1. Hugo Cosh Public Health Wales Staff Conference 14th October 2009
Equity in the provision of coronary angiography and revascularisation in Wales
Hugo Cosh
Public Health Wales Staff Conference
14th October 2009

2. Outline Background to the work Aim of the report Post-lunch strategy:
Results first
Methods after
Discussion
Conclusions & recommendations
Bridgend in Feb; Powys May.
Attract stands for Ask TRIP To Rapidly Alleviate Confusing Thoughts

3. Background
The developing Public Health Observatory for Wales has an MOU with the Welsh Cardiac Networks
Regional Cardiac Network Profiles produced in 2007
Work revealed significant variation in rates of coronary angiography and revascularisation
Agreed that future work would focus on equity of access to these services

4. Aim of the report
To investigate rates of angiography and revascularisation in relation to need, both by area of residence and socioeconomic deprivation
To investigate trends over time in rates by socioeconomic deprivation

5. CHD mortality, males

6. Revascularisation, males

7. Emergency CHD admissions, males
Emergency CHD admissions, females

8. Angiography, males
Angiography, females

9. South East region CHD mortality Revascularisation 2.4 2.9 1.8 2.2
Widening relative inequality gap – by the end of the period, mortality rates nearly 3 times higher in males and over twice as high in females (most deprived compared to least deprived).
Rates have fallen faster in the least deprived than in the most deprived.
1.8
2.4
2.9
2.2

10. Angiographies per 100 emergency CHD admissions: males
North
Mid & West
South East

11. Angiographies per 100 emergency CHD admissions: males
North
Rate Ratio:
Rate in most deprived fifth divided by rate in least deprived fifth
Equity
Mid & West
South East

12. Methods 1: design
Previous work undertaken as part of MPH - the report built on this work.
Ecological design. Potential weaknesses:
Ecological fallacy
Migration
Lower level of the Super Output Area statistical geography (LSOAs) chosen to analyse socioeconomic equity
n=1,896, mean population 1,500, min 1,000
Relative social homogeneity
Reduce the effects of the ecological fallacy

13. Methods 2: socioeconomic deprivation
Townsend index
Census-based measure of material deprivation
Widely used in epidemiological studies, including those investigating equity of access
Available at appropriate geography (LSOA) and period
LSOAs too small for robust data analysis (average population 1500) so aggregation carried out into five groups of LSOAs (“fifths”) according to Townsend, i.e. most deprived fifth to least deprived fifth.

15. Methods 3: measuring need
Direct measures (e.g. via survey) most effective but very costly. Therefore most studies rely on indirect (proxy) measures of need.
Proxy measures used in this study:
premature CHD mortality (Office for National Statistics)
emergency CHD hospital admissions (PEDW)
Assumptions:
Rates of these events are more likely to approximate to need for treatment, rather than outcome of treatment
High levels of mortality or emergency admissions alongside low levels of treatment is indicative of inequity

16. Comparing results to other research
“Access to Cardiac Care in the UK”
Oxford Healthcare Associates (2009)
Jointly commissioned by BCS, British Heart Foundation and the Cardio & Vascular Coalition
Report uses mortality rates to calculate ‘expected’ revascularisation rates for local authorities in Wales, then compares these to actual revascularisation rates
No breakdown by males and females, uses all ages

17. Revascularisation, males
UK ranking according to Oxford report (out of 469, 469 is worst)
125 64
461
453
454
468
371
424
469
We would expect a lot of variation here – different methods, all age bands, all persons,
NPT and Bridgend doing too much or the right amount? This seems to suggest that they are doing ‘more than expected’ – is that good?

18. Summary of findings (1)
Regional variation in rates of angiography and revascularisation
NHS Trusts providing different levels of service, likely due to combination of supply and demand factors
Further research required to gain a more detailed understanding of these variations
Geographical areas and deprivation groups with the highest angiography and revascularisation rates are not those with the highest levels of need
Indicates geographical and socio-economic inequity in the provision of these procedures

19. Summary of findings (2)
Some signs of improvement over time, especially in provision of services to females and the fall in rates of premature CHD mortality in all areas.
However, these falls in mortality have been faster in the least deprived than in the most deprived groups, resulting in a general widening of the inequality ‘gap’.

20. Possible explanations
Differing levels of provision across Trusts
Morbidity detected too late in some groups?
Persons from deprived areas less suitable for treatment due to comorbidities?
Inequitable referral patterns from primary care? More vociferous demands for treatment in less deprived?
Importance of primary care

21. Responses to the report
Well-received by clinicians in the field: impetus to re-run analyses to monitor trends, particularly in light of investment in new catheterisation labs in Wales in recent years
Implications discussed at recent conference organised by Cardiac Networks “Access to Cardiac Services in Wales: Making Sense of Variations”

22. Recommendations (for consideration by Cardiac Networks)
Audits in primary care - to investigate referral patterns for angiography re deprivation
Primary care providers to investigate potential systems for targeting the most deprived groups in order to increase referral rates
Consideration at the national level as to appropriate level of provision
Reorganisation represents an opportunity

23. Acknowledgements NPHS colleagues: Anna Childs, Nathan Lester
Health Solutions Wales:
Gareth John, Tim Hughes