Inequalities in coronary heart disease treatment Professor Azeem Majeed University 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 general practices in England & Wales, part of GPRD 1.3 million patients

CHD: Prevalence per 1,000

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

Prevalence: Area Variations

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 general practices in England & Wales, part of GPRD 1.3 million patients

Statins in CHD Patients

Aspirin in CHD Patients

Statins: Area Variations

Study in Wandsworth PCT 63 general practices September May 2001 Population 378, patients with CHD Some evidence that sex differences narrowing

Prescribing in CHD Patients

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

Admission with CABG/PTCA

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