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

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.

Gender, socioeconomic position, revascularization procedures and mortality in patients presenting with STEMI and NSTEMI in the era of primary PCI. Differences or inequities?

BACKGROUND

Several studies have reported gender and socioeconomic differences in the use of revascularization procedures in patients with acute myocardial infarction. However, it is not clear whether these differences influence patients' survival. Moreover, most of the studies neither considered STEMI and NSTEMI separately, nor included primary PCI, which nowadays is the treatment of choice in case of AMI. In an unselected population of patients admitted to hospital with a first episode of STEMI and NSTEMI we examined gender and socioeconomic differences in the use of cardiac invasive procedures and in one-year mortality.

METHODS

Subjects hospitalized with a first episode of STEMI (n=3506) or NSTEMI (n=2286) were selected from the Piedmont (Italy) hospital discharge database. We considered the percentage of patients undergoing PCI, primary PCI and CABG, and in-hospital mortality. Out of hospital mortality was calculated through record linkage with the regional register. The relation between outcomes and gender or educational level was investigated using appropriate multivariate regression models adjusting for available confounders.

RESULTS

After adjustment for age, comorbidity and hospital characteristics, women and low educated patients had a lower probability of undergoing revascularization procedures. However, neither in-hospital, nor 30-day, nor 1-year mortality showed gender or social disparities.

CONCLUSIONS

Despite gender and socioeconomic differences in the use of revascularization, no differences emerged in in-hospital and 1-year mortality. These findings could suggest that patients are differently, but equitably, treated; differences are more likely due to an inability to fully adjust for clinical conditions rather than to a selection process at admission.

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.

Increasing resources effected equity in access to revascularizations for patients with diabetes

OBJECTIVES

To examine differences in access to coronary revascularization among a cohort of coronary patients with and without diabetes in 1995-2002 in Finland and to examine how rapidly increasing resources effected socioeconomic equity in access to these operations.

DESIGN

An individual level nationwide register-based study of newly diagnosed CHD (coronary heart disease) patients (aged 40-79) in Finland. Rates for revascularizations were calculated per 1 000 person years. Socioeconomic differences were examined using Cox regression.

RESULTS

Revascularization rates increased from 354 to 443 per 1 000 person years among men with CHD and from 301 to 366 among patients with diabetes. Among women with CHD the numbers were 224 and 249 and among patients with diabetes 208 and 325. Comparing trends for first revascularization between patient groups with and without diabetes differences increased somewhat among men. Among women, revascularization rates increased more among diabetic patients. Lower revascularization rates among lower socioeconomic groups were found throughout the study period in both patient groups.

CONCLUSIONS

Simultaneously with large increase in cardiac operation rates, revascularization observed more common among women with diabetes compared to those without. However socioeconomic inequity in access to revascularizations among both genders remained even after increase in resources.

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.

Multilevel modeling of regional variation in equity in health care

BACKGROUND

The use of a concentration index is recommended to estimate socioeconomic equity in health and health services. Methods for the analysis of concentration indices have been developed in several studies. However, these methods do not take into consideration clustering within areas, which is necessary in a comprehensive study of regional variations in equity.

OBJECTIVES

The study aims to develop a statistical method to assess variations in socioeconomic inequities in the use of health services in relation to need in different regions.

METHODS

Concentration index methods were developed further and the advantages of multilevel modeling were exploited. As an empirical example we analyzed revascularizations in 2001-2003 among the Finnish population.

RESULTS

The average inequity indices for the income distribution of revascularizations in Finland obtained with multilevel and standard regression modeling were comparable, but confidence intervals were smaller with multilevel modeling. Inequity indices for different areas estimated using multilevel modeling were more conservative and had smaller confidence intervals than indices estimated using the standard approach.

CONCLUSIONS

The proposed approach is an efficient way of estimating regional variations in the socioeconomic equity of health care use. It enables the inclusion of need in the model and takes into account the varying need for services in different population groups and areas. In addition, the advantages of using multilevel modeling to estimate indices include the possibility to take into account dependence between observations within regions and to overcome the problems associated with random error in small regions.

Estimating CHD prevalence by small area: integrating information from health surveys and area mortality

The risk of coronary heart disease (CHD) is strongly linked both to deprivation and ethnicity and so prevalence will vary considerably between areas. Variations in prevalence are important in assessing health care needs and how far CHD service provision and surgical intervention rates match need. This paper uses a regression model of prevalence rates by age, sex, region and ethnicity from the 1999 and 2003 Health Surveys for England to estimate CHD prevalence for 354 English local authority areas. To allow for the impact of social factors on prevalence, survey information on the deprivation quintile in the respondents' micro-area of residence is also used. Allowance is also made for area CHD mortality rates (obtained from aggregated vital statistics data) which are positively correlated with, and hence a proxy for, CHD prevalence rates. An application involves assessment of surgical intervention rates in relation to prevalence at the level of 28 Strategic Health Authorities.

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.

Utilisation of coronary angiography after acute myocardial infarction in Ontario over time: have referral patterns changed?

OBJECTIVE

To examine how physicians in Ontario, Canada, have altered their referral patterns for coronary angiography after acute myocardial infarction (AMI) over time.

DESIGN

Retrospective analysis of multilinked administrative data.

SETTING

Province of Ontario, Canada.

PATIENTS

146 365 Ontario AMI patients hospitalised between 1 April 1992 and 31 March 1999.

MAIN OUTCOME MEASURES

Utilisation trends of coronary angiography among all patients, as well as within six subgroups: elderly (versus young), women (versus men), high (versus low) risk of 30 day mortality, high (versus low) socioeconomic status, cardiology (versus non-cardiology) attending physician specialty, and hospitals with (versus without) onsite revascularisation capacity. Cox proportional hazard models were adjusted for variations in patient, physician, and hospital characteristics over time.

RESULTS

Angiography rates in Ontario increased from 23.2% in 1992 to 35.5% in 1999 (p < 0.0001). Increases in utilisation of coronary angiography were most pronounced among the elderly (12.4-24.3% v 39.3-54.4% for non-elderly patients, p < 0.0001), the affluent (24.6-38.7% v 22.0-32.3% for less affluent patients, p = 0.01), and those tended to by cardiologists (32.0-47.1% v 20.3-30.1% for non-cardiology attending specialties, p < 0.0001) after adjusting for changes in baseline patient, physician, and hospital characteristics over time.

CONCLUSIONS

Despite universal health care availability, not all patients benefited equally from increases in service capacity for coronary angiography after AMI in Ontario. Wider implementation of data monitoring and explicit management systems may be required to ensure that appropriate utilisation of cardiac services is allocated to patients who are most in need.

Unequal to the task: deprivation, health and UK general practice at the millennium

The NHS is over 50 years old, but health inequalities remain prevalent in the United Kingdom (UK). Material deprivation may be less apparent; however, social deprivation is becoming worse while the markers of socioeconomic disadvantage remain unsatisfactory. Health is an even more elusive concept; nevertheless, the evidence for an increasing association between deprivation, poor health, and early death is overwhelming. Equally unavoidable is the impact of this social degradation on UK primary care. Service industries have deserted deprived communities but, on the whole, GPs struggle on. Denied the supplementary resources they deserve they become disenchanted, too exhausted to convert incentives into rewards. Clear-headed strategic thinking from the top brass is overdue.