Addressing the inverse care law in cardiac services.
BACKGROUND
Wide variation in rates of angiography and revascularization exist that are not explained by the level of need for these services. The National Service Framework for Coronary Heart Disease has set out a number of standards with the aim of increasing the number of revascularizations and reducing inequalities in access to care. In this study we aimed to investigate inequity in angiography and revascularization rates between the four Primary Care Group (PCG) areas in Camden and Islington Health Authority and to put in place measures to address the problems identified.


METHODS
Routinely available data were collected on all residents within Camden and Islington Health Authority undergoing angiography, angioplasty (PTCA) or coronary artery bypass grafting (CABG) between 1997 and 2001. These were used to calculate intervention rates per million population for each of the three procedures within each PCG. Semi-structured interviews were carried out with a sample of clinicians to explore their views on the provision of revascularization services within the Health Authority.


RESULTS
Angiography and revascularization rates varied widely between the four PCGs. In 2001 there was a two-fold difference for angiography and CABG and a 3.5-fold difference for PTCA. The variations were not explained by a measure of the level of need for these services. The highest rates were in the area with the lowest standardized mortality ratio for coronary heart disease. The interviews identified a number of possible explanations for the variations that related to differences in clinical behaviour atthe consultant level and barriers in access to interventional cardiology and cardiac services. Following this research, a further interventional cardiologist appointment is planned, joint protocols of care are being established and barriers to access are being addressed.


CONCLUSIONS
The new strategic health authorities should make it a priority to assess inequity in the provision of services within their areas, investigate the possible causes and support the primary care trusts to implement plans to address them.
London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT.
Sue
S
Langham
Ian
I
Basnett
Peter
P
McCartney
Charles
C
Normand
Julie
J
Pickering
Dilwyn
D
Sheers
Margaret
M
Thorogood
D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data*; D017023:Coronary Angiography / Q000706:statistics & numerical data*; D003327:Coronary Disease / Q000628:therapy*; D004739:England; D005260:Female; D006292:Health Priorities; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000458:organization & administration / Q000706:statistics & numerical data*; D013222:State Medicine