A CHD Health Equity Audit for Hull & the East Riding of Yorkshire

Transcription

1 A CHD Health Equity Audit for Hull & the East Riding of Yorkshire Project team Phil Davies Richard Dixon Goetz Gerstenberger Jilly Gibson Tim Greene Amanda Killoran Mandy Lee Andrew Taylor Helen Thornton-Jones Steering Group Member Statistical data provision and analysis Statistical data provision and analysis Statistical Analysis, risk factors and CHD interventions Statistical analysis CHD rates Author and Co-Ordinator Statistical Analysis, risk factors and CHD interventions CHD Drug analysis, Author and editing Steering Group Member With thanks for proof-reading from Mandy Lee, Rosemary Purcell, Diane Thompson and Jenny Walker - all mistakes and omissions are the responsibility of the authors. 1

2 Abbreviations BMI BP BTEC CABG CC CHD CPU CSE DH ER ERoY EY GCSE GP GVNQ HNC HND IMD KoH LA LDL LSP MI ngms NHS NICE NOF NSF NVQ ONC OND PCI PCT Q&O RSA SMR SOA UK VLDL YW&C Body Mass Index Blood Pressure British Technical Education Certificate Coronary Artery Bypass Graft City Council Coronary Heart Disease Cardiovascular Prescribing Unit Certificate in Secondary Education Department of Health East Riding (of Yorkshire Local Authority) East Riding of Yorkshire (Local Authority) East Yorkshire (Primary Care Trust) General Certificate in Secondary Education General Practitioner General Vocational National Qualifications Higher National Certificate Higher National Diploma Index of Multiple Deprivation Kingston-upon-Hull (Local Authority) Local Authority Low Density Lipoprotein Local Strategic Planning Myocardial Infarction New General Medical Services National Health Service National Institute of Clinical Excellence New Opportunities Fund National Services Framework National Vocational Qualification Ordinary National Certificate Ordinary National Diploma Percutaneous Coronary Intervention Primary Care Trust Quality and Outcome Royal Society of Arts Standardised Mortality Ratio Super Output Area United Kingdom Very Low Density Lipoprotein Yorkshire Wolds and Coast (Primary Care Trust) 2

3 Contents 1.0 Purpose and Outline Defining Health Equity CHD Equity Audit Framework Defining Inequalities in CHD in Hull and East Riding Patterns of Health-Related Behaviours and CHD 5.1 Smoking Obesity and Diet Physical Activity Multiple Risk Factors Section Conclusions and Recommendations Scanning the Potential for Reducing Inequalities in CHD - Selected Case Studies Smoking Cessation Section Conclusion and Recommendations School Based Approaches to Promoting Healthy Eating in Children Section Conclusion and Recommendations a-day Scheme Pilot in Hull and East Riding Section Conclusion and Recommendations Prevention and Management of Coronary Heart Disease in Primary Care Section Conclusion and Recommendations Monitoring of Access to CHD Drugs Section Conclusion and Recommendations Access to CHD Inpatient Treatment Section Conclusion and Recommendations Summary and Recommendations References 74 3

4 CHD health equity audit (Hull and East Riding) 1. Purpose and outline A coronary heart disease (CHD) health equity audit aims to inform the planning and delivery of services for reducing inequalities related to coronary heart disease in Hull and East Riding. Primary Care Trusts (PCTs) are expected to demonstrate the effective use of health equity audit to attain star ratings. Equity is now a dimension of the Government s approach to setting national targets and managing performance on health inequalities. Targets aim to see faster progress compared with the average in the most deprived areas (including Hull PCTs). With respect to CHD, the target is set: to substantially reduce mortality rates by 2010 from heart disease by at least a 40% reduction in the inequalities gap between the fifth of areas with the worst health and deprivation indicators and the population as a whole. (PSA inequalities targets 2004 Spending Review). The objectives of the CHD health equity audit were: 1. To pilot the technique of health equity audit as a method that informs policies concerned with reducing health inequalities in Hull and the East Riding. 2. To support the implementation of the national service framework for coronary heart disease, specifically the effective deployment of services and resources according to need and potential for reducing health inequalities. This would provide recommendations for future service planning priorities within NSFs, Inequalities Strategies, Choosing Health Delivery, LSP, etc. 3. To evaluate the effectiveness/acceptability/usefulness of the new policies in relation to reducing health inequity. Health Equity Audit would be expected to: - Influence the agreement of key local objectives between partners Influence change in investment or delivery Because Health Equity Audit is an iterative process future work should: - Review progress against local objectives Inform the selection of future Health Equity Audit topics. 4

5 Public Health Tools for Change: How are they related? Race Equality Impact Assessment HIA: helps identify positive / negative health effects of proposed policy/ / actions Agree partners, 1 Priorities and topics 6 Health Equity Review progress profile against local objectives 2 The Health equity audit cycle HNA: analysis of need; can contribute to equity profile and priorities for action 5 Influence change in investment / delivery 4 Agree key local objectives with partners 3 Use evidence to prioritise effective actions The health equity audit cycle is not complete until change occurs which reduces health inequalities; therefore it is likely that there will be repetitions of the former steps in future. Health Equity Audit then, is an iterative process which fits in the planning cycle and conforms to the above structure. 5

6 2. Defining health equity There are a range of meanings and definitions relating to health equity and inequalities. The following definitions of health equity have been adopted for the purposes of the audit. Equity in health is the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage...it is the right to the highest attainable standard of health, as reflected by the standard of health enjoyed by the most socially advantaged group within a society.(braveman & Gruskin 2003) Equity of access (opportunity) to services for equal need involves ensuring that there are appropriate and accessible services for all; and consequently that services address any barriers to access and specific needs relating to particular groups. (Mooney 1983) Two primary benchmarks were therefore used to define health inequalities in Hull and East Riding and examine the potential for improvement: The level of inequality in CHD between Hull and East Riding populations in comparison to the national average for England and Wales, and against national targets The inequalities in CHD between the different social groups/areas within Hull and East Riding 6

7 3. CHD equity audit framework The framework for the audit is presented below. Framework for CHD health equity audit : Hull & East Riding Performance management/targets Context Need -health Inequalities: Premature CHD mortality Deprivation CHD risk factors Local strategy NSF Equity of outcome Equity of access/ opportunity Reducing health inequalities: V national V different social groups within district Audit & evaluation The audit framework involved: Profiling the pattern of need with respect to inequalities in CHD. Three main indicators were used to assess need : premature CHD mortality, deprivation and CHD risk factors. The small numbers of CHD deaths within a specific time period in the local context poses limitations for detailed analysis of need. Therefore deprivation (as measured by The Index of Multiple Deprivation (IMD) was used as a proxy of need (CHD mortality and morbidity) due to the body of research which establishes high correlations between deprivation and CHD related disease. The IMD is described in more detail in a subsequent part. 7

8 National IMD scores for small areas, super output areas (SOAs) and wards in Hull and East Riding, (and their quintile bandings) were used to examine the relationship between deprivation and CHD mortality and CHD risk factors (smoking, eating patterns and physical activity levels). Audit of services The National Service Framework for CHD was used to define the scope of possible services and programmes that would be considered in the audit. Audit of selected services against need was based on 2 criteria: Evidence (academic literature and/or national guidelines) that the service was effective in reducing CHD, and that lower social groups could benefit (in principle at least) as well as higher social groups.) Evidence that the service was being accessed locally by the most deprived groups. This equity of access locally was determined by examining the relationship between deprivation (deprivation bandings) and contact/reach of services. If the above criteria were met, it could be assumed that investment in the service could contribute to reducing inequalities in the CHD experienced by the people of Hull and East Riding. The quality of the evidence available was also considered. 8

9 Deprivation and the Index of Multiple Deprivation The Index of Multiple Deprivation (IMD) 2004 has been calculated for small geographical areas of around 1,500 people ( super output areas : SOAs 1 ). The IMD 2004 measures multiple deprivation across seven domains and the scores on each domain are weighted and combined to give the final index score for each SOA (as shown in table 3.1 below). Table 3.1 Domains of multiple deprivation and their weights Domain Domain Weight Income deprivation 22.5% Employment deprivation 22.5% Health deprivation and disability 13.5% Education, skills and training deprivation 13.5% Barriers to housing and services 9.3% Living environment deprivation 9.3% Crime 9.3% Each SOA in England has been assigned a score and a rank for the IMD Hull and East Riding can therefore be compared to other local authority districts and counties. The index can also show relative levels of deprivation between districts and small areas within Hull and the East Riding. The IMD rankings were used to define 5 deprivation bandings based on quintiles. These bandings were used in the various analyses undertaken within the audit. Health and Lifestyle survey 2003 Hull and East Riding This survey of the residents of Hull and East Riding was conducted by the Public Health Development Team (PHDT) during The aim of the survey was to provide information on the health, lifestyle and service use of the population served by the PCTs. The survey involved use of a self-completion questionnaire. Random samples of 6,500 adults and 14,500 (aged 16 years or above) were selected from residents of Kingston upon Hull and East Riding respectively. A response rate of 50% for Hull and 64% for East Riding was achieved. Further specific sources and methods are described in each section of the report. 1 Super Output Areas (SOAs) Super Output Areas (SOAs) are a new geographical unit designed to improve the reporting of small area statistics. They have been introduced initially for use on the Neighbourhood Statistics (NeSS) website, but it is intended that they will eventually become the standard across National Statistics. 9

10 4. Defining inequalities in CHD in Hull and East Riding Coronary heart disease in Hull and East Riding compared to the national average This section describes the levels of CHD in Hull and East Riding populations compared with the national experience as measured by deaths. CHD is the second biggest single killer and in 2001, deaths from CHD in Hull represented 21% of all deaths; and in East Riding 22% of all deaths. A considerable number of these deaths were premature (i.e. deaths under 75 years of age) and 222 premature deaths in Hull and 244 in the East Riding were recorded. Figures 4.1 and 4.2 show the trends in under 75 death rates of CHD in Hull and East Riding for males and females compared with England and Wales. ( ). Figure 4.1 CHD Directly Standardised Death Rates : Men <75 yrs 250 deaths per 100,000 pop EY YW&C Eastern Hull West Hull Eng & Wales Hull CC E Riding 10

11 Figure 4.2 CHD Directly Standardised Rates : Women <75 yrs deaths per 100,000 pop EY YW&C Eastern Hull West Hull Eng & Wales Hull CC E Riding Over the last decade there has been a gradual reduction in premature death rates from CHD in Hull and East Riding which is in line with the national trend. However people living in Hull experience significantly higher levels of premature CHD deaths than the national average and the rate of decline in mortality has been lower. The rates of premature CHD deaths in the East Riding overall are lower than the national figure. However there have been only small reductions in premature CHD mortality in Yorkshire Wolds & Coast PCT, particularly for females. Given that the gap between premature CHD death rates is wider between Hull and the national average than the gap between East Riding and the national average, a faster rate of improvement must occur in Hull relative to both the national average and East Riding in order to achieve national targets. 11

12 4.1 CHD and deprivation in Hull and East Riding This section examines the geographical pattern of deprivation, measured by the IMD 2004, and the relationship between deprivation and coronary heart disease in Hull and East Riding. The higher the IMD score, the worse the deprivation. The local ranks are provided with the a value of 1 denoting the most deprived area locally and 49 denoting the most affluent ward locally. The national ranking is also given, and similarly a low rank denotes more deprivation. The national rank percentile is provided. For example, if the value is 10, it means that that the ward is in the worst 10% of deprived wards nationally, and a value of 75 means that the ward is in the top 75% of deprived wards or alternatively the top 25% most affluent wards. The pattern of deprivation at the SOA level using the IMD 2004 in Hull and East Riding is shown in figure 4.3. The SOAs are divided into quintile bands where the most deprived (ie 20% of areas with the highest IMD score) are shown in red and the most affluent shown in green (20% of areas nationally with the lowest IMD scores). Figure 4.3 Deprivation within Hull and East Riding (SOAs by national deprivation quintile) 12

13 The nature of deprivation between Hull and East Riding is clearly different. There are very high concentrations of urban deprivation in Hull and pockets of deprivation in the East Riding, including parts of Bridlington, Withernsea and Goole wards. In terms of the national quintiles, nobody in either Eastern Hull PCT or West Hull PCT lives in the most affluent 20% of areas, whereas these figures were 8% for Yorkshire Wolds and Coast PCT and over 30% for East Yorkshire PCT. Over 50% of people Hull lived in an area that was in the most deprived 20% of areas nationally, compared to less than 15% for East Riding. Table 4.1 below shows the IMD 2004 scores at ward level derived from SOA scores which have been applied to wards using weighted averages of the population. The national percentile rank of wards column confirms the patterns reported above where Hull wards tend to be in the most deprived centiles and East Riding wards in the least deprived percentiles. Table 4.1 Hull and East Riding ward IMD 2004 scores and ranks Ward Name LA IMD 2004 Score Local Rank (out of 49) National Rank (Out of 7,932) St Andrew's Hull Orchard Park and Greenwood Hull Myton Hull Southcoates East Hull Marfleet Hull Bransholme East Hull Bransholme West Hull Newington Hull Longhill Hull Bridlington South ER Newland Hull University Hull Pickering Hull Avenue Hull Drypool Hull Goole South ER , Ings Hull , Southcoates West Hull , Bridlington Central and Old Town ER Sutton Hull , Derringham Hull , South East Holderness ER , Boothferry Hull , Bricknell Hull , Kings Park Hull , Goole North ER , North Holderness ER , Percentile National Rank 13

14 Table 4.1 continued IMD 2004 Score National Rank (Out of 7,932) Local Rank Ward Name LA (out of 49) Holderness Hull , Beverley Hull , Bridlington North ER , Snaith, Airmyn and Rawcliffe and Marshland ER , East Wolds and Coastal ER , Hessle ER , Cottingham South ER , Driffield and Rural ER , Minster and Woodmansey ER , Tranby ER , Mid Holderness ER , South West Holderness ER , Howdenshire ER , Wolds Weighton ER , Howden ER , St Mary's ER , Cottingham North ER , Beverley Rural ER , Pocklington Provincial ER , Willerby and Kirk Ella ER , Dale ER , South Hunsley ER , Percentile National Rank There is a difference in the percentages obtaining different levels of educational qualifications 2 among the wards (2001 data from Neighbourhood Statistics) as illustrated in table 4.2. In Hull, 58% of people aged years in the Orchard Park and Greenwood ward have no formal qualifications, whereas 23% have no qualifications in Avenue ward. The percentage with HNC, HND or degree level or higher level of qualifications also differs substantially among the wards in Hull. For half of the wards in Hull, 8% or fewer are qualified to this level, with the remaining wards having between 10% and 18% qualified to this level except for Avenue where the figure is 30%. The percentages in East Riding with no formal qualifications is generally lower. Bridlington Central and Old Town has the highest percentage without qualifications (42%) and South Hunsley the lowest percentage (18%). Two wards (Bridlington Central and Old Town and Goole South) have fewer than 10% attaining qualifications to HNC, HND, or degree or higher level, but many wards have over 20% obtaining such qualifications with 2 Level 1 qualifications represent ungraded CSE or GSCE D-G. Level 2 qualifications represent City & Guilds, GCSE at A-C level, O levels, BTEC General Diploma, RSA Diploma, Apprenticeship Qualifications (Basic), GVNQ (Intermediate). Level 3 qualifications represent Apprenticeship qualifications (Advanced), A levels, BTEC National/ONC/OND, etc, GVNQ (Advanced). Level 4 or 5 qualifications represent HNC, NHD, higher BTEC, Teaching qualification, First Degree, NVQ5, Higher Degree, Nursing qualification or other professional qualification. 14

15 South Hunsley having the highest percentage (30%) which is the same percentage as Avenue in Hull. Table 4.2 Highest educational attainment All persons aged years Percentage with qualifications at each level Ward People None Level 1 Level 2 Level 3 Level 4 or 5 Level Unknown Kingston-upon-Hull Orchard Park and Greenwood Marfleet Bransholme West Southcoates East St Andrew`s Bransholme East Longhill Pickering Myton Ings Newington Southcoates West Sutton Derringham Drypool Boothferry University Holderness Kings Park Beverley Bricknell Newland Avenue

16 Table 4.2 continued All persons aged years Percentage with qualifications at each level Ward People None Level 1 Level 2 Level 3 Level 4 or 5 Level Unknown East Riding of Yorkshire Bridlington Central and Old Town Goole South Bridlington South Goole North South East Holderness Bridlington North Snaith Airmyn and Rawcliffe and Marshland Driffield and Rural North Holderness East Wolds and Coastal South West Holderness Mid Holderness Howdenshire Tranby Cottingham South Howden Minster and Woodmansey Hessle Wolds Weighton Pocklington Provincial St Mary`s Willerby and Kirk Ella Dale Beverley Rural Cottingham North South Hunsley

17 Table 4.3 illustrates the economic activity (2001 data from Neighbourhood Statistics). The percentage employed represents those working part-time and full-time, and who are self-employed. This category also includes students who are economically active. Three Hull wards had an unemployment rate of 10% in A total of 14 wards had an unemployment rate of more than 5% in 2001, twelve wards in Hull and two wards in East Riding. Seven of the wards in Hull had a rate of 10% or more for those permanently sick or disabled compared to one ward in East Riding (Bridington South). Table 4.3 Economic activity Percentage of residents Look after home Ward Employed Unemployed Retired Study Hull Avenue Beverley Boothferry Bransholme East Bransholme West Bricknell Derringham Drypool Holderness Ings Kings Park Longhill Marfleet Myton Newington Newland Orchard Park and Greenwood Pickering St Andrew`s Southcoates East Southcoates West Sutton University Permanently sick/disabled 17

18 Table 4.3 continued Percentage of residents Ward Employed Unemployed Retired Study Look after home East Riding Beverley Rural Bridlington Central and Old Town Bridlington North Bridlington South Cottingham North Cottingham South Dale Driffield and Rural East Wolds and Coastal Goole North Goole South Hessle Howden Howdenshire Mid Holderness Minster and Woodmansey North Holderness Pocklington Provincial St Mary`s Snaith Airmyn and Rawcliffe and Marshland South East Holderness South Hunsley South West Holderness Tranby Willerby and Kirk Ella Wolds Weighton Permanently sick/disabled 18

19 General self-reported health from the 2001 Census is given in the following table. In Hull, residents in Myton ward report the worst health with 55% stating that their health is good, compared to Kings Park where 74% report their health as good. The percentages reporting good health are slightly higher in East Riding Wards and range from 61% in Bridlington South to 75% in Beverley Rural. Table 4.4 Self Reported Health Percentage of residents Ward Good health Fairly good health Not good health Hull Myton St Andrew`s Southcoates East Orchard Park and Greenwood Bransholme West Ings Marfleet Longhill Pickering Newington Bransholme East Derringham Drypool University Bricknell Southcoates West Sutton Newland Boothferry Avenue Beverley Holderness Kings Park

20 Table 4.4 continued Percentage of residents Ward Good health Fairly good health Not good health East Riding Bridlington South Bridlington Central and Old Town Bridlington North South East Holderness Cottingham South North Holderness Goole South Goole North Snaith Airmyn and Rawcliffe and Marshland East Wolds and Coastal Tranby South West Holderness Driffield and Rural Mid Holderness Hessle Howdenshire Minster and Woodmansey Howden Cottingham North Willerby and Kirk Ella Pocklington Provincial St Mary`s Wolds Weighton South Hunsley Dale Beverley Rural

21 CHD and deprivation Figures 4.4 and 4.5 show the relationship between local deprivation quintiles (wards ranked into five bands of deprivation) and levels of premature CHD deaths (2001) for males and females. The Standardised Mortality Rate (SMR) as given below, illustrates the age-standardised mortality rate for persons aged under 75 years compared to the national expected rate, given the age distribution. (England and Wales have the average value of 100.) SMRs over 100 therefore indicate worse health than the national rate. Figure 4.4 Male CHD deaths (2001-2) aged under 75 in Hull & East Riding by deprivation band % confidence interval for SMR Most deprived Least Deprived IMD deprivation quintile 21

22 Figure 4.5 Female CHD deaths (2001-2) aged under 75 in Hull & East Riding by deprivation band % confidence interval for SMR Most deprived Least Deprived IMD deprivation Quintile A strong relationship between deprivation level and premature death is demonstrated in the figures where the likelihood of dying prematurely from CHD increases with increasing levels of deprivation. For males the SMR of the most deprived fifth of wards (band 5) at 165 is more than twice the rate of the least deprived quintile which has an SMR of 64. For females the disparity is greater; the most deprived quintile has an SMR of 159 and quintile 1, an SMR of 53. Consequently, to reduce inequalities in premature CHD deaths between the different socio economic areas/ groups across Hull and East Riding, will require a faster rate of improvement in health in the most deprived areas/groups compared with the more affluent groups. Section conclusions and recommendations The greatest inequity highlighted by the analysis in this report is the fact that the premature death rate (under 75) from CHD in the poorest fifth of areas in Hull and East Riding is over two and a half times the death rate in the least deprived areas. This inequity persists, although less sharply, at older ages. 22

23 We adopted the definition of health equity which states that there should be no systematic disparities in health between groups. This section shows that health inequity in terms of health outcome does exist between those living the most deprived and most affluent areas. The next step is to examine why this inequity might be occurring and suggest what policies should be or might be implemented to reduce the inequity. 23

24 5. Patterns of health related behaviours and CHD The inequalities in CHD between groups living in geographical areas with different levels of deprivation can be explained in part in terms of differences in risk factors behaviour patterns such as smoking, exercise, blood pressure and cholesterol levels. National figures show that such risk factors tend to be concentrated disproportionately across lower social groups. Consequently the greatest potential for reducing inequalities in CHD between social groups will be dependent on changes in these behaviour patterns. The Health and Lifestyle Survey in Hull and East Riding (2003) provides information on the local pattern of health-related behaviours. Local patterns were compared with the national position where possible. The relationship between behaviours and levels of deprivation were also examined (using the five deprivation bandings). 5.1 Smoking Smoking is one of the main reasons for the gap in life expectancy between rich and poor in England. Among men, smoking accounts for over half of the difference in risk of premature death between the social classes (Jarvis & Wardle, 1999). With respect to CHD, smoking contributes one seventh of all CHD premature deaths. In 2001, 27% of adults smoked cigarettes in England (Department of Health, 2003). However people in manual social groups continue to be more likely to smoke than those in non-manual groups; 32% of adults in manual groups smoked cigarettes compared with 21% of those in non-manual groups. Figures 5.1 and 5.2 show levels of daily smoking by age groups and gender in Hull and East Riding. Levels of smoking in Hull are high compared with the national average. 33% of men in West and Eastern Hull are smokers compared with 28% nationally. The yrs age group has the highest levels of smoking (46%) 28% of women in West Hull and 34% of women in Eastern Hull are smokers compared with 25% of women nationally. Young women (16-24 yrs) have extremely high levels of smoking. In Eastern Hull, 45% of women in this age group are smokers. 24

25 Figure 5.1 Men Smokers in Hull & East Riding % sm okers in Hull & East Riding: Men (by a ge group) % all EY YW&C Eastern West national 28.0 Levels of smoking in the East Riding are lower than the national average. 23% of men in Yorkshire Wolds & Coast are smokers and 21% in East Yorkshire compared with 28% nationally. 19% of women in Yorkshire Wolds & Coast are smokers and 21% in East Yorkshire, compared with 25% of women nationally. However young women in Yorkshire Wolds & Coast aged years have high levels of smoking. (45%). Figure 5.2 Women Smokers in Hull and East Riding % smokers in Hull & East Riding: women (by age group) % all EY YW&C Eastern West national

26 Figure 5.3 shows the levels of smoking by national deprivation quintile for each PCT. There is a marked gradient in levels of smoking according to deprivation. Almost three times as many people smoke in the most deprived areas in Eastern Hull (41%) compared with the most affluent areas of East Yorkshire (14%). The gradient is particularly steep in West Hull. Figure 5.3 Percentage of smokers by Deprivation per PCT %smokers by deprivaton : PCTs % smokers Most deprived Least deprived EY YW&C EH WH Obesity and diet The Health and Lifestyle Survey for Hull and East Riding (2003) provides information on overweight and obesity levels locally. Survey respondents were asked to give their height and weight. Body Mass Index (BMI= weight (kilograms) divided by height (in metres) squared) was calculated: BMI under 20 are classified as underweight, BMI over 30 is classified as obese, and over 40 (where there are severe risks of consequent health problems) morbidly obese. Table 5.1 below shows that levels of obesity in Hull and East Riding are similar or less than the national average. A range of percentages for local areas are given in order to make them comparable to the England figures, since people tend to underestimate their true weight in self reporting. 26

27 Table 5.1 Percentage of Adults Classified Obese (BMI > 30), 2003 Primary Care Trust Male Female East Yorkshire 15 to to 21 Eastern Hull 14 to to 28 West Hull 15 to to 26 Yorkshire Wolds & Coast 17 to to 24 ENGLAND Figure 5.4 shows the percentage of people by BMI category and level of deprivation. Figure 5.4 Weight (BMI) of Adult Population : Hull & East Riding Wight (BMI) of adult population : Hull & East Riding % of people in weight categories by deprivation level Most deprived Least deprived UNDERWEIGHT <20 DESIRABLE OVERWEIGHT OBESE MORBIDLY OBESE 40+ There is a clear trend of higher levels of obesity amongst the more deprived groups, in comparison with their more affluent counterparts. The pattern is particularly marked for women. Further analysis shows women in the most deprived groups are twice as likely to be obese and five times more likely to be morbidly obese then women in the least deprived groups. Figure 5.4 also shows that people in the most deprived groups are more likely to be underweight compared with their more affluent counterparts. 27

28 The survey data allowed investigation of patterns of eating in relation to deprivation. There is some indication that more deprived groups are more likely to have certain aspects of unhealthy eating patterns. For example the figure 5.5 below shows the type of milk drunk according to the different levels of deprivation. Whole milk is more likely to be drunk by those in the more deprived groups, although this gradient is not very marked. Figure 5.5 Type of Milk Drunk by Deprivation Level Type of milk drunk by deprivation: Hull and East Riding 100% 80% 60% 40% 20% 0% Most deprived Least deprived Whole Semi-Skimmed Skimmed Diet and obesity in childhood are relevant to future risk of heart disease, as well as other diseases. Healthy eating in childhood may protect against adult heart disease. Nationally the prevalence of obesity in children is increasing. Between 1996 and 2001 the proportion of overweight children (aged 2-15 years) increased by over 50% and obese children by over 100% (Health Survey for England 2003). In % of 6 year olds and 15% of 15 year olds were obese. Also children s food intake has been found to be high in fats and sugars and low in fruit and vegetables. Surveys have shown that dietary deficiencies show a social class gradient. The lowest income households consume less fresh fruit and vegetables, skimmed milk, fish, fruit juices and breakfast cereals than all household averages (DH 2000) 28

29 Although local data on children s eating patterns and the prevalence of obesity and overweight is not currently available, a recent survey of young people in Hull and East Riding suggests that children s eating patterns may be similar to those nationally (Public Health Development Team 2002). A report on local obesity levels in 5-year-olds will be produced in May 2005 for the Hull and East Riding of Yorkshire Obesity Strategy Group. 5.3 Physical activity Survey respondents were asked how much physical activity they normally undertook over a week. Responses on the level and type of physical activity were categorised as follows: Plenty = moderate exercise regularly or vigorous exercise occasionally or regularly Some = moderate exercise occasionally or light exercise regularly Little or none = never exercising or occasionally exercising lightly Only the category plenty defines the amount of physical activity that yields long term benefits, particularly with respect to CHD. Overall only about 45% of the population undertook this level of activity. Figure 5.6 shows patterns of physical activity according the different levels of deprivation. There is some indication that that those in more deprived groups are slightly less likely to undertake plenty of physical activity, in comparison with their more affluent counterparts. Figure 5.6 Physical Activity Amount of physical activity by deprivation: Hull and East Riding 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Most deprived Least deprived Little or none Some Plenty

30 5.4 Multiple risk factors The relationship of deprivation and multiple risk factors for CHD was examined. Important CHD risk factors identified in the literature and included in the local Health & Lifestyle Survey were used in the analysis. These factors were: high blood pressure (BP), age (for males >45years and for females >55years), smoking, obesity (BMI >30), and not taking plenty of exercise. The distribution of number of risk factors by deprivation bandings (national quintiles of IMD scores) was examined. Table 5.2 shows the number of people in each band with each risk factor: There are higher numbers of people in the most deprived areas with high BP, who smoke and who have a sedentary lifestyle. In the least deprived areas there are slightly more people at risk due to their age and BMI. Table 5.2 Individual Risk Factors High BP Age Smoking Obesity Sedentary IMD Nat Quintile Most deprived Least deprived Total For the purpose of the analysis it was assumed that each risk factor equally contributes to CHD risk, therefore a total CHD risk of 1-5 was calculated by simply adding individual risk factors. Tables 5.3 and 5.4 show the numbers and percentages of total CHD risk scores. This data is presented graphically in figure 5.7 Table 5.3 Total CHD Risk Total IMD Nat Quintile Most deprived Least deprived Total Table 5.4 Total CHD Risk % within IMD National Quintile Total IMD Nat Quintile Most deprived Least deprived Total

31 Figure 5.7 CHD Risk Factors CHD risk factors 100% 90% % of people by numbers of risk factors 80% 70% 60% 50% 40% 30% 20% % 0% Most deprived Least deprived National IMD Quintile The risk factors presented here are not necessarily fully validated, of equal contribution in the measurement of CHD, or an exhausted list of possible CHD risk factors. However the pattern shows that people in the more deprived areas of Hull & East Riding are more likely to have a range of CHD risk factors than those in the least deprived areas, for example 5% of people in the most deprived areas have a total CHD risk of 4 compared to 2.6% in the least deprived areas. 5.5 Section Conclusions This pattern of risk factors identified within this section clearly indicates the need for targeting integrated action in deprived communities. The next sections examine these identified risk factors in more detail, drawing out potential actions for helping reduce CHD related inequities in the Hull and East Riding area. 31

32 6. Scanning the potential for reducing inequalities in CHD: Selected Studies This section reports the findings of the audit of selected studies of interventions concerned with reducing CHD. However, the overall assessment of options for reducing health inequalities need to be considered within a strategic framework. Although evidence of the impact of strategies on inequalities in CHD mortality is lacking, a number of studies have considered the relative contribution of different approaches to reducing CHD mortality. A recent review of the use of modeling techniques to estimate the contribution of different factors to reducing CHD mortality provides an important overview (Kelly & Capewell 2004). This review compared changes in risk factors (such as smoking, diet and exercise) compared to medical intervention, making judgments regarding the impact on CHD mortality. Key findings included: CHD modeling consistently shows that treatments explain less of the mortality decline than do risk factor changes. This is evident in European countries including England and Wales, US, and New Zealand In England and Wales about 58% of decline in mortality since 1981 was attributable to the change in risk factors, with the largest proportion coming from a fall in smoking prevalence. The rest of the mortality decrease (42%) was attributable to medical and surgical treatment, (with secondary prevention medications and heart failure treatments making the most substantial contribution). Few models considered the differential impact of changes in risk factors and treatment on different sections of the population. The review highlights implications for future CHD strategies. It indicates that modest reductions in the prevalence of risk factors are likely to yield significantly greater impact in terms of life years saved, in comparison to investment in cardiological treatments. The importance of public health initiatives in this respect should therefore be recognised. Consequently, reduction in inequalities in CHD mortality and morbidity locally is dependent on higher rates of reduction in risk factors in the most deprived groups and communities. Additionally the potential to reduce inequity through improving access to and performance of health services should not be ignored. Within this context audit case studies provide examples of interventions concerned with reducing risk factors, and secondary prevention in primary care as well as secondary care treatments. The case studies span the different standards of the CHD National Service Framework as given in table 6.1 and consider their potential contribution to reducing CHD. 32

33 This was a scanning/scoping exercise, and not a comprehensive audit of the NSF standards for CHD in Hull and East Riding. No direct consideration was given to programme costings and the cost-effectiveness of programmes. Nevertheless, it is felt that there is a great need for evaluation of proposed and existing initiatives in order that the maximum impact on health inequity should be realized. The case studies were weighed against 2 criteria: Evidence (academic literature and/or national guidelines) that the service was effective in reducing CHD, and that lower social groups could benefit (in principle at least) as well as higher social groups. Evidence that the service was being accessed locally by those most deprived groups, and most in need. If these criteria were met it could be asserted that investment could potentially contribute to reducing inequalities in CHD in Hull and East Riding. The quality of evidence available locally for audit purposes was also assessed. Table 6.1 CHD national service framework standards Standard 1 & 2: Reducing heart disease in the population Standards 3 & 4: preventing CHD in high risk patients The NHS and partner agencies should develop, implement and monitor policies that reduce coronary risk factors in the population, and reduce inequalities in risks of developing heart disease The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population General practitioners and primary care teams should identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks General practitioners and primary care teams should identify all people at significant risk of cardiovascular disease but who have not developed symptoms and offer them appropriate advance and treatment to reduce their risks Audit case study 5-a-day scheme: pilot School-based programmes Smoking cessation Prevention and health promotion programmes in primary care Access to CHD drugs 33

34 Table 6.1 CHD national service framework standards continued Standards 5,6,7: Heart attack and other acute coronary syndromes Standard 8: stable angina Standard 9 &10 revascularis ation Standard 11: heart failure Standard 12: cardiac rehabilitation People with symptoms of a possible heart attack should receive help from an individual equipped with and appropriately trained in the use of defibrillator within 8 minutes of calling for help, to maximize the benefits of resuscitation People thought to be suffering from a heart attack should be assessed professionally and if indicated receive aspirin. Thrombolysis should be given within 60 minutes of calling for professional help NHS Trusts should put in place agreed protocols/systems of care so that people admitted to hospital with proven heart attack are appropriately assessed and offered treatments of proven clinical and cost effectiveness to reduce their risk of disability and death People with symptoms of angina or suspected angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently or for those at greatest risk as an emergency NHS Trusts should put in place hospital wide systems of care so that patients with suspected or confirmed coronary heart disease receive timely and appropriate investigation and treatment to relieve their symptoms and reduce their risk of subsequent coronary events Doctors should arrange for people with suspected heart failure to be offered appropriate investigations that will confirm or refute the diagnosis. For those in whom heart failure is confirmed its cause should be identified-treatments most likely to both relieve their symptoms and reduce their risk of death should be offered NHS Trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital people admitted to hospital suffering from CHD have been invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation Audit case study Access to secondary care 34

35 6.1 Smoking cessation There are sound evidence-based guidelines demonstrating the cost effectiveness of local smoking cessation programmes (Raw et al 1998). The national evaluation of the smoking cessation programme shows that the service is reaching the smokers who are most socially deprived; although quit rates are higher for smokers who are from non-manual occupations, compared to those from manual occupations. However, it has been estimated that since a higher proportion of smokers from manual occupational groups are accessing the service, the programme can contribute to reducing social differential in smoking prevalence (Bauld et al 2004). The Hull and East Riding Specialist Smoking Cessation Service was established in November The service focuses particularly on disadvantaged adults and pregnant women. A range of activities has been developed including group sessions, one-to-one appointments, telephone support, Nicotine Replacement Therapy (NRT) voucher scheme, interpretation and drop-in sessions. The type of delivery settings has been extended through training of nursing and other staff to provide smoking cessation in primary care, prisons and workplaces and to young people. The impact of the service is monitored in terms of the number of smokers accessing the service who achieve non-smoking status at four week follow up. In smokers accessed the service, and 3208 (66%) quit smoking at 4 weeks. Of these 1001 (31%) had their no-smoking status validated by carbon monoxide testing. Local monitoring data shows that the service is providing higher levels of access to lower social groups. 55% of clients accessing the service were entitled to free prescriptions. 71% of clients accessing the service are from the 3 most deprived wards in Hull and East Riding. The specific contribution of the smoking cessation programme to reducing the number of smokers in Hull and East Riding is difficult to reliably estimate, however there is a strong local consensus that it is amongst the most effective schemes of its kind Section Conclusion and Recommendations Smoking is one of the largest contributing factors to heart disease (and other comorbidities in the UK). Initial work on smoking cessation within the area has achieved much, and apparently reaches the more deprived socio-economic groups achieving good equality of access. 35

36 This report, having described the body of evidence which establishes the impact of lifestyle consumption choices in a deprivation focused approach to health inequalities asserts that high priority should be given to smoking cessation. It is important, when building on the success of this service that rigorous monitoring and evaluation of the service is strengthened. Routine reporting should include uptake and cessation rates by social group at four weeks (and at least three months and yearly follow up), with greater use made of validation by carbon monoxide testing where possible. 36

37 6.2 School based approaches to promoting healthy eating in children School-based approaches to promoting healthy eating provide an important opportunity for addressing inequalities and risks of future chronic heart disease. A review of the evidence supported the use of multi-faceted school-based interventions to reduce obesity and overweight in school children, particularly in girls (Health Development Agency 2003). These interventions included: nutrition education, physical activity promotion, reduction in sedentary behaviour, behavioural therapy, teacher training, curricular material and modification of schools meals and tuck shops. A range of national initiatives have provided a focus for local development of such multi-faceted school-based interventions. Breakfast clubs and fruit schemes are designed to provide free or subsidised healthy food. Furthermore school meals can make a vital contribution to the dietary intake of school children in England. Every day, over 3 million school meals are served. In secondary schools, about 14% of pupils are entitled to free school meals; about 11% actually take up their entitlement. Concern about the quality of children s diets and the contribution of school meals led to the reintroduction of National Nutritional Standards in April However a recent survey of a national sample of secondary schools in England has shown that these standards have not succeeded in changing the eating pattern of children (Nelson et al 2004). Overall the findings showed that the majority of children are not making healthy food choices. Moreover practices in the dining room that were intended to promote healthy eating had little positive influence on pupil choices. The report recommended that the most likely way to ensure healthy eating in schools is to constrain choice to healthy options, manipulate recipes, use modern presentation techniques with which pupils can identify (eg the fast food approach, vending machines with healthier options), and provide encouragement through rewards. In Hull, the City Council pursues a policy of free school meals and the offer of healthy options. However there is currently no routine monitoring system for assessing childrens eating patterns within the school context, and the impact of this policy and other initiatives on promoting healthy eating. The Positive Health in Schools Award provides an important framework for the development and delivery of effective interventions for promoting healthy eating by accessing the approximately 50,000 children attending schools in Hull. The following local target has been set for schools participating in the award at level 3, in line with the national target. By March 2006, all 72 schools and units in Hull with 20% or more of pupils eligible for free schools meals will achieve level 3 (plus the 18 other schools 37

38 already participating in the award). Currently 53 schools (with 20% or more pupils eligible for free school meals) and 22 other schools, are working towards or holding the award at level 3, covering a population of approximately 30,640 children. These schools have been involved in a range of schemes for promoting healthy eating such as healthy tuck shops. However the impact of this initiative may be somewhat limited in improving the eating patterns of children, unless combined with school meals in reaching high numbers of children and providing healthy food Section Conclusions and Recommendations The national survey of schools meals in secondary schools, showing children are not choosing healthy school meals despite healthy options being available, suggests that a review of the local school meal policy should be undertaken with respect to its potential to contribute to promoting healthy eating and changing children s eating patterns, particularly with respect to children in poorer social circumstances. Good partnerships already exist between Health Promotion and Hull school meals services which are already making an impact on school meals. Collaborative links should be encouraged between PCTs and Councils in order to influence healthy eating offerings. Robust evaluation, which will allow measurements of health and lifestyle outcomes, should be built into new initiatives from the start. Retrospective evaluation should, wherever possible, be rigorous and critical in order to justify current activity and make judgments about future service configuration. Existing funding and provision should be reviewed within the obesity strategy group and recommendations be made for future inclusion or otherwise within the planning round. 38

39 6.3 5-a-day scheme pilot in Hull and East Riding Studies have shown that inequities exist with respect to food and diet and nutrition. For example several studies have shown that those least able to purchase a healthy diet due to financial constraints are the most likely to be disadvantaged with regard to access to healthy food (Sooman 1993). Poorer families have been disadvantaged by changes in food retailing (DH 1996). The costs of cooking and of stocking essential items for food preparation represent an additional expenditure. This means that more deprived groups have been encouraged to use convenience items or foods such as sandwiches that require no cooking. The national programme aims to promote the health benefits of eating five or more portions of fruit and vegetables each day. Potentially the scheme allows for the type of equity issues highlighted above to be addressed by targeting activity within deprived areas. The 5-a-day initiative in Hull and East Riding pilots local implementation of programme, with two year funding from the New Opportunities Fund (NOF). The aims included: launch the local 5-a-day initiative across the region develop and implement a food mapping exercise using participatory appraisal methods to engage and involve the community work in partnership with local communities work with schools and link in with the National Healthy Schools Standard, to promote positive messages about fruit and vegetables and increase the knowledge of children and young people develop links with partnerships such as Sure Start and Healthy Living Centres work with a range of local media to promote positive messages and ensure a high profile for work. provide 5-a-day training for training providers. explore the use of allotments, community gardens and school garden schemes to increase knowledge about growing and producing fruit and vegetables. The first phase of implementation of the scheme was based on a targeted approach. Deprived areas were identified using the Index of Multiple Deprivation. Ten electoral wards in Hull and four in the East Riding were selected. This geographical targeting of areas, despite providing a practical and efficient approach to deploying resources, has certain limitations with respect to equity of access. Such targeting may, however, reach only some of people living in deprived circumstances, as people equally deprived but living within more affluent areas, may be not be covered by the scheme. Furthermore the East Riding wards, although relatively deprived in the East Riding, were less deprived than a number of wards in Hull that were not selected. The East Riding wards were included in the scheme to promote partnership between the key agencies 39

40 involved in implementation. However the approach also had a number of important advantages that promote equity of access. Food mapping used the participatory appraisal approach that engaged people rather than targeting deprived areas. Community networks and organisations were involved in order to reach people living in deprived circumstances and to promote the 5-a-day messages and identify their views on local barriers to fruit and vegetable consumption and how they might be overcome. The project annual monitoring report (June 2003 to May 2004) documented the number of beneficiaries involved in the project activities; for example: numbers of community-based workers who received 5-a-day resources, numbers (from community based organizations) involved in the participatory mapping exercise, and numbers (children and teachers) involved in initiatives with the National Healthy Schools Standard Section conclusions and recommendations This initial audit work suggests that: - Achieving the scheme objectives is dependent on the participatory approach to engaging and involving local people in deprived communities, whilst at the same time raising awareness of the 5-a-day message, increasing knowledge and improving skills. Recruitment and training of community workers to undertake the mapping exercise has increased the potential for participatory approaches to planning services. The sustainability of the scheme will need to be considered., ensuring sufficient funding to meet Choosing Health commitments. An aspiration should be that the scheme should be rolled out to all deprived areas. Continuing robust local evidence is required to examine and identify the barriers to fruit and vegetable consumption in the 14 communities with high levels of deprivation. Such evidence is required to design activities that address inequities of food and diet experienced by deprived families and communities. Evidence from such evaluation should be made available to the wider health community through active dissemination where appropriate. The 5-a-day project should link to the Hull and East Riding Integrated Obesity Strategy in order to support its development, evaluation and funding potential. 40

41 6.4 Prevention and management of coronary heart disease in primary care Substantial evidence exists that demonstrates that prevention programmes involving systematic identification of those at risk of CHD and appropriate management can be effective in reducing prevalence of risk factors and associated mortality. Although government policy, including incentives within the GP contract, has long emphasized the importance of prevention programmes within primary care this area is substantially underdeveloped. For example the recent National Institute for Clinical Excellence (NICE) guidance on hypertension demonstrates the potential for substantial health gains. Hypertension is an important contributory factor for CHD (NICE 2004). It is estimated that 40% of the entire adult population in England are hypertensive (blood pressure more than 140/90mmHg), with the proportion increasing with age. Studies show that lowering blood pressure by 10 mmhg is associated with reductions in the risk of a future stroke of 56% and coronary heart disease of 37%. When blood pressure is lowered using drugs all the reduction in stroke and over half of the reduction in coronary heart disease are achieved. However the Health Survey for England (1998) suggests that only 40% of patients who are hypertensive received adequate treatment for their hypertension. PCTs are currently expected to achieve standards 3 and 4 of the CHD National Service Framework concerned with primary and secondary prevention. The National Standards Local Action framework for 2005/8 states that PCTs should: by March 2005 ensure that up to date practice-based registers exist so that patients with CHD and diabetes continue to receive appropriate advice and treatment in line with NSF standards, and by March 2006 ensure practice-based registers and systematic treatment regimes including appropriate advice on diet, physical activity and smoking, also cover the majority of patients at high risk of CHD particularly those with hypertension, diabetes and a BMI greater than 30. The new GMS contract provides significant opportunities for strengthening the prevention and management of coronary heart disease in primary care. The quality and outcomes framework cover the quality indicators with respect to prevention and management of CHD, and determine payments. Furthermore, PCTs are expected to promote chronic disease management in primary care, and a National Service Framework is currently being prepared. The Department of Health (DH) estimates that 80% of primary care consultations and two thirds of emergency hospital admissions are related to chronic conditions such as diabetes, heart failure, asthma, respiratory disease (DH 2004). Much of the evidence and experience is drawn from the US (eg Kings Fund 2004, Surrey 41

42 & Sussex 2004). Programmes identified within these documents of chronic disease management in primary care are made up of many different components. Evidence suggests that such programmes tend: to improve quality of care but it remains uncertain which components are most effective. to improve clinical outcomes but the evidence is not of the highest quality. to reduce the use of health care resources and healthcare costs. Local Progress The local prevalence of CHD within general practice populations might be assessed using the proxy of deprivation ie the most deprived practices are more likely to have higher levels of CHD. While practice populations in Hull are comparatively deprived, particularly when compared with the East Riding, there are some practices that have less deprived populations. Additionally, deprivation measures applied to geographical areas only represent the average or typical level of deprivation over the entire area. Smaller areas within that area will be more deprived whereas others will be more affluent. Some variation in prevalence of CHD across practices could therefore be expected. Locally a number of initiatives aim to promote prevention and management of CHD in primary care. Clinical audit data, (despite some difficulties with data quality) provides some indication of the prevalence of CHD locally as measured through contact with primary care, and level of secondary prevention activity. West Hull PCT s most recent CHD clinical audit provides data for 2003/4, based on a high response rate (26 out of 28 practices). The audit defined the proportion of the practice population under 75 diagnosed with CHD as being on their CHD register, and reports use of drug and lifestyle interventions. The average proportion of the population on CHD registers for West Hull was 2.4%, and ranged from 1.5% to 6%. Overall the findings suggest that there is considerable variation in level of management of CHD registers and application of CHD treatment protocols. Eastern Hull PCT s CHD clinical audit achieved a lower response rate, but suggests a similar variation in secondary prevention activity. National monitoring (QMAS) data will, in the future, provide regular reporting of CHD quality indicators by practice. East Hull PCT is piloting use of a software tool for examining the distribution of indicators and identifying practices which appear to be outside the expected range and should have further investigation. Eastern Hull PCT is also piloting a community outreach evaluation project. This aims to provide CHD risk assessment in community settings (with follow up referral as appropriate). 42

43 The quality of information available did not allow full assessment of equity of access to CHD prevention programmes in primary care. However the findings of clinical audits within Hull suggest that there is considerable variation across practices in level of CHD prevention activity. (The prescribing case study also suggests variation in practice relating to factors other than deprivation) Section Conclusion and Recommendations Overall, the audit suggests that there is considerable potential for development of prevention and management of CHD in primary care, linked to implementation of new GP contracts (ngms). The following should be considered: - The CHD Collaborative should provide agreed guidance and protocols for CHD care pathways (including referral criteria), implementation of NICE guidance with regard to prescribing CHD drugs, and treatment of hypertension. Systematic audit of CHD Quality and Outcome indicators (QMAS data) to benchmark and promote sharing of good practice; and linkage with CHD secondary care audit. PCTs to consider facilitation programmes to support use of registers and strengthen systems of risk factor screening and management, as well as access to secondary care. Piloting and evaluation of outreach initiatives for primary prevention of CHD focused on the most deprived communities. Strengthened links from specialist health promotion services support to practice based CHD prevention programmes particularly in the most deprived areas (including referral schemes for physical activity coverage of low income groups, smoking cessation programme). Review and development of approaches to chronic disease management with respect to CHD. The audit demonstrates the need to investigate the use of new GP data systems for service development, monitoring and audit purposes; including health equity auditing and also linkage to inpatient data. 43

44 6.5 Access to CHD drugs Access to CHD drugs was examined to determine whether or not inequalities existed. Three main categories of CHD drug were considered. Higher prescribing of CHD drugs in areas of greater need, ie the most deprived areas, would provide some evidence of equity of access to CHD drugs locally. Data was anonymised to overcome concerns about identification of GP practices. CHD Equity and Drugs This section begins with an analysis which examines whether or not there are any inequalities of access to CHD drugs and poses the question, are we attempting to improve the health of the most deprived by differentially high prescribing of CHD drugs in areas of greater need? This would be seen as an attempt to achieve equity of health where the health profiles of deprived groups are selectively targeted in order to constrain the worst effects of health inequality. Background This analysis is concerned with three main categories of CHD drugs: - Statins Statins reduce the amount of cholesterol which can be synthesised in the liver by inhibiting an enzyme involved ii its synthesis. In 1997, Statins were found to have direct effects in the form of: - A reduction in recurrent coronary events if given immediately following an acute coronary event such as MI or stent implantation, when compared to placebo or no treatment. A reduction in graft vessel disease following heart or kidney transplants, and reduced re-narrowing after vascular injury. Other Lipid Lowering Drugs These are a range of drugs, separate from Statins, which have an effect of lowering cholesterol levels. Drugs which bind to bile acids in the intestine. This inhibits their reabsorption and increases their excretion by up to tenfold. Drugs which increase the activity of lipoprotein lipase in adipose tissue and thereby increasing catabolism of Very Low Density Lipoprotein (VLDL). Niacin which inhibits VLDL secretion and decreases production of Low Density Lipoprotein (LDL). Clopidogrel Clopidogrel is a drug used in cases which are related to any group of clinical symptoms associated with narrowing of the blood vessels which supply the heart. These may be acute myocardial ischemia, acute myocardial infarction or 44

45 unstable angina. The narrowing is often due to the result of damage to the blood vessels caused by the build up of fat deposits on the arterial walls and subsequent clot formation. Clopidogrel inhibits platelet aggregation by irreversibly modifying the platelet receptor, blocking the aggregation of platelets. It is usually used in conjunction with aspirin. The average annual cost is estimated to be 464 per patient. Caution should be exercised when considering Clopidogrel prescribing. Clopidogrel prescribing is considered by some to be an indicator of poor prescribing if it is prescribed in place of aspirin. NICE technology appraisal guidance No. 80 states that Clopidogrel, in combination with low-dose aspirin, is recommended for use in the management of non-st segment-elevation acute coronary syndrome in people who are at moderate to high risk of MI. CHD Equity and Drug prescribing rates Comparisons between prescribing of CHD related drugs within different geographical areas, as defined by GP practice, gives the opportunity to test whether there is inequality of access to important CHD drugs within different PCTs. In order to make comparisons between different practices and PCTs it is necessary to compensate for different characteristics, such as age, gender, temporary residence status, etc. The approach within the NHS is to issue a Prescribing Unit for each practice. These prescribing units are issued for the main disease areas and attempt to make the adjustments necessary for comparison. This analysis presents in table 6.2 the items per 1000 cardiovascular prescribing unit (CPU) and the cost per 1000 CPU. It should be noted, however, that different practices or PCTs would be expected to have a different need for prescribing. If the health profile of a practice or PCT were to be worse than another, in order to achieve equality of health outcome there would need to be increased prescribing to merely equal the pattern in an area where the health need is less. 45

46 Table 6.2 CHD drug prescribing by PCT April March 2003 April March 2004 ITEMS PER 1000 CARDIO PU COST PER 1000 CARDIO PU ITEMS PER 1000 CARDIO PU COST PER 1000 CARDIO PU STATINS E YORKS E HULL W HULL Y W COAST MEAN OTHER LIPID REGULATING E YORKS E HULL W HULL Y W COAST MEAN CLOPIDOGREL E YORKS E HULL W HULL W COAST MEAN This descriptive analysis indicates that different PCTs have different rates of prescribing CHD drugs. In the case of Statins, East Yorkshire PCT appears to have the lowest prescribing ratio, with West Hull next and Yorkshire Wolds and Coast being close to or below the mean. Eastern Hull, which would be expected to have the worst CHD health profile hence the greatest need has significantly higher prescribing levels than the others, suggesting that there is greater access to CHD drugs for those in greatest need. We see a similar pattern for Lipid regulating drugs and Clopidogrel. The findings with respect to West Hull are surprising. West Hull would be expected to have broadly similar rates to Eastern Hull, due to similar demographics. However this effect is not evident. There is a possibility that West Hull PCT may have a significant number of ( healthier ) people from the East Riding registered with GP practices, approximately 10% of West Hull GP patients are East Riding residents and prescribing rates might be skewed by this effect. 46

47 Pattern of CHD prescribing at practice level, using deprivation of proxy for need A more detailed analysis using a range of regression techniques, including ordinal and multinomial logistic regression, was undertaken to further test whether prescribing differed according to need. The IMD at practice level was used as a proxy for poor CHD health outcome. Data limitations in the form of the small number of events prevented use of actual measures of CHD mortality. However the validity of the IMD as a proxy was assessed by calculation of it s correlation with CHD Standardised Mortality Ratios. The correlation coefficient of , (where perfect correlation would be 1 and no correlation 0) indicates that it is reasonable to adopt the IMD as a proxy for CHD SMR. The relationship between deprivation (IMD) used as a proxy for need, and prescribing of CHD drugs was examined using a set of ordinal logistic regressions (with the dependent variable an expression of deprivation/poor CHD health outcome). Three models were initially run to explore the relationships between deprivation and the three drug types: statins, clopidogrel and lipid lowering drugs for 2003 and It is necessary to run three separate regression models, due to the collinearity of the three drug variables, i.e. associations between the 3 drugs due to their being prescribed for the same illness. The results of the regression analyses are shown in table 6.3 with the quintiles representing the local quintiles (see section on deprivation) where category 5 is the most deprived 20% of local areas. The values in the table may be thought of as the general impact on prescribing from deprivation. All coefficients were statistically significant (at better than the level). Table 6.3 Probability of being prescribed drugs by deprivation (Quintile 5 is most deprived and quintile 1 is the least deprived) R- SQUARED YEAR PROBABILITY IMD QUINTILE 1 PROBABILITY IMD QUINTILE 2 PROBABILITY IMD QUINTILE 3 PROBABILITY IMD QUINTILE 4 PROBABILITY IMD QUINTILE 5 STATINS LIPID REGULATING CLOPIDOGREL Statins There is a strong and positive relationship between prescribing rates and deprivation, which suggests that statin prescribing is greater for those who are more deprived and more likely to have a worse CHD health profile. The analysis indicates that across the range of quintiles of deprivation the probability of being 47

48 prescribed statins is different, those within higher deprivation quintiles having greater probability of being prescribed statins. It can be seen that there is a difference between the probabilities between years 2003 and 2004, with the probabilities increasing significantly in 2004, indicating the influence of time and changing practice which has been proportionate over the deprivation groups. Other lipid lowering drugs Other lipid regulating drugs show a very similar pattern to the statins, with a higher probability of being prescribed the drug if in the group which exhibits greater deprivation/worse CHD health. Increased probabilities are evident in 2004 compared with 2003, indicating prescribing growth. A similar increase in prescribing has occurred over most of the deprivation groups. Clopidogrel It may be seen that the R-squared on the clopidogrel results is smaller, suggesting a smaller influence of deprivation on prescribing compared with other factors than for statins and lipid regulating drugs. A similar, although smaller, increase in probability is shown as deprivation increases between low levels of deprivation (IMD Quintile 1) and the most deprived (IMD Quintile 5). Time Series Cross-Sectional Analysis In order to account for individual heterogeneity at the practice level, a series of regressions were run using the whole dataset combined into a time series crosssectional format. This technique allows such factors as differing views among the practices, such as drug efficacy, patient responsiveness, and other unobservable practice variations to be taken into consideration. (As well as other unobservable missing variables or factors). (The full computer output is not presented here, due to space limitations, but is available on request.) The results supported the previous analysis, but indicated that: Whilst there is evidence of heavier prescribing within the more needy groups in terms of CHD morbidity/mortality and deprivation, there is still a high degree of variability in prescribing patterns due to other factors. The variations in CHD drug prescribing are heavily influenced by different practice level characteristics, which may be accounted for by: o Differing physician opinions on the availability efficacy, effectiveness or cost-effectiveness of the drugs o Differing awareness of the availability of drugs o Differing degrees of patient awareness and demand for drugs from patients. With time (over the 2 years) the variations in prescribing were becoming less, indicating that the above factors were becoming less important with time. 48

49 6.5.2 Section conclusion and recommendations Based on this analysis, there appears to be generally good evidence that, within the Hull and East Yorkshire PCTs areas, the prescribing of CHD-related drugs is being directed towards those in greatest need in terms of CHD morbidity and mortality, (with deprivation indices used as a proxy). This implies, (but does not prove) that equity of access operates, and that there is general movement towards greater equity over time (with less variation in prescribing due to other factors). The results, however, suggest that there is a great deal of variation in prescribing which can not be attributed to deprivation. There is a need for clear prescribing criteria, protocols and audit. It is recommended that this analysis should be repeated at yearly intervals using time-series cross-sectional analysis to evaluate the degree to which prescribing practice is changing, and confirm this pattern of prescribing according to need/deprivation. Future work might assess reasons why there appears to be differences in the uptake/prescribing of CHD drugs within different practices and address these issues through audit, education and appropriate guidelines/protocols. Audit of drugs associated with CHD outcomes should be planned and should consider targets in relation to lipid level outcomes. Consideration should be given to ways in which GPs may be audited for compliance to local or NICE guidelines, particularly in view of the high effectiveness, but also relatively significant cost of these drugs. Such audit should incorporate equity as a domain in the evaluation. Modeling might take place to evaluate the cost-effectiveness of different lipid lowering drugs in the achievement of target levels. Collaborative work with the Acute Sector should be considered to develop ways in which prescribing might be more consistent and targeted towards optimum intermediate outcomes in terms of lipid control. 49

50 6.6 Access to CHD inpatient treatment In order to understand the equity issues with respect to admission to hospital, this audit undertakes analysis of CHD in-patient admission, angiography and revascularisation rates in Hull & East Riding. The number of in-patient admissions with a primary diagnosis of CHD or involving one of the following procedures: angiogram; percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) was obtained from Hospital Episode Statistics for the period April 2002 to March 2004 for each gender, age group (5-year band) and ward of residence of the patient. Overall, there were 7791 in-patient admissions with a primary diagnosis of CHD, 1706 angiograms, 724 PCIs and 521 CABGs undertaken in the two years in Hull and East Riding. The population within each ward by gender and age group was obtained from 2004 GP practice list registration numbers. The age-standardised rates of CHD in-patient admissions, angiography, PCIs, CABGs and PCI/CABG combined (any revascularisation) were calculated using the Hull and East Riding population as the standard population. The age-standardised CHD in-patient admission rates were calculated per thousand persons and the angiography and revascularisation rates were calculated per 100,000 persons. The rates have been examined in relation Index of Multiple Deprivation (2004) scores. Rates of CHD in-patient admissions were calculated for each ward. Due to the smaller number of events, angiography and revascularisation rates were calculated for each PCT and for each Local Authority (LA) area. 50

51 6.6.1 CHD In-Patient Admission Mapping CHD in-patient admission rates across Hull & East Riding Electoral Wards Hospital admission rates (emergency and elective) with a diagnosis of CHD for each of the 49 electoral wards were divided into five approximately equal groups. (an admission rate between 4 and 5.7 per 1000 persons is shaded light blue (the lowest rate) and an admission rate of over 8.4 per 1000 persons is shaded dark blue (the highest rate). Figure 6.1 illustrates the rates for Hull, with figure 6.2 showing the names of the electoral wards. Figures 6.3 and 6.4 show the rates and electoral wards respectively for the East Riding. Figure 6.1 Hull CHD In-patient admission rates by ward 51

52 Figure 6.2 Reference map of Hull wards 52

53 Figure 6.3 East Riding CHD In-patient admission rates by ward 53