title: Community care in England: reducing socioeconomic inequalities in heart failure.
abstract: BACKGROUND
  Socioeconomic deprivation is associated with increased heart failure (HF) incidence, hospitalization rates, and mortality. However, whether the delivery of survival-enhancing medical therapy is equitable remains uncertain. We examined secular trends in the uptake of key medical therapies (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, spironolactone) stratified by socioeconomic circumstances in patients with HF. Secondary analyses examined trends in HF incidence, prevalence, and survival.
  
  
  RESULTS
  This study was a cross-sectional observational analysis of nationally representative primary care data from England. Treatments for patients with HF in 1999 and 2007 (n=13 330) were extracted from the General Practice Research Database. Socioeconomic circumstances were defined with the Index of Multiple Deprivation 2007, a weighted composite of 7 area-level deprivation domains. Treatment uptake estimates were age standardized. The incidence and prevalence of HF decreased year to year. Although clear socioeconomic gradients in both the incidence and prevalence of HF were apparent, the absolute difference between most and least deprived reduced over time. Uptake of therapies improved over time in both men and women. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker uptake increased from 46% to 64%, β-blocker uptake from 12% to 41%, and spironolactone uptake from 3% to 20%. Modest age and sex inequalities were apparent. However, no consistent socioeconomic gradients were observed in either treatment or case fatality.
  
  
  CONCLUSIONS
  Socioeconomic gradients in the incidence and prevalence of HF are reducing. Treatment is generally equitable and independent of socioeconomic circumstances. Most important, no significant inequality in outcomes was apparent. Future strategies should continue to address inequalities in the underlying causes of HF and to increase overall treatment levels further.
authors: Institute of Cardiovascular Medicine and Sciences, Liverpool Heart and Chest Hospital, Thomas Dr., Liverpool, UK. nathawkins@hotmail.com
authors: Nathaniel M
authors: NM
authors: Hawkins
authors: Shaun
authors: S
authors: Scholes
authors: Madhavi
authors: M
authors: Bajekal
authors: Hande
authors: H
authors: Love
authors: Martin
authors: M
authors: O'Flaherty
authors: Rosalind
authors: R
authors: Raine
authors: Simon
authors: S
authors: Capewell
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057911:Angiotensin Receptor Antagonists / Q000191:economics / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000191:economics / Q000627:therapeutic use; D002317:Cardiovascular Agents / Q000191:economics / Q000627:therapeutic use; D003153:Community Health Services / Q000191:economics / Q000706:statistics & numerical data*; D004363:Drug Utilization / Q000706:statistics & numerical data; D004739:England; D005260:Female; D006305:Health Status Indicators; D054625:Healthcare Disparities / Q000191:economics / Q000706:statistics & numerical data*; D006333:Heart Failure / Q000191:economics / Q000453:epidemiology* / Q000209:etiology; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D000451:Mineralocorticoid Receptor Antagonists / Q000191:economics / Q000627:therapeutic use; D009313:National Health Programs / Q000191:economics / Q000706:statistics & numerical data*; D011203:Poverty; D015995:Prevalence; D012959:Socioeconomic Factors; D013148:Spironolactone / Q000191:economics / Q000627:therapeutic use; D015996:Survival Rate
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D002317:Cardiovascular Agents; D000451:Mineralocorticoid Receptor Antagonists; D013148:Spironolactone