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PRIMARY CARE: Helen Mary Richards, Margaret Elspeth Reid, and Graham Charles Murray Watt Socioeconomic variations in responses to chest pain: qualitative study BMJ 2002; 324: 1308 [Abstract] [Full text]

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Are poorer individuals less likely to seek health care with chest pain?

Yoav Ben-Shlomo, Joy Adamson, Jenny Donovan, Nish Chaturvedi   (7 June 2002)

Emergency room chest pain presentations among the uninsured vs. the insured

Mustafa M Hamed, Department of Emergency Medine, Henry Ford Hospital-Fairlane   (8 June 2002)

Are poorer individuals less likely to seek health care with chest pain? 7 June 2002
Yoav Ben-Shlomo, Senior Lecturer in Clinical Epidemiology Dept. of Social Medicine, University of Bristol, Whiteladies Road, Bristol BS8 2PR, Joy Adamson, Jenny Donovan, Nish Chaturvedi Send response to journal: Re: Are poorer individuals less likely to seek health care with chest pain?	Sir - The paper by Richards and colleagues1 is an excellent example of how qualitative research can be nested within an epidemiological study. The authors conclude that individuals with chest pain of lower socioceconomic status are more reluctant to seek care from their general practitioner and this may be important in understanding social inequities in receipt of cardiac care. We have examined this using an alternative case-vignette approach2 in large population-based samples. Subjects report whether they would seek health care if they had experienced the same chest pain as in our vignette as well as their lay diagnosis and various attitudinal measures. Our results support some but not all of the conclusions reached by Richard's and colleagues. More affluent participants were more likely to consider our chest pain history to be cardiac compared to poorer subjects (proportion reporting symptoms coming from the heart: social class I&II, 73.6; IIINM, 71.0; IIIM 61.6; IV&V 63.8; p value for trend=0.003). Poorer subjects, in line with the results reported by Richards and colleagues, were more concerned not to waste their general practitioner's time (proportion who strongly agreed that people use the GP unnecessarily increased across social class groups: social class I&II, 9.5; IIINM 15.5; IIIM 22.1; IV& V 17.7; p value for trend <0.001) . Our results, however, found that poorer subjects, as assessed by a 5 point socioeconomic indicator, were more likely to report seeking medical care (age and sex adjusted odds ratio for 1 unit increase in socio- economic indicator 1.29, 95% CI 1.13-1.46; p value for trend <0.001).3 These results are based on hypothetical rather than "real" consultation behaviour and may therefore be biased. We therefore re-examined the original quantitative data reported by Richards and colleagues as part of the same study.4 These results (see table) are consistent with our findings, showing overall that Rose angina positive subjects residing in poor areas are more likely to actually present to their general practitioner, in contrast to their current conclusion. Studies combining quantitative and qualitative methods are important in understanding the decision making process that patients make when choosing to seek or not seek health care. We do however question their conclusion that poorer individuals are more stoical and less likely to seek medical help when they develop symptoms. Ben-Shlomo Y, Senior Lecturer in Clinical Epidemiology Adamson J, MRC research fellow Donovan J, Prof. of Social Medicine Chaturvedi N* Prof. of Primary Care Epidemology Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR * Department of Epidemiology and Public Health, Imperial College School of Medicine, Norfolk Place, London W2 1PG Author for correspondence: Yoav Ben-Shlomo, email y.ben-shlomo@bristol.ac.uk References 1. Richards HM, Reid ME, Watt GCM. Socioeconomic variations in responses to chest pain: qualitative study. BMJ 2002;324:1308-1311. 2. Chaturvedi N, Rai H, Ben-Shlomo Y. Lay diagnosis and health-care -seeking behaviour for chest pain in South Asians and Europeans. Lancet 1997;350:1578-1583. 3. Adamson J, Donovan J, Chaturvedi N, Ben-Shlomo Y. Open SESAME - the impact of socioeconomic status on health care seeking behaviour. Journal of Epidemiology and Community Health 2000;54 (Supplement):A23. 4. Richards H, McConnachie A, Morrison C, Murray K, Watt G. Social and gender variation in the prevalence, presentation and general practitioner provisional diagnosis of chest pain. Journal of Epidemiology & Community Health 2000;54:714-718. Table: Odds ratio (adjusted for gender) for presenting to general practitioner by area deprivation score and Rose angina grade from Glasgow Monica Project* Deprivation category 1, 2 (least deprived) 3,4,5 6,7 (most deprived) p-value for trend Rose angina II 1.00 1.05 0.85 0.66 Rose angina I 1.00 1.36 2.69 0.0005 Rose angina I & II 1.00 1.51 2.10 0.002 * Data re-analysed from Richards et al4 adjusting for gender but without adjustment for age group as data not available
Emergency room chest pain presentations among the uninsured vs. the insured 8 June 2002
Mustafa M Hamed, Student, University of Michigan-Dearborn. Emergency Room Technician, Henry Ford Health System Dearborn, Michigan 48126, Department of Emergency Medine, Henry Ford Hospital-Fairlane Send response to journal: Re: Emergency room chest pain presentations among the uninsured vs. the insured	First and foremost, I would like to commend the study by Richards, Reid, and Watt. I believe that their study gives us good insight at chest pain presentations along the lines of socioeconomic status. With my experience in a large American inner city emergency room , I have noticed interesting trends among chest pain patients in regards to patients who are insured versus the uninsured. Most patients take chest pains very seriously. I've noticed that the patients who do not have health insurance seem to present their cases to the emergency room for a number of reasons. Among these reasons: 1. No health insurance means it is difficult to seek medical care from a primary care practitioner. 2. The uninsured patients will usually only come to the emergency room for services if they are in great fear of MI, or if the pain is disrupting their normal activities. Patients that do have health insurance tend to come to the emergency room for chest pains for a number of reasons: 1. Advice from their physician to seek medical services at chest pain onset. 2. Relief of pain. 3. Assumption that the they should utilize their health insurance for any pains associated with chest. Insured patients have access to regular medical care from primary care practitioners. They are usually educated about proper health maintenance and illness prevention. This education, in the long run, will save the insurance companies and the hospital money from possible future emergency room expendatures. The uninsured do not have this access to prevention techniques and medical education. They will tend to "shake off" the pain (wait for it to go away) in large part because they do not want to get stuck with a hefty bill from the emergency room. Other uninsured do not trust the medical field, due to some belief that they are treated unequally by medical staff due to lack of insurance coverage. These are just general observations that I picked up at the emergency room where I am at. When it comes to chest pains, immediate medical attention should be given to the patient, whether insured or uninsured. More illness prevention on behalf of all patients will reduce the rates of chest pains to emergency rooms, and in the long run, make the society more equal when it comes to health care equality.