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Does access to cardiac investigation and treatment contribute to social and ethnic differences in coronary heart disease? Whitehall II prospective cohort study

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.38156.690150.AE (Published 05 August 2004) Cite this as: BMJ 2004;329:318
  1. Annie Britton, lecturer in epidemiology1,
  2. Martin Shipley, senior lecturer in medical statistics1,
  3. Michael Marmot, professor of epidemiology and public health1,
  4. Harry Hemingway (h.hemingway{at}ucl.ac.uk), reader in clinical epidemiology1
  1. 1 International Centre for Health and Society, Department of Epidemiology and Public Health, University College London Medical School, London WC1E 6BT
  1. Correspondence to: H Hemingway
  • Accepted 25 May 2004

Abstract

Objective To determine whether access to cardiac procedures and drugs contributes to social and ethnic differences in coronary heart disease in a population setting.

Design Prospective study with follow up over 15 years. Civil service employment grade was used as a measure of individual socioeconomic position. Need for cardiac care was determined by the presence of angina, myocardial infarction, and coronary risk factors.

Setting 20 civil service departments originally located in London.

Participants 10 308 civil servants (3414 women; 560 South Asian) aged 35-55 years at baseline in 1985-8.

Main outcome measures Use of exercise electrocardiography, coronary angiography, and coronary revascularisation procedures and secondary prevention drugs.

Results Inverse social gradients existed in incident coronary morbidity and mortality. South Asian participants also had higher rates than white participants. After adjustment for clinical need, social position showed no association with the use of cardiac procedures or secondary prevention drugs. For example, men in the low versus high employment grade had an age adjusted odds ratio for angiography of 1.87 (95% confidence interval 1.32 to 2.64), which decreased to 1.27 (0.83 to 1.94) on adjustment for clinical need. South Asians tended to be more likely to have cardiac procedures and to be taking more secondary prevention drugs than white participants, even after adjustment for clinical need.

Conclusion This population based study, which shows the widely observed social and ethnic patterning of coronary heart disease, found no evidence that low social position or South Asian ethnicity was associated with lower use of cardiac procedures or drugs, independently of clinical need. Differences in medical care are unlikely to contribute to social or ethnic differences in coronary heart disease in this cohort.

Footnotes

  • Embedded Image An additional table is on bmj.com

    Professor Peter W Macfarlane of the Royal Infirmary, Glasgow, reviewed all the electrocardiographs. We thank all participating civil service departments and their welfare, personnel, and establishment officers; the Occupational Health and Safety Agency; the Council of Civil Service Unions; all participating civil servants in the Whitehall II study; and all members of the Whitehall II study team.

  • Contributors AB and HH had the idea for the study. AB wrote the first draft and incorporated comments from all co-authors. MS did all statistical analyses. AB is the guarantor.

  • Funding The Whitehall II study has been supported by grants from the Medical Research Council; British Heart Foundation; Health and Safety Executive; Department of Health; National Heart Lung and Blood Institute (HL36310), US, NIH; National Institute on Aging (AG13196), US, NIH; Agency for Health Care Policy Research (HS06516); and the John D and Catherine T MacArthur Foundation Research Networks on Successful Midlife Development and Socioeconomic Status and Health. AB and MS are supported by the British Heart Foundation. HH is supported by a public health career scientist award from the Department of Health. MM is supported by an MRC research professorship.

  • Competing interests None declared.

  • Ethical approval Each phase of the Whitehall II study has received ethical approval from the research ethics committee of UCL Hospitals.

  • Accepted 25 May 2004
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