Gender and age inequity in the provision of coronary revascularisation in England in the 1990s: is it getting better?
Introduction
Since the early 1980s, coronary heart disease (CHD) mortality has declined in both men and women in England and Wales, falling from 37 to 21 per 100,000 for men and 26 to 17 for women between 1981 and 2000 (OPCS, 1982; ONS, 2001). This decline is seen in many countries taking part in the WHO MONICA project, where it has been established that declines are partially explained by falls in risk factors, in particular smoking, blood pressure and blood cholesterol levels, and reduced case-fatality attributable to better medical care (Tunstall-Pedoe et al., 2000; Kuulasmaa et al., 2000). It is likely that this decline in mortality is mirrored by a decline in the incidence of CHD (Tunstall-Pedoe et al., 1999). However, findings from The British Regional Heart Study have demonstrated that while the incidence of both fatal and non-fatal CHD events has declined since the late 1970s, and the prevalence of symptomatic coronary heart disease (largely angina) has also declined, the overall prevalence of diagnosed disease has shown virtually no change (Lampe et al., 2001). Thus, with an ageing population and with people now more likely to survive acute cardiac events, the total number of high risk people in the population is likely to increase further, resulting in more people requiring revascularisation.
Revascularisation is valuable in the treatment of CHD. In comparison with medical treatment, a systematic review of randomised controlled trials (Sudlow, Lonn, Pignone, Ness, & Rihal, 2000) demonstrated that coronary artery bypass grafting (CABG) reduced 5-year mortality by about 39% (95% confidence intervals 23%, 52%) although it did not reduce the risk of subsequent myocardial infarction. Since these trials were conducted, medical treatment has improved greatly, potentially reducing the need for this treatment. In patients with stable CHD, percutaneous transluminal coronary angioplasty (PTCA) is more effective than medical treatment in alleviating symptoms and improving exercise tolerance. However, PTCA does not reduce the overall risk of mortality or future myocardial infarction, probably because of the risk of complications during and shortly after the procedure (Sudlow et al., 2000). Furthermore, PTCA is more likely to need repeating (Pocock et al., 1995; BARI Investigators, 1996). In people aged over 75 (mean age 80 years), a recent trial has reported greater symptomatic and quality of life benefits in those randomised to revascularisation compared with those who received optimised medical treatment (TIME Investigators, 2001), suggesting that access to intervention for older people is legitimate. However, evidence of ageism in provision has been documented (Bowling, 1999).
Although more men than women suffer with CHD, there is no evidence to suggest that women are less likely to benefit from treatment. However, inequalities in provision of revascularisation have been associated with gender in studies in the SW and NW Thames regions (Petticrew, McKee M, & Jones, 1993). In a study using data from the Health Survey for England, the adjusted male:female odds ratio of revascularisation was 2.8 (95% Confidence Intervals 1.9, 4.0) (Dong, Ben-Shlomo, Colhoun, & Chaturvedi, 1998).
Previous work has identified inequity of provision for older people and for women, but making due allowance for the different patterns of need in older people and among women makes interpretation of simple comparisons of provision difficult. Furthermore, previous work has considered either small geographic regions or has been confined to a single point in time. Therefore, we aimed to examine equity of the provision of revascularisation according to need by gender and age in England and how it has changed over the last decade and its implications for equitable service provision.
Section snippets
Methods
Hospital Episode Statistics (HES) for England were used. The HES database holds information on patients who are admitted to NHS hospitals in England, either as a day case or as an ordinary admission. Each record in the database relates to one ‘Finished Consultant Episode’. This is the period of time an individual spends under the care of one NHS consultant. Private hospital procedures are excluded from HES as there is no requirement for such hospital to provide routine data (although a
Results
Table 1 presents information on the number of admissions for acute myocardial infarction, the number of CABG and PTCA procedures, and the relevant populations, for males and females, for the years of study: 1991/93, 1994/96 and 1997/99. Over this time period the number of people aged 40 and over in England increased by 4%. In the period 1997–1999 a total of 65,562 CABG and 55,105 PTCA admissions were recorded for people aged 40 years and over in England; this represents 72% and 48% increases,
Discussion
Although encouraging improvements in the rates of revascularisation have been apparent since the early 1990s, it appears that women and older people in England are probably receiving less revascularisation than their need would indicate. To achieve equitable provision for women and for older people up to the age of 79 years would require a substantial increase in the numbers of procedures conducted. However, the increases required are much more modest than the overall rising trend in
Limitations of the study
Assessing equity requires some measurement of need, that is ability to benefit. Ideally, need for revascularisation would be defined by counting the number of people with CHD who would benefit from revascularisation using standardised explicit criterion developed from trials and prognostic studies (Hemingway et al., 1999). However, there is no routine recording of CHD morbidity in England and so it is necessary to assess the need for revascularisation using proxy measures. Need might be
Older age, gender and inequality
Advancing age has long been considered a risk factor for morbidity and mortality following coronary revascularisation. Several recent reports have examined clinical outcome following revascularisation in older patients. Long-term data from the Coronary Artery Surgery Study (CASS) showed that 59% of patients over the age of 75 years at surgery were alive 10 years later, and 33% at 15 years (Myers, Blackstone, Davies, Foster, & Kaiser, 1999). These data support an aggressive approach to the
Implications
Whatever the explanation(s) for the age and gender inequities indicated by our results, the findings presented here have direct policy relevance.
The National Service Framework for Coronary Heart Disease (http://www.doh.gov.uk/nsf/coronary.htm) was published in the year 2000. The major aim of the NSF for CHD is to develop explicit sets of standards that would form the basis for developing and monitoring the quality of services provided by the NHS; improved access to revascularisation is
Acknowledgements
This research was funded by South West Region NHS R&D and was supported by the South West Public Health Observatory and the Medical Research Council - Health Services Research at the Department of Social Medicine at the University of Bristol; Bristol is the lead centre in the collaboration MRC-HSRC. We would like to thank the small area health statistics unit at Imperial College London for provision of under-enumeration adjusted 1991 census population estimates and 1996 population estimates and
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