and treatment of women.
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Legrain S, Delpierre S, Lacaille S, Duc P, Lieberherr D, Bonnet D, Lahjibi-Paulet H, Gouronnec A, Boddaert J, Durand-Gasselin B, Roy C, Faucounau V, Steg PG, Tubach F. Systematic re-evaluation of the diagnosis and treatment of coronary artery disease in hospitalized elderly: Impact on medication underuse. The multicenter IRIDIA study. Eur Geriatr Med 2012. [DOI: 10.1016/j.eurger.2012.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dharampal AS, Papadopoulou SL, Rossi A, Weustink AC, Mollet NRA, Meijboom WB, Neefjes LA, Nieman K, Boersma E, de Feijter PJ, Krestin GP. Computed tomography coronary angiography accuracy in women and men at low to intermediate risk of coronary artery disease. Eur Radiol 2012; 22:2415-23. [PMID: 22669338 PMCID: PMC3472076 DOI: 10.1007/s00330-012-2503-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 03/23/2012] [Accepted: 04/12/2012] [Indexed: 01/01/2023]
Abstract
Objectives To investigate the diagnostic accuracy of CT coronary angiography (CTCA) in women at low to intermediate pre-test probability of coronary artery disease (CAD) compared with men. Methods In this retrospective study we included symptomatic patients with low to intermediate risk who underwent both invasive coronary angiography and CTCA. Exclusion criteria were previous revascularisation or myocardial infarction. The pre-test probability of CAD was estimated using the Duke risk score. Thresholds of less than 30 % and 30–90 % were used for determining low and intermediate risk, respectively. The diagnostic accuracy of CTCA in detecting obstructive CAD (≥50 % lumen diameter narrowing) was calculated on patient level. P < 0.05 was considered significant. Results A total of 570 patients (46 % women [262/570]) were included and stratified as low (women 73 % [80/109]) and intermediate risk (women 39 % [182/461]). Sensitivity, specificity, PPV and NPV were not significantly different in and between women and men at low and intermediate risk. For women vs. men at low risk they were 97 % vs. 100 %, 79 % vs. 90 %, 80 % vs. 80 % and 97 % vs. 100 %, respectively. For intermediate risk they were 99 % vs. 99 %, 72 % vs. 83 %, 88 % vs. 93 % and 98 % vs. 99 %, respectively. Conclusion CTCA has similar diagnostic accuracy in women and men at low and intermediate risk. Key Points • Coronary artery disease (CAD) is increasingly investigated by computed tomography angiography (CTCA). • CAD detection or exclusion by CTCA is not different between sexes. • CTCA diagnostic accuracy was similar between low and intermediate risk sex-specific-groups. • CTCA rarely misses obstructive CAD in low–intermediate risk women and men. • CAD yield by invasive coronary angiography after positive CTCA is similar between sex-risk-specific groups.
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Affiliation(s)
- Anoeshka S Dharampal
- Department of Radiology, Erasmus MC, Room Ca207a, 's-Gravendijkwal 230, P.O. Box 2040, 3015 CE, Rotterdam, The Netherlands.
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Walters K, Rait G, Hardoon S, Kalaitzaki E, Petersen I, Nazareth I. Socio-demographic variation in chest pain incidence and subsequent coronary heart disease in primary care in the United Kingdom. Eur J Prev Cardiol 2012; 21:566-75. [PMID: 22617118 DOI: 10.1177/2047487312449415] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND We know little about socio-demographic differences in chest pain presenting to primary care and subsequent coronary heart disease (CHD) diagnosis. METHODS We conducted a cohort study with 198,209 patients aged 30 years and over with a first episode of chest pain, using data from 339 general practices in The Health Improvement Network (THIN) primary care database during 1997-2007. We calculated incidence of chest pain and subsequent CHD by age, gender and quintiles of Townsend area deprivation score. RESULTS Chest pain incidence was 19.6/1000 person years at risk (PYAR, 95% CI 19.5-19.7). Incidence rose with age and increasing deprivation, with minimal gender differences. The incidence of CHD in the year following chest pain in primary care was 96.6/1000 PYAR (95% CI 95.1-98.0). There were significant interactions with age/deprivation and gender/deprivation on subsequent CHD diagnosis. The effect of deprivation was less for those over 60 years, and greater for younger women. Women in their 30s with chest pain in deprived areas had 8.77 times (95% CI 3.34-23.06) the CHD incidence compared to those in the most affluent areas. The absolute risk difference was small (8/1000 PYAR, 95% CI 4.5-11.5/1000 PYAR). CONCLUSIONS There was a modestly greater incidence of chest pain in primary care in more deprived areas compared to the least deprived areas. There were interactions between age, gender and deprivation on subsequent CHD diagnosis, with the greatest effect of deprivation on CHD diagnosis seen in younger women. This observation suggests the need for targeting health promotion and CHD prevention among younger women in deprived areas.
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Affiliation(s)
- Kate Walters
- Department of Primary Care and Population Health, University College London, UK
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Sekhri N, Timmis A, Hemingway H, Walsh N, Eldridge S, Junghans C, Feder G. Is access to specialist assessment of chest pain equitable by age, gender, ethnicity and socioeconomic status? An enhanced ecological analysis. BMJ Open 2012; 2:bmjopen-2012-001025. [PMID: 22700834 PMCID: PMC3378943 DOI: 10.1136/bmjopen-2012-001025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To determine whether access to rapid access chest pain clinics of people with recent onset symptoms is equitable by age, socioeconomic status, ethnicity and gender, according to need. DESIGN Retrospective cohort study with ecological analysis. SETTING Patients referred from primary care to five rapid access chest pain clinics in secondary care, across England. PARTICIPANTS Of 8647 patients aged ≥35 years referred to chest pain clinics with new-onset stable chest pain but no known cardiac history, 7570 with documented census ward codes, age, gender and ethnicity comprised the study group. Patients excluded were those with missing date of birth, gender or ethnicity (n=782) and those with missing census ward codes (n=295). OUTCOME MEASURES Effects of age, gender, ethnicity and socioeconomic status on clinic attendance were calculated as attendance rate ratios, with number of attendances as the outcome and resident population-years as the exposure in each stratum, using Poisson regression. Attendance rate ratios were then compared with coronary heart disease (CHD) mortality ratios to determine whether attendance was equitable according to need. RESULTS Adjusted attendance rate ratios for patients aged >65 years were similar to younger patients (1.1, 95% CI 1.05 to 1.16), despite population CHD mortality rate ratios nearly 15 times higher in the older age group. Women had lower attendance rate ratios (0.81, 95% CI 0.77 to 0.84) and also lower population CHD mortality rate ratios compared with men. South Asians had higher attendance rates (1.67, 95% CI 1.57 to 1.77) compared with whites and had a higher standardised CHD mortality ratio of 1.46 (95% CI 1.41 to 1.51). Although univariable analysis showed that the most deprived patients (quintile 5) had an attendance rate twice that of less deprived quintiles, the adjusted analysis showed their attendance to be 13% lower (0.87, 95% CI 0.81 to 0.94) despite a higher population CHD mortality rate. CONCLUSION There is evidence of underutilisation of chest pain clinics by older people and those from lower socioeconomic status. More robust and patient focused administrative pathways need to be developed to detect inequity, correction of which has the potential to substantially reduce coronary mortality.
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Affiliation(s)
- Neha Sekhri
- Cardiac Directorate, Barts and the London NHS Trust, London, UK
| | - Adam Timmis
- Cardiac Directorate, Barts and the London NHS Trust, London, UK
| | - Harry Hemingway
- Department of Epidemiology and Public Health, University College London Medical School, London, UK
| | - Niamh Walsh
- Centre for Health Sciences, Barts and the London, Queen Mary's School of Medicine and Dentistry, University of London, London, UK
| | - Sandra Eldridge
- Centre for Health Sciences, Barts and the London, Queen Mary's School of Medicine and Dentistry, University of London, London, UK
| | - Cornelia Junghans
- Department of Epidemiology and Public Health, University College London Medical School, London, UK
| | - Gene Feder
- Centre for Health Sciences, Barts and the London, Queen Mary's School of Medicine and Dentistry, University of London, London, UK
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Altenhöner T, Baczkiewicz C, Weishaar H, Kutschmann M. Inequalities in therapeutic treatment during cardiac inpatient rehabilitation in Germany. Int J Public Health 2011; 57:175-84. [PMID: 21894568 DOI: 10.1007/s00038-011-0298-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2010] [Revised: 07/26/2011] [Accepted: 08/22/2011] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE Cardiac patients of low socio-economic status (SES) display low health status and increased need for rehabilitation. This study's objective was to examine whether and to what extent inequalities in the provision of rehabilitative health care occur in Germany. METHODS We conducted an observational study with two points of measurement on 543 patients in cardiac inpatient rehabilitation. We used logistic regression and analysis of covariance to explore whether patients experience unequal therapeutic rehabilitative treatment. RESULTS Patients of low SES were less frequently physically active, more likely to smoke and displayed a higher number of physical and psychological symptoms when entering rehabilitation. They were less likely to receive a number of therapies with differences being significant for core therapies of cardiovascular rehabilitation. Patients of higher SES received fewer hours of dietary counselling on average. CONCLUSIONS While the latter difference might be in line with the needs of different socio-economic groups, most differences are unlikely to be tailored to patients' needs. Potential causes of inequalities in service provision like structural factors and aspects of the doctor-patient encounter should be further investigated.
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Affiliation(s)
- Thomas Altenhöner
- Department of Health and Nursing, University of Applied Sciences of the Saarland, Saarbrücken, Germany.
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Mieres JH, Heller GV, Hendel RC, Gulati M, Boden WE, Katten D, Shaw LJ. Signs and Symptoms of Suspected Myocardial Ischemia in Women: Results from the What is the Optimal Method for Ischemia Evaluation in WomeN? Trial. J Womens Health (Larchmt) 2011; 20:1261-8. [DOI: 10.1089/jwh.2010.2595] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
| | - Gary V. Heller
- Hartford Hospital, Hartford, and the University of Connecticut School of Medicine, Farmington, Connecticut
| | | | - Martha Gulati
- Ohio State University Medical Center, Columbus, Ohio
| | - William E. Boden
- University at Buffalo Schools of Medicine and Public Health and Buffalo General Hospital, Buffalo, New York
| | - Deborah Katten
- Hartford Hospital, Hartford, and the University of Connecticut School of Medicine, Farmington, Connecticut
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Gender Differences in Patients with Stable Angina attending Primary Care Practices. Heart Lung Circ 2011; 20:452-9. [DOI: 10.1016/j.hlc.2011.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 02/09/2011] [Accepted: 02/21/2011] [Indexed: 11/18/2022]
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Mitchell AJ, Lawrence D. Revascularisation and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta-analysis. Br J Psychiatry 2011; 198:434-41. [PMID: 21628705 DOI: 10.1192/bjp.bp.109.076950] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND High levels of comorbid physical illness and excess mortality rates have been previously documented in people with severe mental illness, but outcomes following myocardial infarction and other acute coronary syndromes are less clear. AIMS To examine inequalities in the provision of invasive coronary procedures (revascularisation, angiography, angioplasty and bypass grafting) and subsequent mortality in people with mental illness and in those with schizophrenia, compared with those without mental ill health. METHOD Systematic search and random effects meta-analysis were used according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies of mental health and cardiovascular procedures following cardiac events were eligible but we required a minimum of three independent studies to warrant pooling by procedure type. We searched Medline/PubMed and EMBASE abstract databases and ScienceDirect, Ingenta Select, SpringerLink and Online Wiley Library full text databases. RESULTS We identified 22 analyses of possible inequalities in coronary procedures in those with defined mental disorder, of which 10 also reported results in schizophrenia or related psychosis. All studies following acute coronary syndrome originated in the USA. The total sample size was 825 754 individuals. Those with mental disorders received 0.86 (relative risk, RR: 95% CI 0.80-0.92, P<0.0001) of comparable procedures with significantly lower receipt of coronary artery bypass graft (CABG; RR = 0.85, 95% CI 0.72-1.00), cardiac catheterisation (RR = 0.85, 95% CI 0.76-0.95) and percutaneous transluminal coronary angioplasty or percutaneous coronary intervention (PTCA/PCI; RR = 0.87, 95% CI 0.72-1.05). People with a diagnosis of schizophrenia received only 0.53 (95% CI 0.44-0.64, P<0.0001) of the usual procedure rate with significantly lower receipt of CABG (RR = 0.69, 95% CI 0.55-0.85) and PTCA/PCI (RR = 0.50, 95% CI 0.34-0.75). We identified 6 related studies examining mortality following cardiac events: for those with mental illness there was a 1.11 relative risk of mortality up to 1 year (95% CI 1.00-1.24, P = 0.05) but there was insufficient evidence to examine mortality rates in schizophrenia alone. CONCLUSIONS Following cardiac events, individuals with mental illness experience a 14% lower rate of invasive coronary interventions (47% in the case of schizophrenia) and they have an 11% increased mortality rate. Further work is required to explore whether these factors are causally linked and whether improvements in medical care might improve survival in those with mental ill health.
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Affiliation(s)
- Alex J Mitchell
- Department of Liaison Psychiatry, Leicestershire Partnership Trust and Department of Cancer Studies and Molecular Medicine, Leicester Royal Infirmary, Leicester, UK.
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Khattar RS, Nair SB, Hamid T, Chacko S, Mamas M, Turkie W, Arumugam P. Prognostic value of demographic factors, pre-test probability scoring, exercise test diagnosis, and inability to exercise in patients with recent onset suspected cardiac chest pain. Eur J Prev Cardiol 2011; 19:419-27. [DOI: 10.1177/1741826711404505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims: To assess the prognostic value of an inconclusive exercise test or inability to exercise in patients with recent onset suspected cardiac chest pain and to determine the independent predictors of events in these patients. Methods: This was an observational follow-up study of patients presenting to a rapid access chest pain clinic with a history of recent-onset suspected cardiac chest pain as referred by the family practitioner. The main outcome measure was a composite endpoint of death and acute coronary syndrome hospital admission. Results: The study cohort consisted of 1851 patients in whom a total of 147 events were recorded during a mean follow-up period of 4.1 ± 1.1 years. Those with events were significantly older (65.1 ± 12.5 years versus 56.4 ± 13.2 years, p < 0.001), had higher mean pre-test probability of coronary artery disease (CAD), and had higher prevalence of diabetes (18.4% vs. 13.6%, p < 0.001), hypertension (55.8% vs. 38.7%, p < 0.001), and smoking (36.7% vs. 25.4%, p = 0.03) than those without events. These patients were also more likely to have a positive exercise electrocardiogram (ECG) (15.6% vs. 8.6%, p < 0.001) or not have a diagnostic exercise test because of an inconclusive result or inability to exercise (60.5% vs. 28.6%, p < 0.001). Cox multivariate regression analysis showed that age (hazard ratio, HR 1.03, p < 0.001), pre-test probability of CAD (HR 1.08, p = 0.04), positive exercise ECG (HR 2.94, p < 0.001), and an inconclusive test or inability to exercise (HR 3.45, p < 0.001) were independent predictors of events. Conclusions: In patients with recent onset suspected cardiac chest pain, not having a diagnostic exercise ECG because of an inconclusive test or inability to exercise is an independent predictor of events and has similar prognostic implications to a positive exercise ECG. In addition, pre-test probability estimation at baseline is a robust indicator of clinical outcome. Future models of care need to incorporate early and increased access to non-exercise cardiac imaging techniques in order to meet the needs of this high-risk subgroup of patients.
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Affiliation(s)
- Rajdeep S Khattar
- Manchester Heart Centre, Manchester Royal Infirmary and The University of Manchester, Manchester, UK
| | - Satheesh B Nair
- Manchester Heart Centre, Manchester Royal Infirmary and The University of Manchester, Manchester, UK
| | - Tahir Hamid
- Manchester Heart Centre, Manchester Royal Infirmary and The University of Manchester, Manchester, UK
| | - Sanoj Chacko
- Manchester Heart Centre, Manchester Royal Infirmary and The University of Manchester, Manchester, UK
| | - Mamas Mamas
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Wajdi Turkie
- Manchester Heart Centre, Manchester Royal Infirmary and The University of Manchester, Manchester, UK
| | - Parthiban Arumugam
- Department of Nuclear Medicine, Manchester Royal Infirmary, Manchester, UK
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Ciambrone G, Kaski JC. Gender differences in the treatment of chronic ischemic heart disease: prognostic implications. Fundam Clin Pharmacol 2011; 24:707-10. [PMID: 19719552 DOI: 10.1111/j.1472-8206.2009.00774.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite the relatively high prevalence of coronary artery disease in women, there are little data on the investigation and treatment of ischemic heart disease in this population. In the last couple of decades authors have addressed health problems in minorities, including women. The great majority of these studies included the acute coronary syndrome population but most recent ones have focused on the management of stable angina from a gender perspective. Many of those studies showed that there are inequities between genders regarding the care of patients with ischemic heart disease. Although little is known about the prognostic implications of such differences, studies have shown that suboptimal treatment in women leads to poor clinical outcomes. Gender-specific and both epidemiological and pathophysiological data are needed.
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Affiliation(s)
- Graciana Ciambrone
- Cardiovascular Biology Research Centre, Division of Cardiac and Vascular Sciences, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
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Purdy S, Griffin T, Salisbury C, Sharp D. Emergency admissions for coronary heart disease: A cross-sectional study of general practice, population and hospital factors in England. Public Health 2011; 125:46-54. [DOI: 10.1016/j.puhe.2010.07.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 06/16/2010] [Accepted: 07/13/2010] [Indexed: 12/21/2022]
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Quan H, Khan N, Li B, Humphries KH, Faris P, Galbraith PD, Graham M, Knudtson ML, Ghali WA. Invasive cardiac procedure use and mortality among South Asian and Chinese Canadians with coronary artery disease. Can J Cardiol 2010; 26:e236-42. [PMID: 20847970 DOI: 10.1016/s0828-282x(10)70414-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Previous studies evaluated cardiac procedure use and outcome over the short term, with relatively few Asian patients included. OBJECTIVES To determine the likelihood of undergoing percutaneous coronary intervention and coronary artery bypass grafting, and survival during 10.5 years of follow-up after coronary angiography among South Asian, Chinese and other Canadian patients. METHODS Using prospective cohort study data from two large Canadian provinces, 3061 South Asian, 1473 Chinese and 77,314 other Canadian patients with angiographically proven coronary artery disease from 1995 to 2004 were assessed, and their revascularization and mortality rates during 10.5 years of follow-up were determined. RESULTS Compared with other Canadian patients, South Asian and Chinese patients were slightly less likely to undergo revascularization (riskadjusted HR 0.94, 95% CI 0.90 to 0.98 for South Asian patients; and HR 0.94, 95% CI 0.88 to 1.00 for Chinese patients). However, South Asian patients underwent coronary artery bypass grafting (HR 1.00, 95% CI 0.94 to 1.07) and Chinese patients underwent percutaneous coronary intervention (HR 0.96, 95% CI 0.89 to 1.04) as frequently as other Canadian patients. Although the 30-day mortality rate was similar across the three ethnic groups, the mortality rate in the follow-up period was significantly lower for South Asian patients (HR 0.76, 95% CI 0.61 to 0.95) and marginally lower for Chinese patients (HR 0.80, 95% CI 0.60 to 1.07) compared with other Canadian patients. CONCLUSIONS South Asian and Chinese patients used revascularization slightly less but had better survival outcomes than other Canadian patients. The factors underlying the better outcomes for South Asian and Chinese patients warrant further study.
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Affiliation(s)
- Hude Quan
- Department of Community Health Sciences, University of Calgary, Alberta.
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Hemingway H, Philipson P, Chen R, Fitzpatrick NK, Damant J, Shipley M, Abrams KR, Moreno S, McAllister KSL, Palmer S, Kaski JC, Timmis AD, Hingorani AD. Evaluating the quality of research into a single prognostic biomarker: a systematic review and meta-analysis of 83 studies of C-reactive protein in stable coronary artery disease. PLoS Med 2010; 7:e1000286. [PMID: 20532236 PMCID: PMC2879408 DOI: 10.1371/journal.pmed.1000286] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Accepted: 04/22/2010] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Systematic evaluations of the quality of research on a single prognostic biomarker are rare. We sought to evaluate the quality of prognostic research evidence for the association of C-reactive protein (CRP) with fatal and nonfatal events among patients with stable coronary disease. METHODS AND FINDINGS We searched MEDLINE (1966 to 2009) and EMBASE (1980 to 2009) and selected prospective studies of patients with stable coronary disease, reporting a relative risk for the association of CRP with death and nonfatal cardiovascular events. We included 83 studies, reporting 61,684 patients and 6,485 outcome events. No study reported a prespecified statistical analysis protocol; only two studies reported the time elapsed (in months or years) between initial presentation of symptomatic coronary disease and inclusion in the study. Studies reported a median of seven items (of 17) from the REMARK reporting guidelines, with no evidence of change over time. The pooled relative risk for the top versus bottom third of CRP distribution was 1.97 (95% confidence interval [CI] 1.78-2.17), with substantial heterogeneity (I(2) = 79.5). Only 13 studies adjusted for conventional risk factors (age, sex, smoking, obesity, diabetes, and low-density lipoprotein [LDL] cholesterol) and these had a relative risk of 1.65 (95% CI 1.39-1.96), I(2) = 33.7. Studies reported ten different ways of comparing CRP values, with weaker relative risks for those based on continuous measures. Adjusting for publication bias (for which there was strong evidence, Egger's p<0.001) using a validated method reduced the relative risk to 1.19 (95% CI 1.13-1.25). Only two studies reported a measure of discrimination (c-statistic). In 20 studies the detection rate for subsequent events could be calculated and was 31% for a 10% false positive rate, and the calculated pooled c-statistic was 0.61 (0.57-0.66). CONCLUSION Multiple types of reporting bias, and publication bias, make the magnitude of any independent association between CRP and prognosis among patients with stable coronary disease sufficiently uncertain that no clinical practice recommendations can be made. Publication of prespecified statistical analytic protocols and prospective registration of studies, among other measures, might help improve the quality of prognostic biomarker research.
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Affiliation(s)
- Harry Hemingway
- Department of Epidemiology and Public Health, University College London, United Kingdom.
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Korda RJ, Clements MS, Kelman CW. Universal health care no guarantee of equity: comparison of socioeconomic inequalities in the receipt of coronary procedures in patients with acute myocardial infarction and angina. BMC Public Health 2009; 9:460. [PMID: 20003401 PMCID: PMC2807435 DOI: 10.1186/1471-2458-9-460] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 12/14/2009] [Indexed: 11/10/2022] Open
Abstract
Background In Australia there is a socioeconomic gradient in morbidity and mortality favouring socioeconomically advantaged people, much of which is accounted for by ischaemic heart disease. This study examines if Australia's universal health care system, with its mixed public/private funding and delivery model, may actually perpetuate this inequity. We do this by quantifying and comparing socioeconomic inequalities in the receipt of coronary procedures in patients with acute myocardial infarction (AMI) and patients with angina. Methods Using linked hospital and mortality data, we followed patients admitted to Western Australian hospitals with a first admission for AMI (n = 5539) or angina (n = 7401) in 2001-2003. An outcome event was the receipt, within a year, of a coronary procedure—angiography, angioplasty and/or coronary artery bypass surgery (CABG). Socioeconomic status was assigned to each individual using an area-based measure, the SEIFA Index of Disadvantage. Multivariable proportional hazards regression was used to model the association between socioeconomic status and procedure rates, allowing for censoring and adjustment of multiple covariates. Mediating models examined the effect of private health insurance. Results In the AMI patient cohort, socioeconomic gradients were not evident except that disadvantaged women were more likely than advantaged women to undergo CABG. In contrast, in the angina patient group there were clear socioeconomic gradients for all procedures, favouring more advantaged patients. Compared with patients in the most disadvantaged quintile of socioeconomic status, patients in the least disadvantaged quintile were 11% (1-21%) more likely to receive angiography, 52% (29-80%) more likely to undergo angioplasty and 30% (3-55%) more likely to undergo CABG. Private health insurance explained some of the socioeconomic variation in rates. Conclusions Australia's universal health care system does not guarantee equity in the receipt of high technology health care for patients with ischaemic heart disease. While such a system might ensure equity for patients with AMI, where guidelines for treatment are relatively well established, this is not the case for angina patients, where health care may be less urgent and more discretionary.
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Affiliation(s)
- Rosemary J Korda
- Australian Centre for Economic Research on Health, The Australian National University, Canberra ACT 0200, Australia.
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Abstract
Coronary artery disease (CAD) is the single most common cause of death in the developed world, responsible for about 1 in every 5 deaths. The morbidity, mortality, and socioeconomic importance of this disease make timely accurate diagnosis and cost-effective management of CAD of the utmost importance. This comprehensive review of the literature highlights key elements in the diagnosis, risk stratification, and management strategies of patients with chronic CAD. Relevant articles were identified by searching the PubMed database for the following terms: chronic coronary artery disease or stable angina. Novel imaging modalities, pharmacological treatment, and invasive (percutaneous and surgical) interventions have revolutionized the current treatment of patients with chronic CAD. Medical treatment remains the cornerstone of management, but revascularization continues to play an important role. In the current economic climate and with health care reform very much on the horizon, the issue of appropriate use of revascularization is important, and the indications for revascularization, in addition to the relative benefits and risks of a percutaneous vs a surgical approach, are discussed.
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Affiliation(s)
- Andrew Cassar
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - David R. Holmes
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Charanjit S. Rihal
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Bernard J. Gersh
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Shaw LJ, Bugiardini R, Merz CNB. Women and ischemic heart disease: evolving knowledge. J Am Coll Cardiol 2009; 54:1561-75. [PMID: 19833255 PMCID: PMC2789479 DOI: 10.1016/j.jacc.2009.04.098] [Citation(s) in RCA: 464] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Revised: 04/20/2009] [Accepted: 04/27/2009] [Indexed: 12/14/2022]
Abstract
Evolving knowledge regarding sex differences in coronary heart disease is emerging. Given the lower burden of obstructive coronary artery disease (CAD) and preserved systolic function in women, which contrasts with greater rates of myocardial ischemia and near-term mortality compared with men, we propose the term "ischemic heart disease" as appropriate for this discussion specific to women rather than CAD or coronary heart disease (CHD). This paradoxical difference, where women have lower rates of anatomical CAD but more symptoms, ischemia, and adverse outcomes, appears linked to abnormal coronary reactivity that includes microvascular dysfunction. Novel risk factors can improve the Framingham risk score, including inflammatory markers and reproductive hormones, as well as noninvasive imaging and functional capacity measurements. Risk for women with obstructive CAD is increased compared with men, yet women are less likely to receive guideline-indicated therapies. In the setting of non-ST-segment elevation acute myocardial infarction, interventional strategies are equally effective in biomarker-positive women and men, whereas conservative management is indicated for biomarker-negative women. For women with evidence of ischemia but no obstructive CAD, antianginal and anti-ischemic therapies can improve symptoms, endothelial function, and quality of life; however, trials evaluating impact on adverse outcomes are needed. We hypothesize that women experience more adverse outcomes compared with men because obstructive CAD remains the current focus of therapeutic strategies. Continued research is indicated to devise therapeutic regimens to improve symptom burden and reduce risk in women with ischemic heart disease.
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Affiliation(s)
- Leslee J Shaw
- Emory Program in Cardiovascular Outcomes Research and Epidemiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Soljak M, Browne J, Lewsey J, Black N. Is there an association between deprivation and pre-operative disease severity? A cross-sectional study of patient-reported health status. Int J Qual Health Care 2009; 21:311-5. [PMID: 19689987 DOI: 10.1093/intqhc/mzp033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Differences in access to elective surgery may contribute to socioeconomic differences in health. We studied the associations between pre-operative health status (as an indicator of clinical need) and deprivation. DESIGN Cross-sectional study with risk-adjusted comparison of preoperative patient-reported health status and deprivation scores. SETTING Thirteen NHS hospitals, two independent sector treatment centres and one private hospital in England and Wales. PARTICIPANTS A total of 1160 NHS-funded patients undergoing hip replacement, knee replacement or varicose vein surgery. INTERVENTION s) None. MAIN OUTCOME MEASURE(S) General health status (EQ-5D), disease-specific health status (Oxford hip score, Oxford knee score and Aberdeen varicose vein symptom severity score) and area deprivation score. RESULTS Patients from more deprived areas reported worse EQ-5D scores. Differences in crude mean disease-specific health status scores between the least and most deprived fifths were small: hip score 3.5; knee score 6.8; varicose vein score 4.8. When risk adjusted the strength of the association fell by about half for hip (0.176-0.083) and knee (0.214-0.117) and one-third for varicose vein surgery (0.215-0.140), although the coefficients remained statistically significant (P < or = 0.01). CONCLUSIONS Deprivation was associated with worse pre-operative general health status. However, given that the variation in pre-operative disease-specific health status by deprivation score was of small clinical significance and the limited power of the risk adjustment model, there is little evidence of socioeconomic inequity in access to three common elective surgical procedures.
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Affiliation(s)
- Michael Soljak
- Department of Primary Care and Social Medicine, Imperial College London, UK.
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Ethnic variation in acute myocardial infarction presentation and access to care. Am J Cardiol 2009; 103:1368-73. [PMID: 19427430 DOI: 10.1016/j.amjcard.2009.01.344] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 01/17/2009] [Accepted: 01/17/2009] [Indexed: 11/22/2022]
Abstract
Given the growing ethnic diversity in Canada, it is essential to recognize potential ethnic variability in acute myocardial infarction (AMI) symptoms to increase timely and effective treatment. We thus examined ethnic variation in symptom presentation and access to care of patients presenting to the emergency department (ED) with AMI. A random sample of 406 health records of Caucasian, Chinese, South Asian, Southeast Asian, and First Nations patients discharged from hospitals in the Calgary Health Region (Alberta, Canada) was audited. Measured variables were compared across ethnic groups and associations with classic AMI symptom profile and timely presentation to a hospital were examined. Chinese, South Asian, and Southeast Asian patients were 64% to 69% less likely than Caucasian patients to have a classic symptom profile reported and were less likely to speak English than their Caucasian and First Nations counterparts (p <0.001). Thirty-nine percent of patients who had a reported distinct time of symptom onset waited >12 hours to present to the ED; even in patients who presented with a classic symptom profile, South Asians were 70% less likely than Caucasians to report to the ED within 3 hours of symptom onset. Caucasians were significantly more likely to undergo angiography within 3 hours of presentation to the ED (42%, p = 0.001). In conclusion, explanatory variables associated with variability in symptom presentation and access to care associated with ethnicity require further exploration to ultimately develop effective strategies aimed at increasing timely presentation and care access.
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Quatromoni J, Jones R. Inequalities in socio-economic status and invasive procedures for coronary heart disease: a comparison between the USA and the UK. Int J Clin Pract 2008; 62:1910-9. [PMID: 19166438 DOI: 10.1111/j.1742-1241.2008.01943.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Coronary heart disease (CHD) is a serious health problem in the USA and UK. Low socio-economic status (SES) has been associated with an increased prevalence of CHD and also with inequalities in related health outcomes. Rates of utilisation of invasive coronary procedures (ICPs), which improve CHD outcomes and quality of life, can be employed as indicators of quality of medical care. OBJECTIVES To investigate and compare inequalities in care experienced by low SES CHD patients in the US Medicaid programme and the UK National Health Service (NHS) in relation to waiting times for, and access to, ICPs. Possible ways of addressing SES inequalities are proposed. SETTING/SUBJECT: Coronary heart disease patients eligible for ICPs in the US Medicaid programme and the UK NHS. METHODS A systematic literature search was performed for relevant SES inequalities. Data from 43 sources were analysed. RESULTS Both countries exhibited differences in waiting times for coronary angiography (CA) and percutaneous transluminal coronary angioplasty/coronary artery bypass graft (PTCA)/(CABG). Low SES patients waited longer than high SES patients within each country. The disparity in CHD care between low and high SES patients within each country appeared to be similar. Low SES patients in both countries experienced reduced rates of CA and CABG/PTCA. IMPLICATIONS/CONCLUSION: Despite differences between the US third-party payer system and the UK socialised, primary care-oriented system, each country faces the same SES inequalities regarding waiting time for and access to the ICPs. Understanding the reasons behind these inequalities is vital to address them.
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Zaman MJ, Junghans C, Sekhri N, Chen R, Feder GS, Timmis AD, Hemingway H. Presentation of stable angina pectoris among women and South Asian people. CMAJ 2008; 179:659-67. [PMID: 18809897 DOI: 10.1503/cmaj.071763] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND There is speculation that women and South Asian people are more likely than men and white people to report atypical angina and that they are less likely to undergo invasive management of angina. We sought to determine whether atypical symptoms of angina pectoris in women and South Asians impacted clinically important outcomes and clinical management. METHODS We prospectively identified 2189 South Asian people and 5605 white people with recent-onset chest pain at 6 chest-pain clinics in the United Kingdom. We documented hospital admissions for acute coronary syndromes, coronary deaths as well as coronary angiography and revascularization procedures. RESULTS Atypical chest pain was reported by more women than men (56.5% vs 54.5%, p < 0.054) and by more South Asian patients than white patients (59.9% vs 52.5%, p < 0.001). Typical symptoms were associated with coronary death or acute coronary syndromes among women (hazard ratio [HR] 2.30, 95% CI 1.70-3.11, p < 0.001) but not among men (HR 1.23, 95% CI 0.96-1.57, p = 0.10). Typical symptoms were associated with coronary outcomes in both South Asian and white patients. Among those with typical symptoms, women (HR 0.76, 95% CI 0.63-0.92, p = 0.004) and South Asian patients (HR 0.52, 95% CI 0.41-0.67, p < 0.001) were less likely than men and white patients to receive angiography. INTERPRETATION Compared to those with atypical chest pain, women and South Asian patients with typical pain had worse clinical outcomes. However, sex and ethnic background did not explain differences in the use of invasive procedures.
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Affiliation(s)
- M Justin Zaman
- Department of Epidemiology and Public Health, University College London, UK.
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Abstract
Sixty years on, the NHS is still struggling to ensure equal access to the best care. In the second article in his series, Tony Delamothe examines the difficulties
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