The impact of social deprivation on coronary revascularisation treatment outcomes within the National Health Service in England and Wales

Abstract

Background

There is strong evidence to suggest that social deprivation is linked to health inequalities. In the UK, concerns have been raised regarding disparities in the outcomes of acute cardiac services within the National Health Service (NHS). This study explored whether differences exist in (a) elective hospital presentation time (b) indicators of severity and disease burden and (c) treatment outcomes (hospital stay and mortality) on the basis of the index of multiple deprivation (IMD) status.

Design

This study was a retrospective analysis of data from NHS databases for 13,758 patients that had undergone cardiac revascularisation interventions at the Liverpool Heart and Chest Hospital between April 2007–March 2012.

Methods

The data was analysed by descriptive, univariate and multivariate statistics to explore the association between the IMD quintiles (Q1–Q5) and revascularisation type, elective presentation time, hospital length of stay and mortality.

Results and conclusions

Univariate analysis indicated that there were significant differences between patients from the most deprived areas (Q5) compared with patients from the least deprived areas (Q1), these included admission volumes, time before presentation to hospital and proportion of non-elective cases. After risk-adjustments, percutaneous coronary intervention patients from Q5 compared with Q1 had significantly greater length of hospital stay and risk of in-hospital major acute cardiovascular events. After multivariate adjustment for baseline risk factors, patients from Q5 were associated with significantly worse five-year survival as compared with Q1 (hazard ratio (HR) 1.52, 95% confidence interval (CI): 1.36–1.71; p < 0.001). In conclusion, there is evidence to suggest that inequalities in cardiac revascularisation choices and outcomes in the UK may be associated with social deprivation.

Keywords

Coronary heart disease index of multiple deprivation burden of disease cardiac interventions acute cardiac services

Get full access to this article

View all access options for this article.

References

Hippisley-Cox

Coupland

Vinogradova

. Predicting cardiovascular risk in England and Wales: Prospective derivation and validation of QRISK2. Br Med J 2008; 336: 1475–1482.

Tunstall-Pedoe

Woodward

. By neglecting deprivation, cardiovascular risk scoring will exacerbate social gradients in disease. Heart 2006; 92: 307–310.

Pearson-Stuttard

Bajekal

Scholes

. Recent UK trends in the unequal burden of coronary heart disease. Heart 2012; 98: 1573–1582.

Scarborough P, Bhatnagar P, Wickramasinghe K, et al. Coronary heart disease statistics 2010. London: British Heart Foundation.

Romeri

Baker

Griffiths

. Mortality by deprivation and cause of death in England and Wales 1999–2003. Health Stat Q 2006; 32: 19–34.

Hacking

Muller

Buchan

. Trends in mortality from 1965 to 2008 across the English north-south divide: Comparative observational study. Br Med J 2011; 342: d508–d508.

McCartney

Scarborough

Webster

. Trends in social inequalities for premature coronary heart disease mortality in Great Britain, 1994–2008: A time trend ecological study. Br Med J Open 2012; 2: e000737–e000737.

Taylor

Ascione

Rees

. Socioeconomic deprivation is a predictor of poor postoperative cardiovascular outcomes in patients undergoing coronary artery bypass grafting. Heart 2003; 89: 1062–1066.

Denvir

Lee

Rysdale

. Influence of socioeconomic status on clinical outcomes and quality of life after percutaneous coronary intervention. J Epidemiol Community Health 2006; 60: 1085–1088.

10.

Sekhri

Timmis

Chen

. Inequity of access to investigation and effect on clinical outcomes: Prognostic study of coronary angiography for suspected stable angina pectoris. Br Med J 2008; 336: 1058–1061.

11.

Alter

Iron

Austin

. for the SESAMI Study Group. Socioeconomic status, service patterns, and perceptions of care among survivors of acute myocardial infarction in Canada. JAMA 2004; 291: 1100–1107.

12.

Barakat

Wells

Ramdhany

. Bangladeshi patients present with non-classic features of acute myocardial infarction and are treated less aggressively in east London. Heart 2003; 89: 276–279.

13.

Pagano

Bridgewater

Ray

. on behalf of the Quality and Outcomes Research Unit (QuORU) UHB Birmingham and the North West Quality Improvement Programme in Cardiac Interventions (UKNWQIP). Social deprivation and prognostic benefits of cardiac surgery: Observational study of 44902 patients from five hospitals over 10 years. Br Med J 2009; 338: 1–6.

14.

Rosenfeldt

Wilson

Buxton

. Coronary artery bypass surgery provides long-term results superior to percutaneous coronary intervention. Heart Lung Circ 2012; 21: 1–11.

15.

Curtis

Southall

Congdon

. Area effects on health variation over the life-course: Analysis of the longitudinal study sample in England using new data on area of residence in childhood. Soc Sci Med 2004; 58: 57–74.

16.

Cox

. Low-dose nonlinear effects of smoking on coronary heart disease risk. Dose Response 2012; 10: 219–232.

17.

Department for Communities and Local Government. The English indices of deprivation 2010, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/6871/1871208.pdf (accessed 26 June 2011).

18.

National Assembly for Wales. The Welsh Index of Multiple Deprivation, Local Government Data Unit, the National Assembly for Wales: Cardiff. http://wales.gov.uk/statistics-and-research/welsh-index-multiple-deprivation/?lang=en (2010, accessed 26 June 2011).

19.

Nashef

Roques

Michel

. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999; 16: 9–13.

20.

Grayson

Moore

Jackson

. on behalf of the North West Quality Improvement Programme in Cardiac Interventions (NWQIP). Multivariate prediction of major adverse cardiac events after 9914 percutaneous coronary interventions in the north west of England. Heart 2006; 92: 658–663.

21.

Health and Social Care Information Centre portal. http://systems.hscic.gov.uk/. (accessed 3 May 2013).

22.

Davies

Dundas

Leyland

. Increasing socioeconomic inequalities in first acute myocardial infarction in Scotland, 1990–92 and 2000–02. BMC Public Health 2009; 9: 134–134.

23.

Leslie

Rysdale

Lee

. Unemployment and deprivation are associated with a poorer outcome following percutaneous coronary angioplasty. Int J Cardiol 2007; 122: 168–169.

24.

Ancona

Agabiti

Forastiere

. Coronary artery bypass graft surgery: Socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy. J Epidemiol Community Health 2000; 54: 930–935.

25.

Reid

Cook

Whincup

. Use of statins in the secondary prevention of coronary heart disease: Is treatment equitable? Heart 2002; 88: 15–19.

26.

Majeed

Moser

Maxwell

. Age, sex and practice variations in the use of statins in general practice in England and Wales. J Public Health Med 2000; 22: 275–279.

27.

Piepoli

Corrà

Adamopoulos

. Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: A policy statement from the Cardiac Rehabilitation Section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology. Eur J Prev Cardiol 2014; 21: 664–681.

28.

Blais

Hamel

Rinfret

. Impact of socioeconomic deprivation and area of residence on access to coronary revascularization and mortality after a first acute myocardial infarction in Québec. Can J Cardiol 2012; 28: 169–177.