Despite universal health care, there continues to be regional access disparities to coronary angiography in Canada. Our objective was to evaluate the extent to which demand-side factors such as clinical urgency/need, and supply-side factors, as reflected by differences in physician and procedural supply account for these inequalities.
Our cohort consisted of 74,254 consecutive patients referred for coronary angiography in Ontario, Canada between April 1st 2005 and March 31st 2006, divided into three urgency strata based on a clinical urgency scale. Cox-proportional hazard models were developed, adjusting for age, gender, socioeconomic status (SES), region, and urgency score, with greater hazard ratios (HR) indicating shorter wait times. To evaluate mediators of any residual wait-time differences, we examined the influence of the regional supply of cath lab facilities, invasive cardiologists and general practitioners (GP).
We found that the urgency score was a significant predictor of wait time in all three strata (urgent patients: HR 1.61 for each unit increase in patient urgency (95% Confidence interval (CI) 1.55-1.67); semi-urgent patients: HR 1.55 (95% CI 1.44-1.68); elective patients: HR 1.13 (95% CI 1.08-1.18)). After accounting for clinical need/urgency, regional wait time differences persisted; these were most consistently associated with variation in cath lab supply. The impact of invasive cardiologist supply was restricted to urgent patients while that of GP supply was confined to semi-urgent and elective patients.
We found that there remained significant regional disparities in access to coronary angiography after accounting for clinical need. These disparities are partially explained by variations in supply of both procedural capacity and physician services, most notably in elective and semi-urgent patients.
Cites: Health Aff (Millwood). 2007 Jul-Aug;26(4):1078-8717630450
Cites: Circulation. 2008 Jan 15;117(2):261-9518079354
Cites: Heart. 2002 Nov;88(5):460-612381632
Cites: CMAJ. 2003 Feb 4;168(3):261-412566329
Cites: J Am Coll Cardiol. 2003 Aug 6;42(3):410-912906964
Cites: JAMA. 2004 Apr 21;291(15):1864-7015100205
Cites: Can J Cardiol. 2005 Nov;21(13):1203-916308597
Cites: Soc Sci Med. 1993 Jul;37(1):61-78332926
Cites: Health Serv Manage Res. 1997 Nov;10(4):216-2410174511
Cites: Med Care. 1998 Jul;36(7):1022-329674620
Cites: N Engl J Med. 1999 Oct 28;341(18):1359-6710536129