Sex inequalities in ischaemic heart disease in general practice: cross sectional survey
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7290.832 (Published 07 April 2001) Cite this as: BMJ 2001;322:832
All rapid responses
The paper by Hippisley -Cox and colleagues makes an important
contribution to the literature on gender differences in health service
use1. Primary care physicians act as gatekeepers to specialist health
services, yet this critical role in the health care system has been
largely ignored by researchers in this field2.
The investigators have stated that their findings "suggest a
systematic bias towards men in terms of secondary prevention of ischaemic
heart disease". I would argue that such a conclusion is premature. The
results may reflect biased decision making, but they may also have been
determined by patient preferences or by mutual agreement between doctor
and patient. In common with other research in this area, the charge of
biased decision making has been made as a result of a process of
exclusion. Once it has been shown that clinical need (in this case a
diagnosis of ischaemic heart disease) cannot account for the finding that
women are less likely to receive a certain treatment than men (in this
case, lipid lowering drugs), then the spectre of bias is raised.
However, it would be preferable to be able to demonstrate positively that
clinical decision making is guided by prejudice before making claims that
a service is biased.
It is very difficult to demonstrate prejudice as clinicians cannot be
blinded to the sex of their patients. Alternative methods including the
use of clinical vignettes, audiotaping consultations, and analysing
individual patient records have been tried, but have proved inconclusive
because of their lack of context3 4. Factors shown to affect physician
response, including the patient's age, ethnicity and social class,
information on the presenting complaint, comorbidity and past medical
history, as well as organisational and structural features, may be missing
5.
Other methods need to be used to examine the extent to which
inequalities such as those reported by Hippesley-Cox, are due to bias.
Qualitative studies, including observations of clinician-patient
encounters and interviews with health professionals, patients and their
carers are needed. Assessing clinicians' judgements at two or more points
in a given clinical interaction may also help in assessing when diagnostic
hypotheses are generated and how long they are adhered to in spite of
contradictory information. Such techniques will clarify the extent to
which differences in patient's expectations or demands, mutual agreement,
and clinician prejudice influence the clinical decision making process.
Such research must be undertaken in order to avoid unfairly tainting
clinicians with the damaging label of prejudice.
Yours sincerely,
Dr Rosalind Raine
MRC/North Thames Clinical lecturer in Health Services Research.
Competing interests: No competing interests
Hippisley-Cox et al described sex inequalities in measurement of risk
factors and treatment of ischaemic heart disease in primary care in the
Trent region.1 We collected similar data from a 50% sample of people with
ischaemic heart disease (defined by disease codes) of 35-75 years of age
from 13 general practices in north Cambridgeshire and west Norfolk in
1999. There were 790 men and 415 women in the sample. We present our
findings for comparison and provide a further analysis by statin use.
In our sample there was no difference in the proportion of women and
men with a total cholesterol measurement in the previous 3 years (62%
versus 65%, p=0.2). The odds ratio for cholesterol measurement for men
versus women adjusted for age, diabetes, hypertension, obesity, smoking
status and practice was 1.3, 95% confidence intervals 0.9-1.8, p=0.15. Use
of statins was similar in women and men (34% versus 38%, p=0.1). The odds
ratio for statin prescription for men versus women adjusted for age,
diabetes, hypertension, obesity, smoking status and practice was 1.1, 95%
confidence intervals 0.8-1.5, p=0.4. Our other findings were similar to
those of Hippisley-Cox et al (data available from authors).
For people who had a cholesterol level recorded, among those not
prescribed statins (147 women and 272 men) 85% of women and 69% of men had
total cholesterol levels above 5 mmol/l (p<0.001) but among those
prescribed statins (126 women and 260 men) the difference was not
statistically significant (74% of women and 66% of men, p=0.12).
Regardless of statin prescription, 80% of women and 68% of men
(p<0.0001 for sex difference) had a total cholesterol level >
5mmol/l and therefore had values above the target set in the coronary
heart disease national service framework (NSF).2
Total cholesterol levels reflect both high- and low-density
cholesterol levels and women have higher high-density cholesterol levels
than men.3 The effect of using low-density cholesterol targets (set at 3
mmol/l in the NSF) on the sex differential is likely to be less marked and
should be explored. Unfortunately these values are not widely available.
An alternative would be to consider designating sex-specific total
cholesterol targets.
Sarah Wild lecturer in public health medicine
Health Care Research Unit, Southampton University, SO16 6YD
Tel. 02380 798930 Fax 02380 796529
shw@soton.ac.uk
Carol Whyman audit facilitator
Marilyn Barter clinical governance nurse facilitator
Kate Wishart GP facilitator
West Anglia Resource Centre, Upwell Health Centre, Cambridgeshire, PE14
9BT
Christine Macleod consultant in public health medicine
Cambridgeshire Health Authority, Kingfisher House, Huntingdon, PE29 6FH
Competing interests: support for the audit in the form of
unrestricted educational grants and the provision of a lap-top computer
was provided by 3 pharmaceutical companies that manufacture statins
1. Hippisley-Cox, J, Pringle M, Crown N, Meal A, Wynn A. Sex
inequalities in ischaemic heart disease in general practice: cross
sectional survey BMJ 2001;322:832-834.
2. Department of Health. National Service Framework for coronary artery
disease: modern standards and service models. London: Stationery Office,
2000.
3. Carlson LA, Ericsson M. Quantitative and qualitative serum lipoprotein
analysis. Part 1. Studies in healthy men and women. Atherosclerosis. 1975
May-Jun;21(3):417-33.
Competing interests: No competing interests
Dear Editor,
I was interested to read the conclusions of the Primary Care article
on sex inequalities in ischaemic heart disease care in general practice,
but its conclusions were not completely unknown to me.
I reached exactly the same conclusions in 1997 when I had performed
an audit on ischaemic heart disease care in our practice.
Having detected the inequality we set out to improve upon it and when
the audit cycle was completed a year later, we found that the sex bias had
been removed. We found that it was easier to get women to come for review
and to accept treatment than the men who had previously been receiving sub
-optimal care.
I was intrigued at the time by the sex bias, but when I presented the
audit at our local audit club and later had it published in our local MAAG
magazine was disappointed that no-one seemed to take any notice of its
conclusions.
The completed audits confirm that the sex bias can be removed by
diligently targeting the women receiving sub-optimal care and this must
surely be the next step forward following upon your published article. It
will be interesting to see if the authors consider completing their audit
cycle for, as you will no doubt be aware, many audits are performed but
very few cycles are completed.
Dr.P.J.Moorhouse
CLIFTON DRIVE SURGERY,
300 Clifton Drive South,
St Annes on Sea,
Lytham St Annes
Competing interests: No competing interests
Sex inequalities in ischaemic heart disease in general practice
Dear Editor
We read Hippisley-Cox's study showing sex inequalities in secondary
prevention of ischaemic heart disease in General Practice with interest
(ref 1). We have just completed an audit of 167 of our ischaemic heart
disease patients (practice size 9,300, total number on ischaemic heart
disease register 450). We had been puzzled and concerned to find a
similar sex difference in secondary prevention uptake, but until the
publication of this paper, had not been able to find anything in the
literature to confirm or refute whether this was happening in other
General Practices.
We found that a higher proportion of men had cardio-vascular surgery
or angioplasty compared to women (35% versus 13%; c=11.0, df=1, p=0.001).
There was a trend for men to have their smoking status recorded more often
compared to women (99% versus 91%; c=3.6, df=1, p=0.058) and men were more
likely to be ex-smokers compared to women (39% versus 18%; c=13.8, df=3,
p=0.003). Women were less likely to have their cholesterol checked within
the past three years (42% versus 67%; c=9.5, df=1, p=0.002) and fewer
received lipid lowering agents compared to men (24% versus 42%, c=5.3,
df=1, p=0.021). There were no sex differences in prescribing anti-platelet
drugs, beta-blockers, ace-inhibitors or nitrates.
The puzzle is whether this represents a form of sexual
discrimination, or whether there are pathophysiological explanations for
such sex differences. This question has been debated with reference to
the well-documented sex differences in management within secondary and
tertiary care settings (ref 2). The consensus seems to be that there are
significant pathophysiological differences in women's ischaemic heart
disease compared to men's but these do not fully explain all of the
differences in management - "women are different - but not that different"
(ref 2).
How then can General Practitioners reduce this inequality? We
suggest with nurse led, protocol driven, secondary prevention clinics
within primary care. The surveys show that secondary prevention is being
done badly in men and even more so in women. This could be because the
increased complexity of secondary prevention can no longer be managed
opportunistically within the existing short GP appointments. Just as
diabetic management in Primary Care has markedly improved following the
widespread use of in-house diabetic clinics, the same is likely to be true
for ischaemic heart disease. There is already evidence and improved
health indices that nurse-led IHD secondary prevention clinics can reduce
hospital admission rates (ref 3). It will also be interesting to see
whether sex differences can be reduced when we repeat this audit after our
introduction of a nurse-led secondary prevention clinic.
Dr T J Ramsbottom, General Practitioner
Dr M G Kirby, General Practitioner
Dr Karin Friedli, Principal Lecturer/Manager of HertNet
The Hertfordshire Primary Care Research Network
References:
1 Hippisley-Cox J, Pringle M, Gown N, Meal A, Wynn A. sex
inequalities in ischaemic heart disease in General Practice: Cross
sectional survey BMJ 2001, 322:832-4 (7 April)
2 Jackson G. Coronary Artery Disease and Women. BMJ 1994, 309:555-556.
3 Campbell N, Thain J, Deans H, Ritchie L, Rawler J, Squair J. Secondary
prevention clinics for coronary artery disease: randomised trial of effect
on health. BMJ 1998, 316:1434-7
Competing interests: No competing interests