Intended for healthcare professionals

Letters

Sex inequalities in ischaemic heart disease in primary care

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7309.400/a (Published 18 August 2001) Cite this as: BMJ 2001;323:400

Clinical decision making is not necessarily guided by prejudice

  1. Rosalind Raine, Medical Research Council/North Thames clinical lecturer in health services research (rosalind.raine{at}lshtm.ac.uk)
  1. London School of Hygiene and Tropical Medicine, University of London, Department of Public Health and Policy, Health Services Research Unit, London WC1E 7HT
  2. Health Care Research Unit, Southampton University, Southampton SO16 6YD
  3. West Anglia Resource Centre, Upwell Health Centre, Cambridgeshire PE14 9BT
  4. Cambridgeshire Health Authority, Kingfisher House, Huntingdon PE29 6FH
  5. Hertfordshire Primary Care Research Network, The Surgery, Letchworth, Hertfordshire SG6 4TS

    EDITOR—The paper by Hippisley-Cox et al makes an important contribution to the literature on sex differences in health service use.1 Primary care physicians act as gatekeepers to specialist health services, yet this critical role in the healthcare system has been largely ignored by researchers in this field.2

    Hippisley-Cox et al said that their findings suggest a systematic bias towards men in terms of secondary prevention of ischaemic heart disease. Such a conclusion is premature. The results may reflect biased decision making, but they may also have been determined by patient preferences or 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. It would, however, be preferable to be able to demonstrate positively that clinical decision making is guided by prejudice before making claims that a service is biased.

    Prejudice is very difficult to show 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 they have proved inconclusive because of their lack of context. 3 4 Factors shown to affect physician response, including the patient's age, ethnic group and social class, information on the presenting complaint, comorbidity, and 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 Hippisley-Cox et al, 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' judgments 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 to avoid unfairly tainting clinicians with the damaging label of prejudice.

    References

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    Designating sex specific total cholesterol targets may be useful

    1. Sarah Wild (shw{at}soton.ac.uk), lecturer in public health medicine,
    2. Carol Whyman, audit facilitator,
    3. Marilyn Barter, clinical governance nurse facilitator,
    4. Kate Wishart, general practice facilitator,
    5. Christine Macleod, consultant in public health medicine
    1. London School of Hygiene and Tropical Medicine, University of London, Department of Public Health and Policy, Health Services Research Unit, London WC1E 7HT
    2. Health Care Research Unit, Southampton University, Southampton SO16 6YD
    3. West Anglia Resource Centre, Upwell Health Centre, Cambridgeshire PE14 9BT
    4. Cambridgeshire Health Authority, Kingfisher House, Huntingdon PE29 6FH
    5. Hertfordshire Primary Care Research Network, The Surgery, Letchworth, Hertfordshire SG6 4TS

      EDITOR—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. We had 415 women and 790 men in our sample. We present our findings for comparison and provide a further analysis by use of statins.

      In our sample the difference (P=0.8) in the proportion of women (66%, n=273) and men (67%, n=532) with any record of total cholesterol concentration was not significant. The odds ratio for cholesterol measurement for men versus women adjusted for age, diabetes, hypertension, obesity, smoking status, and practice was 1.1 (95% confidence interval 0.8 to 1.6, P=0.5). Use of statins was similar (P=0.1) in women (34%, n=140) and men (38%, n=301). The odds ratio for statin prescription for men v women adjusted as above was 1.1 (0.8 to 1.5, P=0.4). Our other findings regarding sex differences were similar to those of Hippisley-Cox et al (data available from us).

      For people who had a cholesterol concentration recorded and were not prescribed statins, 85% (125/147) of women and 69% (188/272) of men had a most recent total cholesterol concentration above 5 mmol/l (P<0.001 for sex difference). Among those prescribed statins who had a cholesterol concentration recorded, 74% (93/126) of women and 66% (172/260) of men had a record of the most recent total cholesterol concentration above 5 mmol/l (P=0.13 for sex difference). Regardless of statin prescription, 80% (218/273) of women and 68% (360/532) of men (P<0.0001 for sex difference) had a record of most recent total cholesterol concentration above 5mmol/l and therefore had values above the target set in the national service framework for coronary heart disease.2

      Almost all people not taking statins with a history of myocardial infarction had total cholesterol concentrations of 4 mmol/l and above (the cut off point for starting statin treatment mentioned in guidelines from the National Institute for Clinical Excellence3): 100% of women (33/33) and 99% of men (100/101).

      Total cholesterol concentrations reflect concentrations of high and low density cholesterol, and women have higher concentrations of high density cholesterol than men.4 The effect of using low density cholesterol targets (set at 3 mmol/l in the national service framework) 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.

      Footnotes

      • Support for the audit in the form of unrestricted educational grants and the provision of a laptop computer was provided by three pharmaceutical companies that manufacture statins.

      References

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      Inhouse clinics may help better to manage patients with heart disease

      1. T J Ramsbottom, general practitioner,
      2. M G Kirby (Kirbym{at}globalnet.co.uk), general practitioner,
      3. Karin Friedli, principal lecturer
      1. London School of Hygiene and Tropical Medicine, University of London, Department of Public Health and Policy, Health Services Research Unit, London WC1E 7HT
      2. Health Care Research Unit, Southampton University, Southampton SO16 6YD
      3. West Anglia Resource Centre, Upwell Health Centre, Cambridgeshire PE14 9BT
      4. Cambridgeshire Health Authority, Kingfisher House, Huntingdon PE29 6FH
      5. Hertfordshire Primary Care Research Network, The Surgery, Letchworth, Hertfordshire SG6 4TS

        EDITOR—We read Hippisley-Cox's study showing sex inequalities in secondary prevention of ischaemic heart disease in general practice.1 We have just completed an audit of 167 of our patients with ischaemic heart disease (practice size 9300, total number of patients on the register for ischaemic heart disease 450). We found 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 cardiovascular surgery or angioplasty compared with women (35% (28/79) v 13% (11/88); χ2=11.0, df=1, P=0.001). There was a trend for men to have their smoking status recorded more often compared with women (99% (78/79) v 91% (80/88); χ2=3.6, df=1, P=0.058), and men were more likely to be former smokers compared with women (39% (31/79) v 18% (16/88); χ2=13.8, df=3, P=0.003). Women were less likely to have had their cholesterol concentrations checked in the past three years (42% (37/88) v 67% (53/79); χ2=9.5, df=1, P=0.002), and fewer received lipid lowering agents compared with men (24% (21/88) v 42% (33/79), χ2=5.3, df=1, P=0.021). There were no sex differences in prescribing antiplatelet drugs, β blockers, angiotensin convertin enzyme 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 sex differences in management in secondary and tertiary care settings.2 The consensus seems to be that there are important pathophysiological differences in ischaemic heart disease in women compared with men, but these do not fully explain all of the differences in management.2

        How then can general practitioners reduce this inequality? We suggest using nurse led, protocol driven, secondary prevention clinics in primary care. Surveys show that secondary prevention is being done badly in men and worse in women, maybe because the increased complexity of secondary prevention can no longer be managed opportunistically in the existing short appointments in general practice.

        The management of diabetes in primary care has markedly improved after the widespread use of inhouse diabetes clinics, and the same is likely to be true for ischaemic heart disease. Already evidence and improved health indices show that nurse led clinics for secondary prevention of ischaemic heart disease can reduce hospital admission rates.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.

        References

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        View Abstract