title: The UK National Health Service: delivering equitable treatment across the spectrum of coronary disease.
abstract: BACKGROUND
  Social gradients in cardiovascular mortality across the United Kingdom may reflect differences in incidence, disease severity, or treatment. It is unknown whether a universal healthcare system delivers equitable lifesaving medical therapy for coronary heart disease. We therefore examined secular trends in the use of key medical therapies stratified by socioeconomic circumstances across a broad spectrum of coronary disease presentations, including acute coronary syndromes, secondary prevention, and clinical angina.
  
  
  RESULTS
  This was a cross-sectional observational analysis of nationally representative primary and secondary care data from the United Kingdom. Data on treatments for all myocardial infarction patients in 2003 and 2007 were derived from the Myocardial Ischemia National Audit Project (n=51 755). Data on treatments for patients with chronic angina (n=33 211) or requiring secondary prevention (n=32 976) in 1999 and 2007 were extracted from the General Practice Research Database. Socioeconomic circumstances were defined using a weighted composite of 7 area-level deprivation domains. Treatment estimates were age-standardized. Use of all therapies increased in all patient groups, both men and women. Improvements were most marked in primary care, where use of β-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for secondary prevention and treatment of angina doubled, from ≈30% to >60%. Small age gradients persisted for some therapies. No consistent socioeconomic gradients or sex differences were observed for myocardial infarction and postrevascularization (hard diagnoses). However, some sex inequality was apparent in the treatment of younger women with angina.
  
  
  CONCLUSIONS
  Cardiovascular treatment is generally equitable and independent of socioeconomic circumstances. Future strategies should aim to further increase overall treatment levels and to eradicate remaining age and sex inequalities.
authors.affiliation: Institute of Cardiovascular Medicine and Sciences, Liverpool Heart and Chest Hospital, Liverpool, UK. nathawkins@hotmail.com
authors.forename: Nathaniel M
authors.initials: NM
authors.lastname: Hawkins
authors.forename: Shaun
authors.initials: S
authors.lastname: Scholes
authors.forename: Madhavi
authors.initials: M
authors.lastname: Bajekal
authors.forename: Hande
authors.initials: H
authors.lastname: Love
authors.forename: Martin
authors.initials: M
authors.lastname: O'Flaherty
authors.forename: Rosalind
authors.initials: R
authors.lastname: Raine
authors.forename: Simon
authors.initials: S
authors.lastname: Capewell
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000367:Age Factors; D000368:Aged; D000787:Angina Pectoris / Q000188:drug therapy; D047228:Angiotensin II Type 1 Receptor Blockers / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D003327:Coronary Disease / Q000188:drug therapy* / Q000401:mortality; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000639:trends*; D005260:Female; D019538:Health Care Surveys; D054625:Healthcare Disparities / Q000639:trends*; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy; D010043:Outcome and Process Assessment, Health Care / Q000639:trends*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D010818:Practice Patterns, Physicians' / Q000639:trends*; D011320:Primary Health Care / Q000639:trends; D063127:Secondary Health Care / Q000639:trends; D055502:Secondary Prevention / Q000639:trends*; D012737:Sex Factors; D012959:Socioeconomic Factors; D013222:State Medicine / Q000639:trends*; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology
chemical_list: D000319:Adrenergic beta-Antagonists; D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D002317:Cardiovascular Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors