title: Equity in healthcare for coronary heart disease, Wales (UK) 2004-2010: A population-based electronic cohort study.
abstract: BACKGROUND
  Despite substantial falls in coronary heart disease (CHD) mortality in the United Kingdom (UK), marked socioeconomic inequalities in CHD risk factors and CHD mortality persist. We investigated whether inequity in CHD healthcare in Wales (UK) could contribute to the observed social gradient in CHD mortality.
  
  
  RESULTS
  Linking data from primary and secondary care we constructed an electronic cohort of individuals (n = 1199342) with six year follow-up, 2004-2010. We identified indications for recommended CHD interventions, measured time to their delivery, and estimated risk of receiving the interventions for each of five ordered deprivation groups using a time-to-event approach with Cox regression frailty models. Interventions in primary and secondary prevention included risk-factor measurement, smoking management, statins and antihypertensive therapy, and in established CHD included medication and revascularization. For primary prevention, five of the 11 models favoured the more deprived and one favoured the less deprived. For medication in secondary prevention and established CHD, one of the 15 models favoured the more deprived and one the less deprived. In relation to revascularization, six of the 12 models favoured the less deprived and none favoured the more deprived-this evidence of inequity exemplified by a hazard ratio for revascularization in stable angina of 0.79 (95% confidence interval 0.68, 0.92). The main study limitation is the possibility of under-ascertainment or misclassification of clinical indications and treatment from variability in coding.
  
  
  CONCLUSIONS
  Primary care components of CHD healthcare were equitably delivered. Evidence of inequity was found for revascularization procedures, although this inequity is likely to have only a modest effect on social gradients in CHD mortality. Policymakers should focus on reducing inequalities in CHD risk factors, particularly smoking, as these, rather than inequity in healthcare, are likely to be key drivers of inequalities in CHD mortality.
authors.affiliation: Aneurin Bevan Gwent Local Public Health Team, Public Health Wales, Newport, Wales, United Kingdom.
authors.forename: William
authors.identifier: http://orcid.org/0000-0003-4341-5620
authors.initials: W
authors.lastname: King
authors.affiliation: College of Medicine, Swansea University, Swansea, Wales, United Kingdom.
authors.forename: Arron
authors.identifier: http://orcid.org/0000-0001-7983-8073
authors.initials: A
authors.lastname: Lacey
authors.affiliation: Centre for the Development and Evaluation of Complex Public Health Interventions and South East Wales Trials Unit, Cardiff University, Wales, United Kingdom.
authors.forename: James
authors.initials: J
authors.lastname: White
authors.affiliation: Division of Population Medicine, Cardiff University, Cardiff, Wales, United Kingdom.
authors.forename: Daniel
authors.identifier: http://orcid.org/0000-0002-8871-1653
authors.initials: D
authors.lastname: Farewell
authors.affiliation: Division of Population Medicine, Cardiff University, Cardiff, Wales, United Kingdom.
authors.forename: Frank
authors.identifier: http://orcid.org/0000-0002-1043-5281
authors.initials: F
authors.lastname: Dunstan
authors.affiliation: Division of Population Medicine, Cardiff University, Cardiff, Wales, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: Fone
mesh_terms: D015331:Cohort Studies; D003327:Coronary Disease / Q000628:therapy*; D057286:Electronic Health Records; D049674:History, 21st Century; D006801:Humans; D012307:Risk Factors; D012923:Social Class; D012935:Social Justice; D014852:Wales