Retrospective study of influence of deprivation on uptake of cardiac rehabilitationBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7052.267 (Published 03 August 1996) Cite this as: BMJ 1996;313:267
- Jill Pell, senior registrara,
- Alastair Pell, senior registrarb,
- Caroline Morrison, consultanta,
- Oliver Blatchford, senior registrara,
- Henry Dargie, consultantc
- a Department of Public Health, Greater Glasgow Health Board, Glasgow G1 1ET
- b Department of Cardiology, Stobhill Hospital, Glasgow G21 3UW
- c Department of Cardiology, Western Infirmary, Glasgow G11 6NT
- Correspondence to: Dr Pell.
- Accepted 5 December 1995
Mortality from ischaemic heart disease is higher in Scotland than in most developed countries.1 Comprehensive cardiac rehabilitation after myocardial infarction, incorporating exercise training and lifestyle counselling, can reduce mortality and the rate of fatal reinfarction2 and also improve quality of life.3 Socioeconomic deprivation is associated with both an increased risk of developing myocardial infarction and a poorer prognosis afterwards.4 Our aim was to determine whether deprivation affected uptake of rehabilitation after myocardial infarction.
Subjects, methods and results
Scottish morbidity record (SMR1) data were used to identify all patients discharged from Glasgow hospitals from 1 June 1994 to 31 November 1994 with an International Classification of Diseases (revision 9) code of 410 (myocardial infarction). Each patient's age, sex, postcode, comorbidities, and consultant were recorded, together with whether they died before discharge. Postcodes were used to obtain the Carstairs deprivation score for the 5000 or so residents within each postcode sector.5 This is calculated from 1991 census data on overcrowding and male unemployment in each sector and the numbers of residents who belong to a low social class and who have no access to a car. Higher scores represent a higher level of deprivation. Four of Glasgow's five main hospitals offer a cardiac rehabilitation programme, and a list of patients invited to rehabilitation was obtained from the hospitals. Information was provided on which of these patients started the programme and which completed it.
Over the six months 1120 patients had a discharge diagnosis of myocardial infarction. Their median age was 66 years (interquartile range 57-74) and 59% were men. Only 7% of patients were recorded as having coexistent peripheral arterial disease, 5% diabetes mellitus, 4% cerebrovascular disease, and 4% renal failure. Comorbidity is, however, known to be poorly recorded (J Blair, personal communication). Two hundred and thirty three patients (21%) died before discharge. The age, sex, and deprivation scores of patients with myocardial infarction were compared with those of the Glasgow population obtained from 1991 census data. Logistic regression showed that increasing deprivation score was associated with increased risk of myocardial infarction (P<0.0001). This remained significant after adjustment for age and sex (P<0.0001). The incidence of myocardial infarction in the most deprived quartile was 1.7 times that in the least deprived.
Three hundred and sixteen (36%) of the patients discharged alive were invited to rehabilitation. Of these, 188 (59%) started the programme and 109 (34%) completed it. Stepwise multiple logistic regression analysis showed that hospital (P<0.0001), age (P<0.0001), sex (P<0.05), and the type of consultant (cardiologist v general physician; P<0.05) were significant independent determinants of whether patients were invited to rehabilitation (table 1). Deprivation score was not a significant factor. Uptake of rehabilitation after invitation was significantly associated with the type of consultant (P<0.05), hospital (P<0.005), and deprivation (P<0.001). Patients with recorded peripheral arterial disease were less likely to be invited to rehabilitation (P<0.05). Otherwise comorbidity was not associated with invitation to or attendance at rehabilitation. Once rehabilitation had been started the only determinant of completion was deprivation (P<0.05). Both uptake and completion of rehabilitation were less likely among more deprived patients.
Deprivation was associated with an increased risk of myocardial infarction. Overall only 36% of patients discharged alive after myocardial infarction were invited to rehabilitation. Deprived patients were no less likely to be invited but they were significantly less likely to start rehabilitation. Also, deprived patients who did start the programme were less likely to complete it. A further study is required to ascertain why deprived patients are less likely to complete rehabilitation so that uptake can be improved.
We thank Sisters Pat Isuid (Western Infirmary, Glasgow), Liz Keith (Glasgow Royal Infirmary), Isabel Stewart (Victoria Infirmary, Glasgow) and Wilma Sutherland (Stobhill Hospital) for providing information on which patients were invited to and attended rehabilitation and Mr Allan Boyd (Greater Glasgow Health Board) for providing discharge data.
Conflict of interest None.