Objectives To determine whether coronary angiography for suspected stable angina pectoris is underused in older patients, women, south Asian patients, and those from socioeconomically deprived areas, and, if it is, whether this is associated with higher coronary event rates. Design Multicentre cohort with five year follow-up. Setting Six ambulatory care clinics in England. Participants 1375 consecutive patients in whom coronary angiography was individually rated as appropriate with the Rand consensus method. Main outcome measures Receipt of angiography (420 procedures); coronary mortality and acute coronary syndrome events.Results In a multivariable analysis, angiography was less likely to be performed in patients aged over 64 compared with those aged under 50 (hazard ratio 0.60, 95% confidence interval 0.38 to 0.96), women compared with men (0.42, 0.35 to 0.50), south Asians compared with white people (0.48, 0.34 to 0.67), and patients in the most deprived fifth compared with the other four fifths (0.66, 0.40 to 1.08). Not undergoing angiography when it was deemed appropriate was associated with higher rates of coronary event.Conclusions At an early stage after presentation with suspected angina, coronary angiography is underused in older people, women, south Asians, and people from deprived areas. Not receiving appropriate angiography was associated with a higher risk of coronary events in all groups. Interventions based on clinical guidance that supports individualised management decisions might improve access and outcomes.
ObjectivesTo 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.DesignRetrospective cohort study with ecological analysis.SettingPatients referred from primary care to five rapid access chest pain clinics in secondary care, across England.ParticipantsOf 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).Outcome measuresEffects 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.ResultsAdjusted 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.ConclusionThere 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.
Clinical studies on the use and activity of drugs often rely on data generated from a relatively small number of patients, and definitive conclusions are drawn that are assumed to represent the population at large. Similarly, interpretation and comparison of studies are made difficult when end points of effectiveness, particularly with antihypertensive agents, are arbitrarily chosen. The results from a clinical study of more than 1400 hypertensive patients after indapamide therapy for 3 months, alone or in combination with a beta blocker, are presented using a different graphic approach. This is based on the assumption that the magnitude of the fall in blood pressure after hypertensive therapy is dependent on initial blood pressure. Diastolic and systolic pressures were plotted as a scattergram against the change in blood pressure. Predetermined response lines were drawn with a slope of 1 and intercepts on the initial blood pressure axis of 90 mm Hg for diastolic and 140 mm Hg for systolic pressures with tolerance limits of ± 10 mm Hg drawn about it. Subdivisions of response can be achieved by counting the number of patients above and below these lines. This allows a drug to be "finger-printed" in terms of its pattern of activity in all degrees of severity of hypertension and, more relevant, direct comparisons with other drugs can be made. Similarly, the potential activity of the drug can be determined by computing the slope and intercept of the actual regression line through the data points. Using this approach, indapamide, at a fixed dosage of 2.5 mg/day, was shown to be an effective antihypertensive agent in all degrees of hypertension, in young and elderly patients. This analytical approach can also be used for other therapeutic classes of drugs. (
Challenges exist in respect of people with intellectual disabilities who, with the increasing life expectancy, have a growing risk of age-related degenerative conditions. Changes in bone health are associated with increasing age and the bone health of people who have intellectual disabilities is well documented in the literature as being poor in comparison to the general population. A heel scan clinic was set up in an intellectual disability service as a service improvement initiative. There were 12 females and 17 males scanned using a heel scanner. Only 3 (10.3%) people with intellectual disabilities were in the normal bone mineral density (BMD) range. Peripheral BMD screening for people has been shown to provide important information about the bone health of people with intellectual disabilities which has prompted further treatment by general practitioners and has the potential to provide an accessible way to obtain information on the bone health of people with intellectual disabilities.
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