BMJ Open 2:e001025 doi:10.1136/bmjopen-2012-001025
  • Epidemiology
    • Research

Is access to specialist assessment of chest pain equitable by age, gender, ethnicity and socioeconomic status? An enhanced ecological analysis

  1. Gene Feder3
  1. 1Cardiac Directorate, Barts and the London NHS Trust, London, UK
  2. 2Department of Epidemiology and Public Health, University College London Medical School, London, UK
  3. 3Centre for Health Sciences, Barts and the London, Queen Mary's School of Medicine and Dentistry, University of London, London, UK
  1. Correspondence to Professor Adam Timmis; adamtimmis{at}
  • Received 14 February 2012
  • Accepted 1 May 2012
  • Published 14 June 2012


Objectives To determine whether access to rapid access chest pain clinics of people with recent onset symptoms is equitable by age, socioeconomic status, ethnicity and gender, according to need.

Design Retrospective cohort study with ecological analysis.

Setting Patients referred from primary care to five rapid access chest pain clinics in secondary care, across England.

Participants Of 8647 patients aged ≥35 years referred to chest pain clinics with new-onset stable chest pain but no known cardiac history, 7570 with documented census ward codes, age, gender and ethnicity comprised the study group. Patients excluded were those with missing date of birth, gender or ethnicity (n=782) and those with missing census ward codes (n=295).

Outcome measures Effects of age, gender, ethnicity and socioeconomic status on clinic attendance were calculated as attendance rate ratios, with number of attendances as the outcome and resident population-years as the exposure in each stratum, using Poisson regression. Attendance rate ratios were then compared with coronary heart disease (CHD) mortality ratios to determine whether attendance was equitable according to need.

Results Adjusted attendance rate ratios for patients aged >65 years were similar to younger patients (1.1, 95% CI 1.05 to 1.16), despite population CHD mortality rate ratios nearly 15 times higher in the older age group. Women had lower attendance rate ratios (0.81, 95% CI 0.77 to 0.84) and also lower population CHD mortality rate ratios compared with men. South Asians had higher attendance rates (1.67, 95% CI 1.57 to 1.77) compared with whites and had a higher standardised CHD mortality ratio of 1.46 (95% CI 1.41 to 1.51). Although univariable analysis showed that the most deprived patients (quintile 5) had an attendance rate twice that of less deprived quintiles, the adjusted analysis showed their attendance to be 13% lower (0.87, 95% CI 0.81 to 0.94) despite a higher population CHD mortality rate.

Conclusion There is evidence of underutilisation of chest pain clinics by older people and those from lower socioeconomic status. More robust and patient focused administrative pathways need to be developed to detect inequity, correction of which has the potential to substantially reduce coronary mortality.


  • To cite: Sekhri N, Timmis A, Hemingway H, et al. Is access to specialist assessment of chest pain equitable by age, gender, ethnicity and socioeconomic status? An enhanced ecological analysis. BMJ Open 2012;2:e001025. doi:10.1136/bmjopen-2012-001025

  • Contributors NS, AT and GF contributed to design and analysis. NW, SE and CJ contributed to analysis. All authors contributed to preparation of manuscript.

  • Funding This study was funded by the NHS Service Delivery and Organisation Research and Development Programme, to which interim progress reports were submitted. The funding body was not involved in study design or analysis.

  • Competing interests None.

  • Patient consent Permission was given by the National Patient Information Advisory Group17 to link anonymised data sets without individual patient consent.

  • Ethics approval Ethics approval was provided by the multiregional ethics committee (MREC /02/04/095).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement We would be happy to share anonymised data on request.

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