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RESEARCH: Neha Sekhri, Adam Timmis, Ruoling Chen, Cornelia Junghans, Niamh Walsh, Justin Zaman, Sandra Eldridge, Harry Hemingway, and Gene Feder Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris BMJ 2008; 0: bmj.39534.571042.BEv1 [Abstract] [Full text]

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Inequity in access to care in a deprived area in France

Frédéric Lapostolle, Lydia Ameur, Jean Catineau, Frédéric Adnet   (19 May 2008)

Inequity in access to care in a deprived area in France 19 May 2008
Frédéric Lapostolle, MD 93000, Bobigny, France, Lydia Ameur, Jean Catineau, Frédéric Adnet Send response to journal: Re: Inequity in access to care in a deprived area in France	We read with interest the paper from Sekhri et al.1 We would like to emphasize that inequity due to deprivation can occur upstream to care access and in acute situations. We recently studied patients with acute myocardial infarction (AMI) managed by our out-of-hospital emergency care department. All these patients were treated with prehospital fibrinolysis or primary PCI. They were followed-up during a seven year period and contacted by phone. They were questioned about the event they were managed for. They had to answer three questions regarding (1) their final diagnosis (2) the treatment they received and (3) what they should do in case of recurrent chest pain. 976 patients were included, 162 (19%) were dead at time of the contact and 111 (11%) were lost to follow up. 703 (70%) were finally interviewed with a median (25-75 percentiles) time of 985 (413-1596) days. The ratio of correct answers was very poor (table). Interestingly, patient’s socio-economic status (i.e. according to our criteria: their study level) was the lone (for questions 1 and 2) or, at least, the most determinant (question 3) independent factor correlated with the correct answer (table). These results reinforce those from Sekhri et al. This disappointing situation has to be corrected in order to allow optimal AMI management which, in France, includes early involvement of the dispatching centers (SAMU-Centre 15) and prehospital management with direct transfer for primary PCI or prehospital fibrinolysis and subsequent direct transfer to a cath-lab or a cardiologic ICU. 2, 3 This is a crucial point as our out-of-hospital emergency care department is located in one of the most deprived area of France. Results • Question 1 : What was your final diagnosis? Expected answer : Myocardial infarction or heart attack : 394 (56%) Multivariate analysis : superior studies : OR (95% IC) : 8,9 (5,8-15,2) ; < 0,0001 - secondary studies : OR (95% IC) : 4,8 (3,1-7,3); < 0,0001 • Question 2 : What treatment did you receive? Expected answer : Fibrinolysis, angioplasty or identifiable treatment : 522 (74%) • Question 3 : What to do in case of chest pain? Expected answer : Call to SAMU-Centre 15 : 169 (24%) References 1. Sekhri N, Timmis A, Chen R, Junghans C, Walsh N, Zaman J, Eldridge S, Hemingway H, Feder G. Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris. BMJ 2008;336:1058-1061, doi:10.1136/bmj. 39534.571042.BE (published 24 April 2008) 2. Lapandry C, Laperche T, Lambert Y, Sauval P, Zurek M, Fosse S. Prise en charge préhospitalière des syndromes coronaires aigus ST + en Ile-de- France. Le registre E-must. Arch Mal Cœur. 2005;98:1137-42 3. Danchin N, Blanchard D, Steg PG, et al, for the USIC 2000 Investigators. Impact of prehospital thrombolysis for acute myocardial infarction on 1-year outcome. Results from the French Nationwide USIC 2000 Registry. Circulation. 2004;110:1909-15 Frédéric Lapostolle, Lydia Ameur, Jean Catineau, Frédéric Adnet SAMU 93, EA 3409, Hôpital Avicenne, Bobigny 125, rue de Stalingrad, 93009, Bobigny, France E-mail: frederic.lapostolle@avc.aphp.fr Competing interests: None declared