Abstract
BackgroundDespite 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 findingsLinking 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.ConclusionsPrimary 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.
Highlights
Coronary heart disease (CHD) mortality rates have declined rapidly in recent decades in most middle- to high-income countries [1,2,3]
We investigated whether inequity in CHD healthcare in Wales (UK) could contribute to the observed social gradient in CHD mortality
Evidence of inequity was found for revascularization procedures, this inequity is likely to have only a modest effect on social gradients in CHD mortality
Summary
Coronary heart disease (CHD) mortality rates have declined rapidly in recent decades in most middle- to high-income countries [1,2,3]. Marked socioeconomic inequalities in major risk factors for CHD have been found in the UK [6,7, 8] but it is not clear whether these inequalities fully explain the mortality gradient, as inequity (inequality to the disadvantage of more deprived groups) in provision of or access to healthcare might contribute to the gradient. Modelling studies of UK populations have estimated that the decline in CHD mortality has been largely due to population-level reduction in risk factors, rates of smoking and levels of blood pressure and cholesterol. 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
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