Population need for coronary revascularisation: are national targets for England credible?
OBJECTIVE
To estimate the need for coronary revascularisation, by using an incidence of indications approach, among 45-84 year olds with stable angina, unstable angina, and acute myocardial infarction.


METHODS
Modelling exercise. Six key steps along the pathway of care from initial diagnosis in primary or secondary care to revascularisation were defined and the frequency of indications estimated using routine data from hospital admissions and data from studies in the general population, and primary and secondary care.


METHODS
Mid-1998 population of England.


METHODS
Coronary revascularisation.


METHODS
Ability to benefit (need), defined by randomised trials, expert panel ratings from the ACRE (appropriateness of coronary revascularisation) study, or by informal consensus.


RESULTS
The need for coronary revascularisation was estimated to be 92 000 procedures, equivalent to a rate of 1861 per million population. Overall, the model of need exceeded current provision by 3.3:1, although among people aged 75 years and over the ratio was 7.7:1. A plausible upper estimate of need--obtained by assuming that 90% of patients with stable angina were referred from primary care and that angiography would be performed in 65% of patients with acute myocardial infarction and 75% of patients with unstable angina--was 2626 per million population.


CONCLUSIONS
The national target of 1500 revascularisation procedures per million population is credibly related to population need, although upper estimates of need are considerably higher. Better understanding is required of the benefits of referring patients with specific indications from primary care. The greatest relative increase in provision is required for those aged 75 and older, among whom trial evidence of benefit is scant.
Martin
R M
RM
Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol, UK. richard.martin@bristol.ac.uk
Hemingway
H
H
Gunnell
D
D
Karsch
K R
KR
Baumbach
A
A
Frankel
S
S
D000368:Aged; D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000453:epidemiology / Q000601:surgery*; D000789:Angina, Unstable / Q000453:epidemiology / Q000601:surgery; D002908:Chronic Disease; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D009203:Myocardial Infarction / Q000453:epidemiology / Q000601:surgery*; D009204:Myocardial Revascularization / Q000706:statistics & numerical data*; D020380:Needs Assessment; D010343:Patient Admission / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012680:Sensitivity and Specificity