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Does access to cardiac investigation and treatment contribute to social and ethnic differences in coronary heart disease? Whitehall II prosp
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     1 International Centre for Health and Society, Department of Epidemiology and Public Health, University College London Medical School, London WC1E 6BT

    Correspondence to: H Hemingway h.hemingway@ucl.ac.uk

    Abstract

    Low social position and South Asian ethnicity are both associated with increased risk of dying from coronary heart disease,1 2 but the impact of differential access to medical care on these inequalities remains uncertain. If access to coronary management matched coronary incidence, then low social position and South Asian ethnicity would be associated with higher rates of use. For social position, most studies,3-10 but not all,11-13 find the opposite—high social deprivation is associated with lower rates of coronary angiography and revascularisation. Several studies, mainly small and retrospective, report less aggressive treatment of South Asian people with coronary disease compared with white patients.14-22 Such potential healthcare disparities have stimulated calls in the United States and United Kingdom for remedial action.23 24

    Three interrelated questions remain unanswered. Firstly, in a general population that exhibits social and ethnic differences in rates of coronary heart disease, do differences exist in access to care? Population studies are lacking; all but a few studies are confined to patients who have sought hospital care for coronary disease and therefore exclude many people with angina in the community.12 Furthermore, studies have concentrated on invasive procedures, ignoring non-invasive investigation and secondary prevention, which may be particularly relevant in primary care. Secondly, how does the social deprivation of an individual patient, as opposed to an area, influence access to cardiac investigation and treatment? Most previous studies have used neighbourhood measures of social deprivation.3-11 One of the few prospective studies reporting individual social class, albeit confined to white men, found no effect on access to coronary angiography but lower revascularisation rates among men from non-manual occupations.25 Thirdly, among South Asians, is the apparent lower use of cardiac investigation and treatment independent of or explained by their social position?26 Previous studies have made little attempt to answer this question.

    The Whitehall II prospective cohort study of civil servants offers the opportunity to consider each of these questions. Our objective was to determine whether access to cardiac procedures (exercise electrocardiography, coronary angiography, and coronary revascularisation) and secondary prevention drugs contributes to social and ethnic differences in coronary heart disease in a population setting.

    Methods

    Table 1 shows that incident coronary morbidity and mortality were higher among lower employment grades than among higher grades and higher among South Asians than among white participants. For example, in men, the age adjusted rate ratio for incident angina and myocardial infarction was 1.66 (95% confidence interval 1.32 to 2.10) for low versus high employment grades and 1.95 (1.28 to 2.96) for South Asians compared with white participants. Risk factors tended to be adverse in low employment grades and among South Asians. South Asians were less likely to be in a high employment grade than were white participants.

    Table 1 Age adjusted and mean coronary risk factors at baseline by employment grade and ethnicity and rates of subsequent coronary events

    Social position

    Men and women in the low employment grades reported higher use of exercise electrocardiography (age adjusted proportion 17.5% in men and 10.6% in women) than did those in the high employment grades (14.7% in men and 8.6% in women) (table 2). When we adjusted for history of coronary heart disease during follow up and baseline risk factors, we found no evidence of an overall grade gradient in either men or women. Men and women in the low employment grades had the highest use of angiography with adjustment for age alone, but no grade differences existed when we added clinical need and other risk factors to the models. Similarly, participants in the low grades had the highest use of revascularisation when we adjusted for age alone, but among men these differences were removed by further adjustment. Employment grade was not associated with taking secondary prevention drugs among the subgroup of participants with a history of angina or myocardial infarction (table 3).

    Table 2 Use of exercise electrocardiography, coronary angiography, and coronary revascularisation by employment grade

    Table 3 Age adjusted use of secondary prevention drugs by employment grade among participants with a history of angina or myocardial infarction. Values are percentages unless stated otherwise

    Ethnicity

    South Asian men and women were more likely to have an exercise electrocardiogram or coronary angiography than white participants, even after adjustment for clinical need and employment grade (table 4). We found less evidence for ethnic differences in revascularisation procedures. Further adjustment for presence of the metabolic syndrome or diabetes or abnormality on resting electrocardiogram did not attenuate any of these effects (data not shown). South Asians also tended to be more likely to take secondary prevention drugs than white participants—for example, among men with a history of angina or myocardial infarction, 34% of South Asians were taking blockers compared with 14% of white men (see table on bmj.com).

    Table 4 Use of exercise electrocardiography, coronary angiography, and revascularisation by ethnicity

    Sex

    Women were less likely to have coronary investigations and treatments than men within each grade (table 2) and ethnic group. When adjusted for age, coronary heart disease, employment grade, and ethnicity, the odds ratios of women having an exercise electrocardiogram, angiogram, and revascularisation compared with men were 0.51 (95% confidence intervals 0.42 to 0.62), 0.48 (0.38 to 0.62), and 0.25 (0.15 to 0.40).

    Discussion

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