BMJ, doi: 10.1136/bmj.39534.571042.BE, (Published 24 April 2008)

Research

Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris

Neha Sekhri, clinical research fellow1, Adam Timmis, professor of clinical cardiology1, Ruoling Chen, senior lecturer in epidemiology2, Cornelia Junghans, research fellow in epidemiology2, Niamh Walsh, statistician3, Justin Zaman, clinical research fellow in epidemiology2, Sandra Eldridge, professor of biostatistics3, Harry Hemingway, professor of clinical epidemiology2, Gene Feder, professor of primary health care4

1 Cardiac Directorate, Barts and the London NHS Trust, London, 2 Department of Epidemiology and Public Health, University College London Medical School, London, 3 Centre for Health Sciences, Barts and the London, Queen Mary’s School of Medicine and Dentistry, Queen Mary, University of London, London, 4 Academic Unit of Primary Health Care, University of Bristol, Bristol BS8 2AA

Correspondence to: G Feder gene.feder{at}bristol.ac.uk

Objectives To determine whether coronary angiography for suspected stable angina pectoris is underused in older patients, women, south Asian patients, and those from socioeconomically deprived areas, and, if it is, whether this is associated with higher coronary event rates.

Design Multicentre cohort with five year follow-up.

Setting Six ambulatory care clinics in England.

Participants 1375 consecutive patients in whom coronary angiography was individually rated as appropriate with the Rand consensus method.

Main outcome measures Receipt of angiography (420 procedures); coronary mortality and acute coronary syndrome events.

Results In a multivariable analysis, angiography was less likely to be performed in patients aged over 64 compared with those aged under 50 (hazard ratio 0.60, 95% confidence interval 0.38 to 0.96), women compared with men (0.42, 0.35 to 0.50), south Asians compared with white people (0.48, 0.34 to 0.67), and patients in the most deprived fifth compared with the other four fifths (0.66, 0.40 to 1.08). Not undergoing angiography when it was deemed appropriate was associated with higher rates of coronary event.

Conclusions At an early stage after presentation with suspected angina, coronary angiography is underused in older people, women, south Asians, and people from deprived areas. Not receiving appropriate angiography was associated with a higher risk of coronary events in all groups. Interventions based on clinical guidance that supports individualised management decisions might improve access and outcomes.


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