Inequalities in coronary heart disease treatment

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Inequalities in coronary heart disease treatment

• Professor Azeem Majeed
• University College London

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Outline of talk

• Why CHD is important
• Inequalities in CHD
• Inequalities in treatment
• Possible explanations
• Proposed solutions

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Why is CHD important?
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Mortality Numbers

• CHD is the single most common cause of death in
  both men and women.
• One in four men and one in six women die from CHD
  (about 125,000 deaths in the UK in 2000)
• CHD is also the commonest cause of premature
  death (about 45,000 deaths)

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Mortality International

• Death rate from CHD in the UK is among the
  highest in the world
• Although death rates have fallen in the UK, rates
  have fallen more quickly in many other countries
• Within UK, rates are highest in Scotland,
  Northern Ireland and Northern England

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Morbidity Prevalence

• Calendar year 1998
• 210 general practices in England Wales, part of
  GPRD
• 1.3 million patients

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CHD Prevalence per 1,000
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Inequalities in CHD
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Inequalities Type

• Social Class
• Geographical
• Ethnic Group

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SMR Social Class

• Standardised mortality ratios
• Adjust for age ( sex)
• Average for population 100
• Values gt 100 imply more deaths than expected
• Values lt 100 imply less deaths than expected

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SMR Men by Social Class
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Prevalence Area Variations
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Inequalities in CHD Treatment
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CHD Treatments

• Lifestyle changes
• Drugs for angina
• Drugs to reduce risk of acute events e.g.
  aspirin statins
• Control of risk factors e.g. diabetes, high
  blood pressure
• Interventions Angioplasty CABG

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Age sex differences

• Calendar year 1998
• 210 general practices in England Wales, part of
  GPRD
• 1.3 million patients

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Statins in CHD Patients
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Aspirin in CHD Patients
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Statins Area Variations
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Study in Wandsworth PCT

• 63 general practices
• September 2000 - May 2001
• Population 378,000
• 6778 patients with CHD
• Some evidence that sex differences narrowing

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Prescribing in CHD Patients
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Secondary Tertiary Care

• Several studies have examined equity of access to
  care
• Thrombolysis
• Angiography
• Angioplasty CABG
• Drug treatment on discharge

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Older studies

• Studies carried out in early - mid 1990s
• Age, sex and socio-economic differences present
• Women, elderly, deprived had poorer access to
  specialist investigation treatment

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SW Thames Early 1990s

• Admissions for CHD in one year
• Proportion of admissions in which angiography
  carried out
• Proportion of admissions in which coronary artery
  bypass graft (CABG) or percutaneous transluminal
  angioplasty (PTCA) carried out

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Admissions with angiography
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Admission with CABG/PTCA
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Newer studies

• Many studies carried out in late 1990s early
  2000s
• Show a narrowing of gap between men women and
  elderly younger patients
• Possibly still some socio-economic differences in
  access to specialist care

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Possible Explanations

• Patient society
• Clinical trials
• Primary care
• Secondary care
• Tertiary care

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Proposed solutions

• Greater awareness among clinicians and patients
• More women and elderly in clinical trials
• National service frameworks
• Review of health inequalities
• Clinical governance
• Better use of NHS data for monitoring

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Conclusions

• Even in a free health care system like the NHS,
  some groups have poorer access to care than
  others
• Greater awareness among patients, clinicians,
  policymakers
• Interventions in place to reduce inequalities
  discrimination