Sekhri Neha, Timmis Adam, Hemingway Harry, Walsh Niamh, Eldridge Sandra, Junghans Cornelia, Feder Gene
Cardiac Directorate, Barts and the London NHS Trust, London, UK.
BMJ Open. 2012 Jun 14;2(3). doi: 10.1136/bmjopen-2012-001025. Print 2012.
To determine whether access to rapid access chest pain clinics of people with recent onset symptoms is equitable by age, socioeconomic status, ethnicity and gender, according to need.
Retrospective cohort study with ecological analysis.
Patients referred from primary care to five rapid access chest pain clinics in secondary care, across England.
Of 8647 patients aged ≥35 years referred to chest pain clinics with new-onset stable chest pain but no known cardiac history, 7570 with documented census ward codes, age, gender and ethnicity comprised the study group. Patients excluded were those with missing date of birth, gender or ethnicity (n=782) and those with missing census ward codes (n=295).
Effects of age, gender, ethnicity and socioeconomic status on clinic attendance were calculated as attendance rate ratios, with number of attendances as the outcome and resident population-years as the exposure in each stratum, using Poisson regression. Attendance rate ratios were then compared with coronary heart disease (CHD) mortality ratios to determine whether attendance was equitable according to need.
Adjusted attendance rate ratios for patients aged >65 years were similar to younger patients (1.1, 95% CI 1.05 to 1.16), despite population CHD mortality rate ratios nearly 15 times higher in the older age group. Women had lower attendance rate ratios (0.81, 95% CI 0.77 to 0.84) and also lower population CHD mortality rate ratios compared with men. South Asians had higher attendance rates (1.67, 95% CI 1.57 to 1.77) compared with whites and had a higher standardised CHD mortality ratio of 1.46 (95% CI 1.41 to 1.51). Although univariable analysis showed that the most deprived patients (quintile 5) had an attendance rate twice that of less deprived quintiles, the adjusted analysis showed their attendance to be 13% lower (0.87, 95% CI 0.81 to 0.94) despite a higher population CHD mortality rate.
There is evidence of underutilisation of chest pain clinics by older people and those from lower socioeconomic status. More robust and patient focused administrative pathways need to be developed to detect inequity, correction of which has the potential to substantially reduce coronary mortality.
根据需求，确定近期出现症状的人群进入快速胸痛诊所的机会在年龄、社会经济地位、种族和性别方面是否公平。
采用生态分析的回顾性队列研究。
从初级保健转诊至英格兰二级保健机构中五家快速胸痛诊所的患者。
在8647名年龄≥35岁、因新发稳定型胸痛但无已知心脏病史而被转诊至胸痛诊所的患者中，7570名具有登记的普查病房编码、年龄、性别和种族信息的患者组成了研究组。被排除的患者包括出生日期、性别或种族信息缺失者（n = 782）以及普查病房编码缺失者（n = 295）。
采用泊松回归，以就诊次数为观察指标，以各层的常住人口年数为暴露因素，计算年龄、性别、种族和社会经济地位对诊所就诊率的影响，以就诊率比表示。然后将就诊率比与冠心病（CHD）死亡率比进行比较，以确定就诊是否根据需求公平进行。
尽管老年人群的总体冠心病死亡率比几乎高出15倍，但65岁以上患者的调整后就诊率比与年轻患者相似（1.1，95%可信区间1.05至1.16）。与男性相比，女性的就诊率比更低（0.81，95%可信区间0.77至0.84），总体冠心病死亡率比也更低。与白人相比，南亚人的就诊率更高（1.67，95%可信区间1.57至1.77），标准化冠心病死亡率比为1.46（95%可信区间1.41至1.51）。尽管单变量分析显示最贫困患者（第5五分位数）的就诊率是较不贫困五分位数患者的两倍，但调整分析显示他们的就诊率低13%（0.87，95%可信区间0.81至0.94），尽管其总体冠心病死亡率更高。
有证据表明老年人和社会经济地位较低者对胸痛诊所的利用不足。需要制定更有力且以患者为中心的管理途径来发现不公平现象，纠正这种现象有可能大幅降低冠心病死亡率。
