Age- and sex-related bias in the management of heart disease in a district general hospital.
Dudley NJ., Bowling A., Bond M., McKee D., McClay Scott M., Banning A., Elder AT., Martin AT., Blackman I.
OBJECTIVE: To investigate the clinical management of heart disease and determine whether there was age- and sex-related bias in the use of investigations and interventions. DESIGN: Retrospective analysis of individual patient records against criteria of appropriateness based on published guidelines, clinical practice and literature relevant to the 1996-7 study period. SETTING: A single, district general hospital in London, serving a population of 185,000 people. SUBJECTS: General medical, elderly medical, and cardiology inpatients and patients attending elderly medical and cardiology outpatient clinics as new referrals between 1 April 1996 and 31 March 1997. RESULTS: We located case notes of 1790 of the 1975 subjects eligible for the study: 911 (51%) were outpatients and 51% were men. Patients aged <75 were significantly more likely than patients aged >or=75 years to be given thrombolysis after an acute myocardial infarction, to be given secondary prevention with aspirin and beta-blockers, to undergo exercise testing and coronary angiography, and to receive an echocardiogram. Men were also significantly more likely than women to have these investigations and interventions as well as to receive an angiotensin-converting enzyme inhibitor when left ventricular dysfunction was identified. Investigations and interventions were underused at all ages. CONCLUSION: As well as identifying age and sex bias, we found the underuse of investigations and interventions in all age groups in this district general hospital. Should similar patterns of care be found elsewhere, the delivery of high-quality care in an equitable manner (as identified by the National Service Framework for coronary heart disease) may require considerably more resources than have been allocated.