Inequalities in coronary heart disease treatment

Professor Azeem MajeedUniversity College London

Outline of talk Why CHD is important Inequalities in CHD Inequalities in treatment Possible explanations Proposed solutions

Why is CHD important?

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)

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

Morbidity: Prevalence Calendar year 1998 210 general practices in England &

Wales, part of GPRD 1.3 million patients

CHD: Prevalence per 1,000

0

50

100

150

200

250

35-44 45-54 55-64 65-74 75-84 85+

MenWomen

Inequalities in CHD

Inequalities: Type Social Class Geographical Ethnic Group

SMR: Social Class Standardised mortality ratios Adjust for age (& sex) Average for population = 100 Values > 100 imply more deaths

than expected Values < 100 imply less deaths

than expected

SMR: Men by Social Class

020406080

100120140160180200

I I I I I IN II IM IV V

Prevalence: Area Variations

0

5

10

15

20

25

30

35

40

Q1 Q2 Q3 Q4 Q5

Inequalities in CHD Treatment

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

Age & sex differences Calendar year 1998 210 general practices in England &

Wales, part of GPRD 1.3 million patients

Statins in CHD Patients

0

10

20

30

40

50

60

35-44 45-54 55-64 65-74 75-84 85+

MenWomen

Aspirin in CHD Patients

0

10

20

30

40

50

60

70

35-44 45-54 55-64 65-74 75-84 85+

MenWomen

Statins: Area Variations

0

5

10

15

20

25

30

Q1 Q2 Q3 Q4 Q5

Study in Wandsworth PCT 63 general practices September 2000 - May 2001 Population 378,000 6778 patients with CHD Some evidence that sex

differences narrowing

Prescribing in CHD Patients

0

10

20

30

40

50

60

70

Women Men

History of MI &prescribed beta-blockerAngina &prescribed beta-blockerHistory of MI &prescribed ACE-inhibitorPrescribed statin

Prescribed aspirin

Secondary & Tertiary Care Several studies have examined

equity of access to care Thrombolysis Angiography Angioplasty & CABG Drug treatment on discharge

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

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

Admissions with angiography

0

5

10

15

20

25

35-44 45-54 55-64 65-74 75-84 85+

MenWomen

Admission with CABG/PTCA

0

2

4

6

8

10

12

14

35-44 45-54 55-64 65-74 75-84 85+

MenWomen

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

Possible Explanations Patient & society Clinical trials Primary care Secondary care Tertiary care

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

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