Equity in access to exercise tolerance testing, coronary angiography, and coronary artery bypass grafting by age, sex and clinical indications

Abstract

Objectives-To assess whether patients with heart disease in a single UK hospital have equitable access to exercise testing, coronary angiography, and coronary artery bypass graft surgery (CABG). Method-Retrospective analysis of patients' medical case notes (n = 1790), tracking each case back 12 months and forward 12 months from the patient's date of entry to the study. Setting-Single UK district hospital in the Thames Region. Patients-Patients (elective and emergency) with a cardiac ICD inpatient code at discharge or death, or who were referred to cardiology or care of the elderly unit over a 12 month period in 1996-7 (new episodes) were included. Results-Analysis of 1790 hospital case notes revealed that, despite having indications for intervention identical to those of younger patients, older patients (that is, those aged > 75 years) and women, independently, were significantly less likely to undergo exercise tolerance testing (exercise ECG) and cardiac catheterisation. The similar trends for age and access to CABG did not achieve significance. While clinical priority scores also independently predicted access to cardiac catheterisation and CABG, considerable numbers of patients in high clinical priority groups were not referred for either procedure. Conclusions-The management and treatment of older patients and women with cardiac disease may be diVerent from that of younger patients and men. Given the similarity of the indications for treatment and the lack of significant contraindications or comorbidities as a cause for these diVerences, one possible explanation is that these patients are being discriminated against principally because of their age and sex. Although clinical priority scores independently predicted access to catheterisation and CABG, large proportions of patients in high priority groups were not referred. This implies that the New Zealand priority scoring system may be more equitable than UK practice. The cost implications of redressing these inequities in service provision would be considerable. (Heart 2001;85:680-686)

Influências temporais nas características e fatores de risco de pacientes submetidos a revascularização miocárdica

“…Since the risk for elderly patients varies greatly, risk evaluations should be preferentially determined on an individual basis 19 . Studies using data banks confirmed the predominance of male patients 20,21 . Surgical indications for women are generally postponed due to conditions such as equivocal symptom interpretations and therefore a late diagnostic process.…”

Sex Differences in Health and Survival

“…This result suggests that in addition to the differences in the distribution of comorbid conditions, the relative risk associated with a comorbidity may help to explain the gender differences in the prognoses for MI and stroke. Moreover, considerably more men than women undergo invasive cardiac procedures and receive aggressive treatment (Bowling et al 2001;Shaw et al 2004;Blomkalns et al 2005;Smith et al 2009). The marked differences observed in the treatment strategies for men and women have been partially explained by differences in disease severity, comorbid conditions, symptom presentation, and patient preferences for surgical or less aggressive forms of treatment (Vaccarino et al 2003;Anand et al 2005).…”

Age and sex interaction in reported help seeking in response to chest pain

“…Bond and colleagues previously examined the independent effects of both age and sex on the treatment of cardiac hospital patients in two district general hospitals. They reported that patients aged over 75 years, and women, independently, were significantly less likely to receive indicated interventions in one hospital; 1 and although significant age effects were found in the second hospital, there were fewer independent sex effects. 30 While the latter were all patients who had actually been referred (or admitted via emergency services) to specialist services, the reasons for the inequity experienced post-referral were unknown.…”

“…[1][2][3] Despite policies orientated specifically for the health and health care of older people emphasising equity, 4 age-related patterns of utilisation remain. 5 Coronary heart disease (CHD) is an important condition to consider; its risk increases with age, it remains the major cause of death in many countries, by 2020 it is predicted to be the leading cause of disease burden worldwide, 6 and, importantly, it has clear recommendations set out for appropriate treatment regimes.…”