People living in the Most Deprived (MD) areas of Sheffield experience more than double the rate of premature mortality from coronary heart disease when compared with Least Deprived (LD) areas. While the social determinants of health are likely to be the most significant factors contributing to this inequity, this two-phase pragmatic health services research project explored the effect of deprivation on the triggers and rates of cardiology outpatient referrals from Sheffield General Practitioners (GPs).
The first qualitative phase involved semi-structured interviews and a focus group with GPs working in socio-economically contrasting areas of Sheffield. The second quantitative phase produced a retrospective observational analysis of the relationship of deprivation upon GP cardiology outpatient referrals in Sheffield (2008/09).
Themes influencing referral triggers from GPs working in MD areas included patient fear, reluctance and health literacy. In contrast, themes from GPs working in LD areas included articulate patients with high expectations, private referrals and awareness of litigation. Decision-making in MD areas was described as being ‘doctor-led’ which contrasted with ‘patient-led’ descriptions from participants in LD areas.
Binary logistic regression analysis revealed a positive relationship between deprivation and elective cardiology referrals for patients aged ≤70 years; however, this relationship was lost for older patients*
The novel findings of this research present the GP experience when making referral decisions, and reflect the differing pressures of consulting with patients at the extremes of socio-economic position. The findings highlight some of the many challenges faced by people living in deprived areas, contributing to health inequity. Despite the encouraging positive association found between deprivation and referral rates, further analysis is needed to confirm if referrals are proportionate to need, and therefore equitable.
*(<55 years: OR= 1.23, p<=0.0010, 95%, CI 1.15 to1.31) (55-70 years: OR= 1.08, p=0.005, 95% CI 1.02 to 1.14) (>70 years: OR= 0.96, p=0.095, 95% CI 0.91 to 1.01).
