Inequalities in access to coronary angiography and revascularisation: the association of deprivation and location of primary care services

Background. Coronary artery surgery reduces re-infarction rates and mortality in patients with ischaemic heart disease. This study examines inequality in relation to primary care services. Aim. To determine the effect of primary care services on access to coronary angiography and revascularisation. Method. A cross-sectional survey of all 180 Nottinghamshire practices in the Trent region that were in existence between 1993 and 1997. The numbers of coronary bypass grafts, angioplasties, and angiographies were determined from the regional National Health Service database and linked to a database of general practice characteristics. Poisson regression analysis was used to determine the relationship between the angiography and revascularisation rates and the following practice characteristics: deprivation score, distance from nearest secondary or tertiary referral centre, medical cardiology admission rate for ischaemic heart disease, fundholding status, and partnership size. Multiple linear regression analysis was used to determine the relationship between practice characteristics and the waiting times for revascularisation and angiography. Results. Practices with high deprivation scores had significantly lower rates of utilisation of angiography and revascularisation procedures. Their patients also waited longer for angiography. Practices that were 20 km or further from a revascularisation centre had significantly lower angiography and revascularisation rates. On average, their patients had to wait more than twice as long for an angiography compared with patients from nearer practices. Fundholding practices had higher angiography rates but similar revascularisation rates compared with non-fundholding practices. Conclusion. The results suggest that there may be some under-investigation and/or treatment of patients with ischaemic heart disease from 'deprived' practices and for those from practices far from a secondary or tertiary referral centre.