5 Implications of findings
The analysis of routinely available data up to the end of March 2000 provides a picture of the use of revascularisation in the South West and the progress that has been made over the last decade.
Although encouraging improvements in the rates of revascularisation are apparent since 1991, it appears that older people and women are probably receiving less revascularisation than their need would indicate. This implies that there is a substantial 'iceberg' of unmet need which requires further investigation as the implications for service delivery of attempting to meet the scale of need identified are great.
In both men and women, it appears that revascularisation accounting for need is less often provided to those living in the least deprived areas, suggesting an 'inverse care law' is operating (Tudor Hart, 1971). These patterns may reflect geographically based patterns of service contracts or clinical patterns of referral and treatment. A more definitive explanation for this mismatch would involve assessing the appropriateness of intervention, using a consensus approach, from a stratified random sample of cases of IHD who have received an intervention and those who have not, by area deprivation. Such a study would establish whether or not residents of poorer areas are being under treated and the possible reasons (e.g. less likely to be referred to a cardiologist acutely, less likely to be investigated by angiography, less likely to be offered angioplasty or CABG).
The lack of comparable data from the private sector is a serious problem in attempting to plan provision. A reporting system for revascularisation procedures performed in the private sector is needed.
In the interim, clear guidelines relating to pathways of care and appropriateness of intervention should be established and future trends monitored to assess whether such protocols have any effect on current inequities in health care provision for IHD. This approach has been shown in a previous large trial of high blood pressure management to reduce inequalities in mortality rates in groups differing on educational level and ethnicity (Hypertension Detection and Follow Up Program, 1979).
No evidence of inequity in revascularisation among rural and urban parts of the South West was found after taking need into account.
No evidence of proximity to revascularisation services affecting revascularisation rates was found. PTCA rates were lower than expected in Avon. It is possible that private sector PTCAs in Avon are substituting for NHS activity. A further possibility is that Avon residents living in more deprived areas may be slipping down the waiting list to be overtaken by those living in more affluent areas.
Estimates of need based on alternative models using different assumptions arrive at similar conclusions both in terms of the need for much more revascularisation and fairly similar targets of provision which should meet need and improve equity.
There is major underprovision of cardiological services in terms of consultants and adult ITU facilities. A substantial proportion of revascularisation is being conducted outside the South West region. Plans are already advanced for establishing a third centre which would aim to provide the services currently performed elsewhere.
