King William, Lacey Arron, White James, Farewell Daniel, Dunstan Frank, Fone David
Aneurin Bevan Gwent Local Public Health Team, Public Health Wales, Newport, Wales, United Kingdom.
College of Medicine, Swansea University, Swansea, Wales, United Kingdom.
PLoS One. 2017 Mar 16;12(3):e0172618. doi: 10.1371/journal.pone.0172618. eCollection 2017.
Despite substantial falls in coronary heart disease (CHD) mortality in the United Kingdom (UK), marked socioeconomic inequalities in CHD risk factors and CHD mortality persist. We investigated whether inequity in CHD healthcare in Wales (UK) could contribute to the observed social gradient in CHD mortality.
Linking data from primary and secondary care we constructed an electronic cohort of individuals (n = 1199342) with six year follow-up, 2004-2010. We identified indications for recommended CHD interventions, measured time to their delivery, and estimated risk of receiving the interventions for each of five ordered deprivation groups using a time-to-event approach with Cox regression frailty models. Interventions in primary and secondary prevention included risk-factor measurement, smoking management, statins and antihypertensive therapy, and in established CHD included medication and revascularization. For primary prevention, five of the 11 models favoured the more deprived and one favoured the less deprived. For medication in secondary prevention and established CHD, one of the 15 models favoured the more deprived and one the less deprived. In relation to revascularization, six of the 12 models favoured the less deprived and none favoured the more deprived-this evidence of inequity exemplified by a hazard ratio for revascularization in stable angina of 0.79 (95% confidence interval 0.68, 0.92). The main study limitation is the possibility of under-ascertainment or misclassification of clinical indications and treatment from variability in coding.
Primary care components of CHD healthcare were equitably delivered. Evidence of inequity was found for revascularization procedures, although this inequity is likely to have only a modest effect on social gradients in CHD mortality. Policymakers should focus on reducing inequalities in CHD risk factors, particularly smoking, as these, rather than inequity in healthcare, are likely to be key drivers of inequalities in CHD mortality.
尽管英国冠心病（CHD）死亡率大幅下降，但冠心病危险因素和冠心病死亡率方面显著的社会经济不平等现象依然存在。我们调查了威尔士（英国）冠心病医疗保健方面的不公平现象是否会导致观察到的冠心病死亡率的社会梯度差异。
我们将初级和二级医疗保健数据相链接，构建了一个包含1199342人的电子队列，并在2004年至2010年期间进行了六年随访。我们确定了推荐的冠心病干预措施的指征，测量了实施干预的时间，并使用带有Cox回归脆弱模型的事件发生时间方法，估计了五个有序贫困组中每组接受干预的风险。初级和二级预防干预措施包括危险因素测量、吸烟管理、他汀类药物和抗高血压治疗，而在已确诊的冠心病中，干预措施包括药物治疗和血运重建。对于一级预防，11个模型中有5个更倾向于贫困程度较高的人群，1个更倾向于贫困程度较低的人群。对于二级预防和已确诊冠心病的药物治疗，15个模型中有1个更倾向于贫困程度较高的人群，1个更倾向于贫困程度较低的人群。在血运重建方面，12个模型中有6个更倾向于贫困程度较低的人群，没有一个模型更倾向于贫困程度较高的人群——这种不公平现象的证据表现为稳定型心绞痛患者血运重建的风险比为0.79（95%置信区间0.68, 0.92）。主要研究局限性在于，由于编码的变异性，临床指征和治疗可能存在未充分确定或错误分类的情况。
冠心病医疗保健的初级保健部分得到了公平提供。在血运重建程序方面发现了不公平现象的证据，尽管这种不公平现象可能对冠心病死亡率的社会梯度差异影响不大。政策制定者应专注于减少冠心病危险因素方面的不平等现象，尤其是吸烟，因为这些因素而非医疗保健方面的不平等，可能是冠心病死亡率不平等的关键驱动因素。
