- Open Access
Practice characteristics and prescribing of cardiovascular drugs in areas with higher risk of CHD in Scotland: cross-sectional study
International Journal for Equity in Healthvolume 7, Article number: 18 (2008)
We examine whether practices in areas with higher risks of CHD prescribe different levels of cardiovascular drugs and describe how they differ in GP and practice characteristics.
Propensity score matching was used to identify two groups of practices in Scotland. The cases were in areas with 5% or more of the population in South Asian ethnic groups. The controls were in areas with less than 1% of the population in South Asian ethnic groups and were matched for other population characteristics.
The 39 case practices have lower prescribing rates than the matched controls for all heart disease drugs Significant different are found for six drugs (statins, ace Inhibitors, clopidogrel, thiazides, warfarin and digoxin. The differences range from 12.8% less for amlodipine to 43.9% for clopidogrel. The case practices also have lower prescribing costs than the unmatched group with the exception of ace inhibitors and aspirin. The highest prescribing costs for all drugs are found in the matched control group. The case practices are smaller than the controls, and have fewer GPs per 1,000 patients. Case practices have fewer quality markers and receive less in total resources, but have higher sums reimbursed to cover their employed staff costs.
Patients with higher risk of CHD tend to live in areas served by practices with lower prescribing rates and poorer structural characteristics. The scale of the differences in prescribing suggests that health care system factors rather than individual treatment decisions cause inequity in care. Identifying whether South Asian individuals are less likely to receive heart disease drugs than non South Asians requires individual-level prescribing data, which is currently not available in the UK.
In 2003 CHD was second only to cancer as the major cause of mortality in Scotland.  Although CHD mortality has fallen in recent years death rates from CHD are amongst the highest in the world and the second highest in Western Europe.  There is a strong correlation between increasing incidence and mortality from CHD and deprivation. CHD is also the major cause of morbidity and mortality in the South Asian population in the United Kingdom.  South Asians have been found to be at increased risk compared to the rest of the population of England and Wales  by at least 40 percent. [5–7] Though Scotland has one of the worst incidences of heart disease in Europe  only one of the 19 studies identified in Bhopal's review was based in Scotland. [4, 9]
The concept of equity is a central objective of most health care systems in the developed world. While governments from across the political spectrum, both in the UK and internationally, have attempted to tackle perceived inequities in health care the concept of equity remains somewhat elusive. [10, 11] A theoretical framework has been set out which examines equity through three domains: equal access to health care for people in equal need; equal treatment for people in equal need; and equal outcomes for people in equal need.  This simple framework has been used as a basis to examine the equity of GP prescribing rates for statins and five major CHD drug groups focused around the equal treatment in equal need domain. [12, 13] These papers are amongst a growing body of work in the UK, which have focused on equity of prescribing. However, these studies have largely been confined to England and Wales. The purpose of this paper is to explore the equity of prescribing for a range of heart disease drugs in Scotland. Having established prescribing differences, the analysis then considers structural differences in GP and practice provision. Using a matching technique, we use examine the notion of equal treatment for people in equal need and how this relates to differences in equal access to health care.
Many patients do not receive the appropriate treatment for CHD. Research has found that prescribing rates of statins and lipid lowering drugs were negatively correlated with deprivation. [9, 14] The Acheson report highlighted the need for studies of ethnic inequalities.  Several studies have highlighted ethnic variations in access to and provision of hospital interventions. [16, 17] Although a more recent study found no evidence that South Asian ethnicity was associated with lower use of cardiac procedures or drugs independent of clinical need,  there has been little research conducted on the equity of prescribing in the community.
One US study based on individual data discovered that black and minority ethnic group patients were less likely to be prescribed a beta-blocker.  There are no studies based on individual level data from the UK. Two studies in England have shown negative correlations between prescribing of lipid-lowering drugs  and beta-blockers  with the estimated proportion of patients from South Asian ethnic groups. Members of ethnic minorities tend to be situated in deprived areas and deprived areas have been shown to have lower quality and fewer general practitioner services than more affluent areas. [21–23] While a study in Scotland has found under the new GMS contract that achievement levels for the taking of beta blockers for patients with CHD, was found to be negatively associated with deprivation .
Since ethnicity data are not available on individual prescriptions, we compare prescribing rates for practices serving areas with higher proportions of South Asian patients to those serving areas with lower proportions of South Asian patients. Thus, we can use higher proportions of South Asian patients as a proxy for higher risk of CHD and then assess whether practices with populations associated with higher CHD prevalence have higher prescribing rates. We use a statistical matching process since practices differ in a range of other dimensions that may influence prescribing. Propensity score matching is a method for matching members of different groups based on a range of characteristics. Comparisons of the matched groups reveal the impact of the stratifying variable. The use of a matching process allows for the formation of groups based on their risk of having CHD, which can be assessed from their ethnicity, deprivation, social factors such as health and education and demographic factors. Comparisons are made in prescribing rates of a wide range of drugs used in the treatment of heart disease.
National data are used to give 100% coverage of practices. Collection of characteristics of persons receiving prescriptions has only recently started to be piloted in the Scottish prescribing information system. It is therefore possible only to analyse variations in prescribing between practices (or higher organisational units). Ethnic compositions of practice populations are also not collected, so these must be estimated based on the ethnic compositions of the areas from which practices draw their populations.
The most recent and comprehensive information on the ethnicity of the Scottish population comes from the 2001 Census. Figures are produced for output areas (N = 42,604; average population = 117 persons) using the following ethnic groups: White (97.9%); Indian (0.3%); Pakistani and Other South Asian (0.9%); Chinese (0.3%); Other (0.6%).
We combined the Indian and Pakistani and Other South Asian groups and calculated the proportion of each output area's population from South Asian ethnic groups. We calculated the proportion of each practice's list resident in each output area as at September 2002 using an extract from the Community Health Index. We attributed the South Asian proportions to practices using this geographical breakdown to estimate the likely South Asian proportion of each practice's list. This process assumes that practices draw representative samples of individuals from the output areas.
We analysed the characteristics of patients and practices that were associated with the estimated South Asian proportion. We used a binomial logit multiple regression model  to identify the significant population characteristic predictors used to match the GP practices. [26–28] As well as providing an epidemiological analysis of the geographical distribution of South Asians in Scotland, this allowed us to generate a propensity score for each practice, representing the expected South Asian proportion given the other population factors with which it is significantly correlated. 
We compared the prescribing rates for the cases (practices with South Asian proportions over 5%) with figures for matched controls and unmatched controls. These figures are weighted averages where the weights represent the propensity of each control to match the cases. The propensity score matching results were estimated using STATA v8.2. We used the Kernel matching method , though the results are similar with other options. We estimated standard errors via bootstrapping with 100 replications.
We analysed data for a wide range of drugs used in the treatment of heart disease, including: statins, beta blockers, aspirin, warfarin, ACE inhibitors, clopidogrel, thiazide, digoxin, spironolactone and amlodipine. Prescribing rates were measured by age and sex standardisation of total Gross Ingredient Costs in 2001/2 by Specific Therapeutic group age-sex weightings related prescribing units (Star_PUs) for cardiovascular drugs, with the exception of lipid-lowering drugs for which we had Defined Daily Doses.
We also obtained a set of GP and practice characteristics from the General Medical Practitioner Database for October 2002 and GMS payments made to practices in the 2002/3 financial year. The Royal College of General Practitioners (RCGP) supplied lists of practices that had received Practice Accreditation (PA) or the Quality Practice Award (QPA) by the end of 2002.
Five variables were used in the matching equation covering deprivation, health rurality and number of temporary residents. Deprivation was measured by the Carstairs score, derived at output level. The Carstairs score is an unweighted sum of z-scores for four variables representing car ownership, male unemployment, social class and overcrowding. For health, two indirectly standardised variables taken from the Census representing the age sex standardised ratio for limiting long term illness and not good health were used. Variables representing the proportion of temporary residents and number of patients qualifying for a road mileage payment were also used.
Table 1 lists the variables used for matching and the matching equation. The table shows that the matching equation indicates that the cases group is significantly different from practices with less than 1% of the population with South Asian patients for all the variables with the exception of the number of temporary residents. Table 1 also shows that the matching process leaves us with a matched control group of 140 practices. The matched control group has higher deprivation and morbidity scores but the differences are not statistically significant. Both the cases and matched control group have higher deprivation and morbidity scores than the unmatched control group.
For all CHD drugs, case practices have lower prescribing costs than the matched controls. Significant different are found for six drugs (statins, ace Inhibitors, clopidogrel, thiazides, warfarin and digoxin. The differences range from 12.8% less for amlodipine to 43.9% for clopidogrel. The case practices also have lower prescribing costs than the unmatched group with the exception of ace inhibitors and aspirin. The highest prescribing costs for all drugs are found in the matched control group. However, this does not account for differences in deprivation and morbidity between the matched and unmatched controls group.
Table 3 shows that the cases group has nearly double the proportion of GPs over 55 than the matched control. Practices in the case group have significantly fewer GPs per practice (2.9 to 3.9) and receive less through performing minor surgery. There are no QPA or PMS practices in the cases group. The cases group have significantly fewer GPs (0.57 to 0.66) and WTE GPs (0.58 to 0.73) per 1000 of the population than the matched controls group. The cases group also receive significantly lower GMS payments (47.9 to 53.4)
The unmatched control group has the highest number of GPs per practice and higher number of GP and WTE per 100 of the population. They are more likely to be a training, PA or QPA practice. Practices in the unmatched control group also receive more through minor surgery and GMS payments than the other two groups.
This paper has examined equity of prescribing for a range of heart disease drugs in Scotland. We have found notable differences between practices serving areas with more than 5% of the population in South Asian ethnic groups and those with similar characteristics, but serving populations with less than 1%.
Previous research has consistently found that patients from South Asian ethnic groups have higher levels of CHD and consequently a greater need for provision and quality of health care. Thus, the findings of this study would suggest that prescribing rates and provision of care in Scotland are inequitable and that the inverse care law still applies. [10, 23]
Possible explanations and implications
Scotland has higher overall rates of CHD than the rest of the UK and most European countries as evidenced by available mortality and morbidity statistics. [2, 31] South Asian populations in the UK have a younger age profile than average leading to lower CHD rates and lower expected rates of prescribing. [32, 33] However, our case practices are concentrated in one Scottish NHS Board and this Board has the highest recorded rates of CHD in Scotland. [34, 35] Moreover the cases group has higher levels of deprivation than the unmatched control group. Thus prescribing should be higher in the cases group if deprivation is related to CHD prevalence. But we found higher prescribing for all drug groups in the unmatched control group for all but two of the indicators.
The degree to which differences in practice characteristics can explain our prescribing results is mixed. Case practices have fewer numbers of GPs who tend to work longer hours than those in the matched control group. This is of concern since South Asian patients have higher than average consultation rates.  Consequently a greater workload is placed on a fewer number of doctors within the cases group and lower prescribing rates have been found to be positively associated with lower ratios of GPs to patients.  Moreover, research into aspects of quality of care have emphasised the importance of adequate time for consultations with the view that GPs require greater time to be allowed to treat complex diseases such as CHD in the proper manner. [36, 38] There is little evidence with regard to the impact on prescribing rates for practices with accreditation. However, there is some evidence that training practices, of which there are far fewer in the cases group, have lower prescribing rates than non-training practices. [39, 40]
Strengths and weaknesses of the study
This study has the advantage of 100% coverage since the data are available for all practices. At the time the study was conducted other than for statins only cost data was available to the authors. Previous research has suggested that using prescribing rates based on prevalence rates is more beneficial than derived from costs patterns.  However volume remains the main driver of prescribing costs and needs based formulas adopted in England for prescribing expenditures have been based on net ingredient cost. . This study has the advantage of 100% coverage since the data are available for all practices. The findings are consistent across a wide range of drugs used in the treatment of heart disease. Lower levels of prescribing are observed relative to all other practices and to a set of matched controls. However, the analysis is ecological and the magnitude of the differences suggests that the results cannot be explained wholly by relative under-prescribing to South Asian individuals but rather is indicative of prescribing of practices in more deprived areas. We have estimated more than 20% differences in prescribing rates, yet South Asians represent only 9% of the population in the cases group. Taking account of the higher prevalence rate in South Asians suggests that no more than 11% of heart disease patients are South Asian. Even if no South Asian patients receive treatment and all non-South Asian patients receive treatment, this cannot account for the 20% difference in prescribing. Our results must therefore reflect, at least in part, contextual influences rather than compositional characteristics alone.  Our comparison of structural factors suggests that there are considerable differences in the structure of care delivery that may constitute part of these contextual influences.
This study shows that South Asians tend to be registered with practices with lower prescribing rates, but it would appear that all patients in these practices are at greater risk of having lower prescribing rates. Moreover, patients in these practices also suffer from poorer access to and lower quality GP services. Understanding the structural, attitudinal or behavioural reasons for lower prescribing in these practices and how these are affected by GP and practice provision is a challenge for future work. Identifying whether South Asian individuals are less likely to receive heart disease drugs than non South Asians will require individual-level prescribing analysis. Our results suggest that it will be important to identify the role of practice-related factors.
Scottish Health Executive Department: CHD/Stroke Task force Report. 2000, Scottish Executive
Wild S, McKiegue PM: Cross sectional analysis of mortality by country of birth in England and Wales. BMJ. 1997, 314: 705-710.
Bhopal R: What is the risk of coronary heart disease in South Asians? A review of UK research. Journal of Public Health Medicine. 2000, 22: 375-385. 10.1093/pubmed/22.3.375.
Shaukat N, de Bono DP: Are Indo-origin people especially susceptible to coronary heart disease?. Postgraduate Medical Journal. 1994, 70: 315-318.
McKiegue PM, Marmot MG: Mortality from coronary heart disease in Asian communities in London. BMJ. 1998, 297: 903-
Balarajan R: Ethnicity and variations in mortality from CHD. Health Trends. 1996, 28: 45-51.
Scottish Intercollegiate Guidelines Network: Lipids and the Primary Prevention of Coronary Heart Disease. Sign Publication Number 40. 1999
Primatesta P, Poulter NR: Lipid concentrations and the use of lipid lowering drugs: evidence from a national cross sectional survey. BMJ. 2000, 321: 1322-1325. 10.1136/bmj.321.7272.1322.
Hart JT: The inverse care law. Lancet. 1971, 1: 405-12.
Goddard M, Smith P: Equity of access to health care services: theory and evidence from the UK. Soc Sci Med. 2001, 53: 1149-1162. 10.1016/S0277-9536(00)00415-9.
Ward P, Noyce P, Leger A: How equitable are GP prescribing rates for statins?: an ecological study in four primary care trusts in North West England. International Journal for equity in Health. 2007, 6: 2-10.1186/1475-9276-6-2.
Ward PR, Noyce PR, St Leger AS: Exploring the equity of GP practice prescribing rates for selected coronary heart disease drugs: a multiple regression analysis with proxies of healthcare need. International Journal for Equity in Health. 2005, 4: 3-10.1186/1475-9276-4-3.
Patel MG, Wright DJ, Gill PS: Prescribing of lipid lowering drugs to South Asian patients: ecological study. BMJ. 2002, 325: 25-6. 10.1136/bmj.325.7354.25.
Acheson D: Independent report into inequalities in health. 1998, London: HMSO
Majeed FA, Chaturvedi N, Reading R: Equity in the NHS. Monitoring and promoting equity and secondary care. BMJ. 1994, 308: 1426-9.
Majeed FA, Eliahoo J, Bardsley M: Variation in coronary artery bypass grafting, angioplasty, cataract surgery, and hip replacement rates among primary care groups in London: association with population and practice characteristics. Journal of Public Health Medicine. 2002, 24: 21-26. 10.1093/pubmed/24.1.21.
Britton A, Shipley M, Marmot M, Hemingway H: Does Access to cardiac investigation and treatment contribute to social and ethnic differences in coronary heart disease? Whitehall II prospective cohort study. BMJ. 2004, 329: 318-321. 10.1136/bmj.38156.690150.AE.
Gottlieb S, McCarter R, Vogel R: Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. New England Journal of Medicine. 1998, 339: 489-497. 10.1056/NEJM199808203390801.
Ward P, Noyce P, Leger A: Are GP practice prescribing rates for coronary heart disease drugs equitable? A cross sectional analysis in four primary care trusts in England. Journal of Epidemiology and Community Health. 2004, 58: 89-96. 10.1136/jech.58.2.89.
Baker R: General practice in Gloucestershire, Avon and Somerset; explaining variations in standards. British Journal of General Practice. 1992, 42: 415-8.
Gilliam S: Provision of health clinics in relation to population need: another example of the inverse care law. British Journal of General Practice. 1992, 42: 54-6.
Watt G: The inverse care law today. The Lancet. 2002, 360: 252-254. 10.1016/S0140-6736(02)09466-7.
McLean G, Sutton M, Guthrie B: Deprivation and quality of primary care services: evidence for the persistence of the inverse care law from the UK Quality and Outcomes Framework. Journal of Epidemiology and Community Health. 2006, 60: 917-922. 10.1136/jech.2005.044628.
Maddala GS: Limited Dependent and Qualitative Variables in Econometrics. Econometric Society Monographs No.3. 1983, Cambridge University Press: New York
Scottish Health Executive Department: Fair Shares for All: Final Report. The National Review of Resources Allocation for the NHS in Scotland. 2000, Scottish Executive
Social Disadvantage Research Centre: Scottish Indices of Deprivation 2003. 2003, Department of Social Policy and Research Work University of Oxford
Scottish Executive Health Department: Statement of Fees and Allowances Payable To General Medical Practitioners in Scotland From 1 April 1990. 1990, Edinburgh: Scottish Executive, accessed October 2005, [http://www.sfa.scot.nhs.uk/]
Foster EM: Propensity score matching: an illustrative analysis of dose response. Medical Care. 2003, 41 (1): 1183-1192. 10.1097/01.MLR.0000089629.62884.22.
Deeks JJ, Dinnes J, D'Amico R, Sowden AJ, Sakovitch C, Song F, Petticrew M, Altman DG: Evaluating non-randomised intervention studies. Health Technology Assessment. 2003, 7 (27): 1-173.
General Registrar Office for Scotland. Vital events reference tables. 2002, (accessed 2 October 2005), [http://www.groscotland.gov.uk/files/02t1-7.pdf]
Pears E, Hannaford PC, Taylor MW: Gender, age and deprivation differences in the primary care management of hypertension in Scotland: a cross sectional database study. Family Practice. 2003, 20 (1): 22-31. 10.1093/fampra/20.1.22.
Watt GCM, Hart CL, Hole DJ, Smith GD, Gillis CR, Hawthorne VM: Risk Factors for cardio respiratory and all cause mortality in men and women in Urban Scotland: 15-year follow up. Scottish Medical Journal. 1995, 40 (4): 108-112.
Information and Statistics Division: Scottish Health Statistics 1999. NHS Scotland. 2000
Public Health Institute of Scotland: Health and well-being profiles for Scottish constituencies. NHS Scotland. 2004
Gilliam S, Jarman B, White P, Law R: Ethnic differences in consultation rates in urban general practice. BMJ. 1989, 299: 953-7.
Baker D, Klein R: Explaining outputs of primary health care: population and practice factors. BMJ. 1991, 303: 225-229.
Rice N, Dixon P, Lloyd DCEF, Roberts D: Derivation of a needs based capitation formula for allocating prescribing budgets to health authorities and primary care groups in England: regression analysis. BMJ. 2000, 320: 284-8. 10.1136/bmj.320.7230.284.
Sutton M, Gravelle H, Morris S, Leyland A, Windmeijer F, Dibben C, Muirhead M: Allocation of Resources to English Areas: Individual and small area determinants of morbidity and use of healthcare resources. Report to the Department of Health in England. Edinburgh: Information and Statistics Division. 2002
Steinke D, Bain D, McDonald T, Davey P: Practice factors that influence antibiotic prescribing in general practice in Tayside. Journal of Antimicrobial Chemotherapy. 2000, 46: 509-512. 10.1093/jac/46.3.509.
Ward P, Noyce P, Leger A: Developing prevalence-based prescribing units for analysing variations in general practitioner prescribing: a case study using statins. J Clin Pharm Ther. 2003, 28: 23-29. 10.1046/j.1365-2710.2003.00451.x.
Diez-Roux A: Bringing context back into epidemiology: variables and fallacies in multi-level analysis. Am J Public Health. 1998, 88: 216-22.
GM conceptualised the study with Prof Matt Sutton from the University of Manchester. GM conducted the data analysis, wrote and revised the manuscript. GM is the guarantor. The author would like to thank Prof Matt Sutton for his role in conceptualising the paper and advice on conducting the analysis.
GM was funded by the Platform Project when this analysis was undertaken. The Platform Project is a Scottish School of Primary Care collaborative venture between the Universities of Aberdeen, Dundee, Edinburgh and Glasgow, with ISDScotland and the Royal College of General Practitioners. It is jointly-funded by the Chief Scientist Office (Award No: RDG HR01012) and the Scottish Higher Education Funding Council (Award No: OOB/3/67).
The views expressed are the sole responsibility of the authors and not the funders.
The author declares that he has no competing interests.