Super Profile analysis of socioeconomic variations in coronary investigation and revascularisation rates

Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature

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.

Equity in healthcare for coronary heart disease, Wales (UK) 2004-2010: A population-based electronic cohort study

BACKGROUND

Despite substantial falls in coronary heart disease (CHD) mortality in the United Kingdom (UK), marked socioeconomic inequalities in CHD risk factors and CHD mortality persist. We investigated whether inequity in CHD healthcare in Wales (UK) could contribute to the observed social gradient in CHD mortality.

METHODS AND FINDINGS

Linking data from primary and secondary care we constructed an electronic cohort of individuals (n = 1199342) with six year follow-up, 2004-2010. We identified indications for recommended CHD interventions, measured time to their delivery, and estimated risk of receiving the interventions for each of five ordered deprivation groups using a time-to-event approach with Cox regression frailty models. Interventions in primary and secondary prevention included risk-factor measurement, smoking management, statins and antihypertensive therapy, and in established CHD included medication and revascularization. For primary prevention, five of the 11 models favoured the more deprived and one favoured the less deprived. For medication in secondary prevention and established CHD, one of the 15 models favoured the more deprived and one the less deprived. In relation to revascularization, six of the 12 models favoured the less deprived and none favoured the more deprived-this evidence of inequity exemplified by a hazard ratio for revascularization in stable angina of 0.79 (95% confidence interval 0.68, 0.92). The main study limitation is the possibility of under-ascertainment or misclassification of clinical indications and treatment from variability in coding.

CONCLUSIONS

Primary care components of CHD healthcare were equitably delivered. Evidence of inequity was found for revascularization procedures, although this inequity is likely to have only a modest effect on social gradients in CHD mortality. Policymakers should focus on reducing inequalities in CHD risk factors, particularly smoking, as these, rather than inequity in healthcare, are likely to be key drivers of inequalities in CHD mortality.

Trends of relative and absolute socioeconomic equity in access to coronary revascularisations in 1995-2010 in Finland: a register study

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.

Impact of service redesign on the socioeconomic inequity in revascularisation rates for patients with acute myocardial infarction: a natural experiment and electronic record-linked cohort study

AIM

To investigate the impact of service redesign in the provision of revascularisation procedures on the historical socioeconomic inequity in revascularisation rates for patients with acute myocardial infarction (AMI).

DESIGN

Natural experiment and retrospective cohort study using linked data sets in the Secure Anonymised Information Linkage databank.

NON-RANDOMISED INTERVENTION

An increase in the capacity of revascularisation procedures and service redesign in the provision of revascularisation in late 2011 to early 2012.

SETTING

South Wales cardiac network, Census 2011 population 1 359 051 aged 35 years and over.

PARTICIPANTS

9128 participants admitted to an NHS hospital with a first AMI between 1 January 2010 and 30 June 2013, with 6-months follow-up.

MAIN OUTCOME MEASURE

Hazard ratios (HRs) for the time to revascularisation for deprivation quintiles, age, gender, comorbidities, rural-urban classification and revascularisation facilities of admitting hospital.

RESULTS

In the preintervention period, there was a statistically significant decreased adjusted risk of revascularisation for participants in the most deprived quintile compared to the least deprived quintile (HR 0.80; 95% CI 0.69 to 0.92, p=0.002). In the postintervention period, the increase in revascularisation rates was statistically significant in all quintiles, and there was no longer any statistically significant difference in the adjusted revascularisation risk between the most and the least deprived quintile (HR 1.04; 95% CI 0.89 to 1.20, p<0.649). However, inequity persisted for those aged 75 years and over (HR 0.40; 95% CI 0.35 to 0.46, p<0.001) and women (HR 0.77; 95% CI 0.70 to 0.86, p<0.001).

CONCLUSIONS

Socioeconomic inequity of access to revascularisation was no longer apparent following redesign of revascularisation services in the south Wales cardiac network, although inequity persisted for women and those aged 75+ years. Increasing the capacity of revascularisation did not differentially benefit participants from the least deprived areas.

Socioeconomic inequities in invasive cardiac procedures among patients with incident angina pectoris or myocardial infarction

Aims: In many countries, systematic socioeconomic disparities have emerged in the use of invasive cardiac procedures among myocardial infarction patients and hospitalized coronary patients. This study prospectively examined socioeconomic differences in the use of cardiac procedures in a national cohort of incident coronary patients. Methods: The data were based on individual register linkages among 49,846 patients with incident angina pectoris (AP) or myocardial infarction (MI) during one-year follow-up in 1995—98 in Finland. Socioeconomic differences in invasive coronary procedures were examined using proportional hazard models. Results: The analyses showed that women, AP patients, and persons with lower socioeconomic status received fewer procedures during the one-year follow-up than men, MI patients, and those with higher socioeconomic status. Socioeconomic differences in the utilization of cardiac procedures were similar in both AP and MI groups, among both men and women, and by all socioeconomic indicators: social class, education, and income. Disparities were already emerging after the 28-day follow-up among men and women in both patient groups, and they persisted throughout the study period. Controlling for disease severity, comorbidity, and hospital district did not modify the results. Conclusions: Socioeconomic disparities in receiving invasive coronary procedures among AP patients without MI were similar to those in MI patients.

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Background

A 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.

Objectives

To 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.

Design

Cross-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).

Results

The 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.

Conclusions

We 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.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Application of commercial software to the classification of suicide cases: a brief report

Mosaic Profiler software was used to classify suicide and open verdict cases during 1996 to 1998 in England and within England, for the London and the North West regions. The classification system was based on the socioeconomic characteristics of the last place of residence of the cases at the level of postcode. The results highlighted that deprived areas and areas that contain elderly population or those areas that suffer from lack of social cohesion are overrepresented, whereas affluent areas are underrepresented. All of these, although in the larger scale, seem to support the results of other studies. Nevertheless, more studies would be required before one can fully evaluate the application of the Mosaic Profiler in the field of spatial epidemiology.

Inequalities in socio-economic status and invasive procedures for coronary heart disease: a comparison between the USA and the UK

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.

How close have universal health systems come to achieving equity in use of curative services? A systematic review

Most governments in established market economies have developed universal systems of health care, but these are being increasingly threatened by widespread health sector reforms. Hence, it is more important than ever to monitor the effects of policy changes on the ability of universal systems to achieve their equity goals. This article provides evidence for such monitoring. The authors present the results of a systematic review of equity in use of curative health services in universal systems, together with a critical appraisal of the essential components of studies to address this question. Of the 79 studies identified that addressed the review question, only 26 met the inclusion criteria and adjusted for differential health need across socioeconomic groups. The authors found a pro-rich bias in use of specialist hospital services and a reasonably equitable access to primary health care by different socioeconomic groups. There was a wide inter-study variation in the difference in utilization rates between people of high and low socioeconomic groups. Improvements are needed in the way that equity in universal systems is monitored, with particular attention to how "need" is defined and to the impact on patients of indirect costs.

Associations of area based deprivation status and individual educational attainment with incidence, treatment, and prognosis of first coronary event in Rome, Italy

BACKGROUND

Socioeconomic gradients in the occurrence of myocardial infarction are well known, but few studies have examined socioeconomic disparities in post-infarction outcomes. The objective of this study was to explore relations of socioeconomic status with the incidence, treatment, and outcome of first coronary event in Rome, Italy, during the period 1998-2000, examining effect modification by gender.

METHODS

Subjects were Rome residents aged 35-84 years who died from first acute coronary event before reaching the hospital (n=3470) or were hospitalised for first acute myocardial infarction (n=8467). Area based deprivation status and patients' educational attainment were the exposure variables. The outcomes were: incidence of coronary event; recanalisation at the index hospitalisation and fatality within 28 days of hospitalisation; cardiac readmissions and fatality between 28 days and one year of index hospitalisation.

RESULTS

Incidence rates increased as area based deprivation status increased; the effect was stronger among women than among men (men RR=1.40, 95%CI:1.30, 1.50, women RR=1.78, 95%CI:1.60, 1.98, most compared with least deprived). Rates of recanalisation were significantly lower in the most deprived patients than in the least deprived (OR=0.77, 95%CI:0.59, 0.99) and in the less educated than in the highly educated (OR=0.73, 95%CI:0.58, 0.90). Associations of short term fatality with area based deprivation status and educational attainment were weak and inconsistent. However, neither deprivation status nor education was associated with one year outcomes.

CONCLUSIONS

Area based deprivation status is strongly related to incidence of coronary events, and more so among women than among men. Deprivation status and educational attainment are weakly and inconsistently associated with short term fatality but seem not to influence one year prognosis of acute myocardial infarction. Deprived and less educated patients experience limited access to recanalisation procedures.

Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes

AIMS

A cross-sectional study has been performed in order to estimate the prevalence, severity, and current treatment of chronic painful peripheral neuropathy (CPPN) in people with diabetes in the community.

METHODS

Using a structured questionnaire and examination we have assessed these factors in a community sample of people with diabetes (n=350) and compared them with 344 age- and sex-matched people without diabetes from the same locality.

RESULTS

The prevalence of CPPN was estimated to be 16.2%[95% confidence interval (CI): 6.8-16%] in people with diabetes compared with 4.9% (95% CI: 2.6-7.2%) in the control sample (P < 0.0001). Diabetic subjects with and without CPPN did not differ in age, sex, type and duration of diabetes, body mass index, smoking status and glycaemic control. However, CPPN diabetic subjects had significantly higher Visual Analogue Scale (VAS) scores for pain over the preceding 24 h [median (interquartile range) 3.5 (1.5-6.7) cm vs. 0.7 (0-3.9) cm, P < 0.0001]. Also, the total McGill Pain Questionnaire Score (a measure of pain quality and severity) was 18 (13-31.5) vs. 10 (4-16) (P < 0.0001). Of patients with diabetes and CPPN, 12.5% (7/56) had never reported their symptoms to their treating physician and 39.3% (22/56) had never received any treatment for their painful symptoms.

CONCLUSIONS

CPPN is common, often severe but frequently unreported and inadequately treated.

Does access to cardiac investigation and treatment contribute to social and ethnic differences in coronary heart disease? Whitehall II prospective cohort study

OBJECTIVE

To determine whether access to cardiac procedures and drugs contributes to social and ethnic differences in coronary heart disease in a population setting.

DESIGN

Prospective study with follow up over 15 years. Civil service employment grade was used as a measure of individual socioeconomic position. Need for cardiac care was determined by the presence of angina, myocardial infarction, and coronary risk factors.

SETTING

20 civil service departments originally located in London.

PARTICIPANTS

10,308 civil servants (3414 women; 560 South Asian) aged 35-55 years at baseline in 1985-8.

MAIN OUTCOME MEASURES

Use of exercise electrocardiography, coronary angiography, and coronary revascularisation procedures and secondary prevention drugs.

RESULTS

Inverse social gradients existed in incident coronary morbidity and mortality. South Asian participants also had higher rates than white participants. After adjustment for clinical need, social position showed no association with the use of cardiac procedures or secondary prevention drugs. For example, men in the low versus high employment grade had an age adjusted odds ratio for angiography of 1.87 (95% confidence interval 1.32 to 2.64), which decreased to 1.27 (0.83 to 1.94) on adjustment for clinical need. South Asians tended to be more likely to have cardiac procedures and to be taking more secondary prevention drugs than white participants, even after adjustment for clinical need.

CONCLUSION

This population based study, which shows the widely observed social and ethnic patterning of coronary heart disease, found no evidence that low social position or South Asian ethnicity was associated with lower use of cardiac procedures or drugs, independently of clinical need. Differences in medical care are unlikely to contribute to social or ethnic differences in coronary heart disease in this cohort.

The pursuit of equity in NHS resource allocation: should morbidity replace utilisation as the basis for setting health care capitations?

Although the English NHS has been described as a world leader in pioneering methods of distributing expenditure in relation to population needs, concerns about the legitimacy of using the current utilisation-based model to allocate health service resources are mounting. In this paper, we present a critical review of NHS resource allocation in England and demonstrate the feasibility and impact of using direct health estimates as a basis for setting health care capitations. Comparing target allocations for the inpatient treatment of coronary heart disease in a sample of 34 primary care trusts in contrasting locations in England, we find that a morbidity-based model would result in a significant shift in hospital resources away from deprived areas, towards areas with older demographic profiles and towards rural areas. Discussing the findings in relation to a wider policy context that is generally concerned to direct more health care resources towards the poor, the paper concludes by calling for greater clarity between the goals of health care equity and health equity. Whilst the former demands that the legitimate needs of demographically older populations for more health care resources are acknowledged, the goal of health equity requires real political commitment to resource broader social policy initiatives.

Universal health insurance coverage does not eliminate inequities in access to cardiac procedures after acute myocardial infarction

BACKGROUND

It remains unclear whether socioeconomic status (SES) influences access to invasive cardiac procedures after acute myocardial infarction (AMI) in a universal health care system. The objective of this study was to evaluate the effect of SES on access to cardiac procedure after AMI in a universal health care system.

METHODS

This was an observational cohort study of all patients with a first AMI in the province of Quebec, Canada, between 1985 to 1995. Information on treatment was obtained from the discharge and physicians' claims databases. SES was obtained from census data by linking postal codes. SES-independent predictors of use were identified, then incorporated in hierarchical models to predict use in low, medium, and high SES areas. The main outcome measures were rates of cardiac catheterization, percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABG) as a function of SES.

RESULTS

SES data were available for 62,364 individuals with a first AMI. Of these, 65% were men and the mean age was 64 +/- 13 years. Rates of cardiac procedures rose with an increase in several SES measures. After adjustment for individual-level predictors of use of cardiac catheterization, average rent, (odds ratio per $100 difference: 1.57, 95% credible interval: 1.36 to 1.80) and proportion of renters, (odds ratio, 2.2; 95% CI: 1.21 to 3.73) in the area were independent SES predictors. Patients in low SES areas (median family income: $ 30,809 CDN) were less likely to undergo cardiac catheterization than patients in high SES areas ($92,169 CDN) (men: 33%; compared with 47%; women: 18%; compared with 47%). However, among patients with cardiac catheterization, SES was not associated with the use of revascularization procedures. For example, PCI rates for men within 90 days after AMI were 26%, compared with 25% in low and high SES areas, respectively. CABG rates were 15%, compared with 19%.

CONCLUSIONS

We found that in the universal health care system of Canada, access to cardiac catheterization after AMI varied according to SES. Among those with cardiac catheterization, SES did not appear to influence further use of revascularization procedures.

Socioeconomic deprivation is a predictor of poor postoperative cardiovascular outcomes in patients undergoing coronary artery bypass grafting

OBJECTIVE

To investigate the effects of socioeconomic deprivation on cardiovascular risk factors and postoperative clinical outcomes of patients undergoing coronary artery bypass grafting (CABG).

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Surgical population of the southwest of England, April 1996 and August 2000.

STUDY GROUP

Data on 3578 consecutive patients undergoing CABG at the Bristol Royal Infirmary NHS Trust were abstracted. Data were retrieved from the Patient Analysis & Tracking System. Carstairs index was used to measure socioeconomic deprivation of area of residence and was divided into five quintiles, where quintile 1 denotes least deprived and 5 most deprived.

OUTCOME MEASURES

End points were postoperative complications and 30 day mortality.

RESULTS

Higher deprivation scores were associated with younger age (p < 0.004), greater body mass index, diabetes, smoking at time of surgery, and higher EuroSCOREs (all p < or = 0.001). After adjustment for EuroSCORE, socioeconomic deprivation was independently associated with postoperative myocardial infarction (p = 0.05) and combined postoperative myocardial infarction, stroke, and death (p = 0.016). Hospital length of stay for the patients in the highest quintiles was also significantly longer than for those in the lower quintiles (p = 0.04).

CONCLUSION

Patients undergoing CABG living in areas with high deprivation scores are younger, have more clinical risk factors, and experience more postoperative cardiovascular complications than patients living in low deprivation score areas.

How did the recent increase in the supply of coronary operations in Finland affect socioeconomic and gender equity in their use?

STUDY OBJECTIVE

To explore how the increased supply of coronary bypass operations and angioplasties from 1988 to 1996 influenced socioeconomic and gender equity in their use.

DESIGN

Register based linkage study; information on coronary procedures from the Finnish Hospital Discharge Register in 1988 and 1996 was individually linked to national population censuses in 1970-1995 to obtain patients' socioeconomic data. Data on both hospitalisations and mortality attributable to coronary heart disease obtained from similar linkage schemes were used to approximate the relative need of procedures in socioeconomic groups.

SETTING

Finland, 2,094,846 inhabitants in 1988 and 2,401,027 in 1996 aged 40 years and older, and Discharge Register data from all Finnish hospitals offering coronary procedures in 1988 and 1996.

MAIN RESULTS

The overall rate of coronary revascularisations in Finland increased by about 140% for men and 250% for women from 1988 to 1996. Over the same period, socioeconomic and gender disparities in operation rates diminished, as did the influence of regional supply of procedures on the extent of these differences. However, men, and better off groups in terms of occupation, education, and family income, continued to receive more operations than women and the worse off with the same level of need.

CONCLUSIONS

Although revascularisations in Finland increased 2.5-fold overall, some socioeconomic and gender inequities persisted in the use of cardiac operations relative to need. To improve equity, a further increase of resources may be needed, and practices taking socioeconomic and gender equity into account should be developed for the referral of coronary heart disease patients to hospital investigations.

Variations in use of tertiary cardiac services in part of North-West England

We assess the extent to which the need for tertiary cardiac care is being met uniformly within two Health Authorities in North-West England. We analyse small-area data from 1993-1996 on standardised rates of investigation (angiography) and surgery (bypass grafts and angioplasty). Utilisation by electoral ward is shown to be related to material deprivation. Small areas in which the Asian population is high have significantly fewer angiograms and angioplasties than might be expected according to need, while there is some evidence that women do not receive the levels of bypass surgery that might be expected.

Geographies of need and the new NHS: methodological issues in the definition and measurement of the health needs of local populations

For a variety of purposes it is increasingly necessary to establish the health needs of local populations. Following a critique of existing proxies of need, this paper presents and evaluates an alternative which draws upon epidemiological evidence concerning the age, sex and social class distribution of morbidity in order to estimate the prevalence of specific conditions in designated populations. By way of demonstrating the insights to be gained through the use of these indicative prevalence rates, the paper considers the treatment of ischaemic heart disease in a sample of 539 practices and presents evidence regarding the significance of deprivation and rurality in determining health service use relative to needs.

Effect of socioeconomic deprivation on waiting time for cardiac surgery: retrospective cohort study

OBJECTIVE

To determine whether the priority given to patients referred for cardiac surgery is associated with socioeconomic status.

DESIGN

Retrospective study with multivariate logistic regression analysis of the association between deprivation and classification of urgency with allowance for age, sex, and type of operation. Multivariate linear regression analysis was used to determine association between deprivation and waiting time within each category of urgency, with allowance for age, sex, and type of operation.

SETTING

NHS waiting lists in Scotland.

PARTICIPANTS

26 642 patients waiting for cardiac surgery, 1 January 1986 to 31 December 1997.

MAIN OUTCOME MEASURES

Deprivation as measured by Carstairs deprivation category. Time spent on NHS waiting list.

RESULTS

Patients who were most deprived tended to be younger and were more likely to be female. Patients in deprivation categories 6 and 7 (most deprived) waited about three weeks longer for surgery than those in category 1 (mean difference 24 days, 95% confidence interval 15 to 32). Deprived patients had an odds ratio of 0.5 (0.46 to 0.61) for having their operations classified as urgent compared with the least deprived, after allowance for age, sex, and type of operation. When urgent and routine cases were considered separately, there was no significant difference in waiting times between the most and least deprived categories.

CONCLUSIONS

Socioeconomically deprived patients are thought to be more likely to develop coronary heart disease but are less likely to be investigated and offered surgery once it has developed. Such patients may be further disadvantaged by having to wait longer for surgery because of being given lower priority.

Does increased investment in coronary angiography and revascularisation reduce socioeconomic inequalities in utilisation?

OBJECTIVES

To investigate whether additional resources for tertiary cardiology services, aimed at increasing coronary angiography and revascularisation rates, can improve socioeconomic equity of utilisation.

DESIGN

Cross sectional ecological study, using the Super Profile classification of enumeration districts and ischaemic heart disease (IHD) standardised mortality ratios (SMR) as a proxy for need. The degree of equity before the provision of extra resources was determined using data for April 1992 to March 1994, and the corresponding picture after, using data for April 1994 to March 1996.

SETTING

South Humberside (United Health-Grimsby and Scunthorpe Health Authority, a district of the former Yorkshire Region, before the April 1996 boundary changes).

SUBJECTS

Patients with a primary diagnosis of IHD aged > or = 25 years who underwent investigation by angiography, or treatment by coronary artery bypass grafting or percutaneous transluminal coronary angioplasty, as a primary procedure.

MAIN RESULTS

In 1992/4, before concerted intervention, both investigation and revascularisation rates, although increasing, were low in Grimsby and Scunthorpe district compared with most other districts in the Yorkshire Region. Also, there was a decreasing trend across Super Profile Lifestyle groups from the Affluent Achievers to the Have-Nots despite a two-fold increase in SMRs indicating the greater need of the more deprived. After appointing a consultant general physician with an interest in cardiology in the Scunthorpe district general hospital in 1994; arranging for both the Grimsby physician and the Scunthorpe physician to undertake angiography at a neighbouring district tertiary cardiology centre in 1995; together with significant additional health authority investment in cardiac procedures in 1995/6, district rates increased considerably, (a 41% increase in investigation and a 47% increase in revascularisation rates). Also, after additional resource input began, the trend for angiographies across socioeconomic groups clearly became more equitable, although increased equity for revascularisations is less apparent.

CONCLUSION

Early indications are that additional resources for tertiary cardiology may have reduced socioeconomic inequities in angiography, without being specifically targeted at the needier, more deprived groups. Improvement in socioeconomic equity of utilisation of revascularisation is not yet clear, although data for April 1996 to March 1998 (after a lengthier intervention period) may confirm improved equity. Should this not be so, it might be necessary to specifically target resources to the deprived to increase equity in revascularisation.