Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris

Q: What are the key findings of this study?

Not undergoing appropriate coronary angiography for suspected stable angina was associated with a higher risk of coronary mortality or acute coronary syndrome.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Suspected stable angina pectoris deemed appropriate for coronary angiography (n=1375). Intervention: Non-receipt of appropriate coronary angiography (and demographic exposures: older age >64, female sex, South Asian ethnicity, socioeconomic deprivation) vs. Receipt of appropriate coronary angiography within 3 years of index clinic visit (and reference groups: age <50, men, white ethnicity, less deprived fifths 1-4). Primary outcome: Combined endpoint of death from coronary heart disease (ICD-10 I20-I25) and hospital admission for acute coronary syndromes (acute myocardial infarction or unstable angina) within 5 years (HR 1.71, 95% CI 1.24-2.34).

Q: What does this research mean for the field?

Failing to undergo appropriate coronary angiography in patients presenting with suspected stable angina is associated with a significantly higher risk of coronary mortality or acute coronary syndrome. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Neha Sekhri; Adam Timmis; Ruoling Chen; Cornelia Junghans; Niamh Walsh; Justin Zaman; Sandra Eldridge; Harry Hemingway; Gene Feder

doi:10.1136/bmj.39534.571042.be

April 24, 2008BMJOpen Access

Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris

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Key result

Omitting appropriate coronary angiography for stable angina is linked to ~71% higher coronary mortality or ACS.

HR 1.71
95% CI 1.24-2.34
n=1,375

Why the study?

Is appropriate coronary angiography for suspected stable angina underused in older patients, women, South Asian patients, and socioeconomically deprived patients, and is non-receipt of appropriate angiography associated with higher rates of coronary mortality and acute coronary syndrome events?

Key Points

To determine whether coronary angiography for suspected stable angina pectoris is underused in older patients, women, south Asian patients, and socioeconomically deprived groups, and whether underuse worsens coronary outcomes.
Multicentre cohort study of 1375 consecutive patients across six ambulatory care clinics in England rated as appropriate for coronary angiography by the Rand consensus method, followed for 5 years.
Tracked receipt of angiography within 3 years (420 procedures performed) and incidence of coronary events (non-fatal acute coronary syndrome or coronary heart disease death) over 5 years.
Multivariable survival analyses adjusted for age, sex, ethnicity, socioeconomic deprivation quintile, secondary prevention medications (aspirin, beta-blockers, statins), and exercise ECG results.
Angiography was significantly less likely in patients aged >=65 versus <=49 (adjusted HR 0.60, 95% CI 0.38 to 0.96; P=0.031), women versus men (HR 0.42, 95% CI 0.35 to 0.50; P<0.001), south Asian versus white patients (HR 0.48, 95% CI 0.34 to 0.67; P<0.001), and the most deprived quintile versus others (HR 0.66, 95% CI 0.40 to 1.08; P=0.099).
Coronary event risk among patients who did not undergo appropriate angiography was notably higher in women (adjusted HR 2.75, 95% CI 1.52 to 5.00; P=0.001), men (HR 1.90, 95% CI 1.12 to 3.22; P=0.017), and those aged <=49 (HR 3.30, 95% CI 1.70 to 6.43; P<0.001).

Study Design

Type

Cohort (n=1,375)

Multicenter

Yes

Structured PICO

Is appropriate coronary angiography for suspected stable angina underused in older patients, women, South Asian patients, and socioeconomically deprived patients, and is non-receipt of appropriate angiography associated with higher rates of coronary mortality and acute coronary syndrome events?

P

Population

1,375 consecutive white or south Asian adults with suspected stable angina and no prior known coronary disease attending six rapid access chest pain clinics in England who were rated appropriate for coronary angiography, followed for up to 5 years (average 3 years).

E

Exposure

Exposure 1 (Access analysis): Demographic factors including age ≥65 years, female sex, South Asian ethnicity, and socioeconomic deprivation (most deprived fifth of Townsend index). Exposure 2 (Prognostic analysis): Not undergoing coronary angiography within 3 years despite being rated appropriate.

C

Comparator

Comparator 1 (Access analysis): Age <50 years, male sex, white ethnicity, and less deprived four fifths (1-4). Comparator 2 (Prognostic analysis): Receipt of coronary angiography within 3 years of index clinic attendance (n=420, 31%).

O

Outcome

1) Receipt of coronary angiography within 3 years of index clinic visit (420 procedures); 2) Combined clinical endpoint of death from coronary heart disease (ICD-10 I20-I25) and hospital admission for non-fatal acute coronary syndromes (acute myocardial infarction I21-I23 and unstable angina I20.0-I20.9, I24.0, I24.8, I24.9) within 5 years of index clinic visit.composite

Main Result

Hazard Ratio: 1.71 (95% CI 1.24–2.34)

Absolute Event Rate: 19.2% vs 11.2%

Demonstrates that underuse of clinically appropriate coronary angiography in women, older adults, South Asians, and socioeconomically deprived patients with suspected stable angina is directly associated with a higher risk of subsequent coronary mortality and acute coronary syndrome events.

Limitations

Broad classification of ethnicity assigned by clinicians rather than self-reported
Socioeconomic deprivation measured at the ward level (Townsend score) rather than individual level, creating potential for ecological fallacy
Did not assess potential inequities in initial referral from primary care to rapid access chest pain clinics
Canadian Cardiovascular Society (CCS) angina class was not recorded and had to be assumed in analyses
Broad classification of ethnicity ascribed by assessing clinicians rather than patient self-report
Use of ward-level Townsend score for socioeconomic deprivation rather than individual-level socioeconomic data, which is prone to the ecological fallacy
Did not assess potential inequities in primary care referral into rapid access chest pain clinics
Canadian Cardiovascular Society (CCS) angina functional class was not recorded in the cohort and had to be assumed as class I-II (with sensitivity analysis for class III-IV)

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Implication

May signal need for disparity-reducing strategies in stable angina care; leaves open whether angiography receipt causally lowers event rates.

Abstract

OBJECTIVES: To determine whether coronary angiography for suspected stable angina pectoris is underused in older patients, women, south Asian patients, and those from socioeconomically deprived areas, and, if it is, whether this is associated with higher coronary event rates. DESIGN: Multicentre cohort with five year follow-up. SETTING: Six ambulatory care clinics in England. PARTICIPANTS: 1375 consecutive patients in whom coronary angiography was individually rated as appropriate with the Rand consensus method. MAIN OUTCOME MEASURES: Receipt of angiography (420 procedures); coronary mortality and acute coronary syndrome events. RESULTS: In a multivariable analysis, angiography was less likely to be performed in patients aged over 64 compared with those aged under 50 (hazard ratio 0.60, 95% confidence interval 0.38 to 0.96), women compared with men (0.42, 0.35 to 0.50), south Asians compared with white people (0.48, 0.34 to 0.67), and patients in the most deprived fifth compared with the other four fifths (0.66, 0.40 to 1.08). Not undergoing angiography when it was deemed appropriate was associated with higher rates of coronary event. CONCLUSIONS: At an early stage after presentation with suspected angina, coronary angiography is underused in older people, women, south Asians, and people from deprived areas. Not receiving appropriate angiography was associated with a higher risk of coronary events in all groups. Interventions based on clinical guidance that supports individualised management decisions might improve access and outcomes.

Discussion

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Cite This Study

Sekhri et al. (2008) conducted a cohort in Suspected stable angina pectoris deemed appropriate for coronary angiography (n=1,375). Non-receipt of appropriate coronary angiography (and demographic exposures: older age >64, female sex, South Asian ethnicity, socioeconomic deprivation) vs. Receipt of appropriate coronary angiography within 3 years of index clinic visit (and reference groups: age <50, men, white ethnicity, less deprived fifths 1-4) was evaluated on Combined endpoint of death from coronary heart disease (ICD-10 I20-I25) and hospital admission for acute coronary syndromes (acute myocardial infarction or unstable angina) within 5 years (HR 1.71, 95% CI 1.24-2.34). Not undergoing appropriate coronary angiography for suspected stable angina was associated with a higher risk of coronary mortality or acute coronary syndrome.

synapsesocial.com/papers/6a777525a7498e5110ae940a https://doi.org/10.1136/bmj.39534.571042.be

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Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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