Heart disease mortality disparities remain despite universal health care

Patients and health care providers cannot rely on a national health care system to eliminate disparities in mortality rates from conditions such as heart disease, English researchers found.

Louis S. Levene, MB, BCHIR, of the University of Leicester, and colleagues conducted a cross-sectional study involving 152 primary care trusts to determine which factors account for variations in coronary heart disease (CHD) mortality rates observed among different regions of the country. The full study appears in the Nov. 10 issue of the Journal of the American Medical Association.

After a national policy to reduce CHD mortality rates was implemented, the researcher found that age-standardized CHD mortality rates dropped steadily from a mean of 97.9 per 100,000 in 2006 to 93.5 in 2007 and 88.4 in 2008 – accounting for a drop of about 5 per 100,000 population per year.  However, despite these improvements and access to universal health care, CHD mortality rates still varied by more than three standard deviations from the mean in some regions.

Using a hierarchical regression model, the researchers identified the following influential factors: sociodemograpic status as measured by an index of multiple deprivation; smoking; white ethnicity; and diabetes prevalence as recorded in patient registries. They warned that the inclusion of white ethnicity might be misleading and may be attributable to the higher level of hypertension detection among this population due to higher proportions of white individuals.

Levels of detected hypertension were the only practice-related factor negatively associated with CHD mortality (adjusted r2 = 0.66-0.68).

Based on these results, the researchers suggest that pay for performance incentive schemes that focus only on clinical management indicators may only have a limited affect on population outcomes such as mortality.

“Incentive schemes should be designed to promote systemic, population-wide identification of individuals at risk, as well as reward the appropriate care of individuals identified,” the researchers wrote.

An example of this would be an incentive scheme that encourages clinicians to invite patients to come in for hypertension screening, Aldo Maggioni, MD, director of the Italian Association of Hospital Cardiologists and a spokesperson for the European Society of Cardiology, suggested in a press release.

“However, in the United States and some Eastern European [countries], where there's no national health service, it's likely that variations in primary care services available to patients would have the biggest impact on CHD mortality,” Maggioni said.

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