Socioeconomic variations in responses to chest pain: qualitative study
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7349.1308 (Published 01 June 2002) Cite this as: BMJ 2002;324:1308
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Sir - The paper by Richards and colleagues1 is an excellent example
of how qualitative research can be nested within an epidemiological study.
The authors conclude that individuals with chest pain of lower
socioceconomic status are more reluctant to seek care from their general
practitioner and this may be important in understanding social inequities
in receipt of cardiac care. We have examined this using an alternative
case-vignette approach2 in large population-based samples. Subjects report
whether they would seek health care if they had experienced the same chest
pain as in our vignette as well as their lay diagnosis and various
attitudinal measures. Our results support some but not all of the
conclusions reached by Richard's and colleagues.
More affluent
participants were more likely to consider our chest pain history to be
cardiac compared to poorer subjects (proportion reporting symptoms coming
from the heart: social class I&II, 73.6; IIINM, 71.0; IIIM 61.6;
IV&V 63.8; p value for trend=0.003). Poorer subjects, in line with the
results reported by Richards and colleagues, were more concerned not to
waste their general practitioner's time (proportion who strongly agreed
that people use the GP unnecessarily increased across social class groups:
social class I&II, 9.5; IIINM 15.5; IIIM 22.1; IV& V 17.7; p value
for trend <_0.001 _.="_." p="p"/> Our results, however, found that poorer subjects, as assessed by a 5
point socioeconomic indicator, were more likely to report seeking medical
care (age and sex adjusted odds ratio for 1 unit increase in socio-
economic indicator 1.29, 95% CI 1.13-1.46; p value for trend <_0.001.3 these="these" results="results" are="are" based="based" on="on" hypothetical="hypothetical" rather="rather" than="than" real="real" consultation="consultation" behaviour="behaviour" and="and" may="may" therefore="therefore" be="be" biased.="biased." we="we" re-examined="re-examined" the="the" original="original" quantitative="quantitative" data="data" reported="reported" by="by" richards="richards" colleagues="colleagues" as="as" part="part" of="of" same="same" study.4="study.4" see="see" table="table" consistent="consistent" with="with" our="our" findings="findings" showing="showing" overall="overall" that="that" rose="rose" angina="angina" positive="positive" subjects="subjects" residing="residing" in="in" poor="poor" areas="areas" more="more" likely="likely" to="to" actually="actually" present="present" their="their" general="general" practitioner="practitioner" contrast="contrast" current="current" conclusion.="conclusion." p="p"/> Studies combining quantitative and qualitative methods are important
in understanding the decision making process that patients make when
choosing to seek or not seek health care. We do however question their
conclusion that poorer individuals are more stoical and less likely to
seek medical help when they develop symptoms.
Ben-Shlomo Y, Senior Lecturer in Clinical Epidemiology
Adamson J, MRC research fellow
Donovan J, Prof. of Social Medicine
Chaturvedi N* Prof. of Primary Care Epidemology
Department of Social Medicine, University of Bristol, Canynge Hall,
Whiteladies Road, Bristol BS8 2PR
* Department of Epidemiology and Public Health, Imperial College School of
Medicine, Norfolk Place, London W2 1PG
Author for correspondence: Yoav Ben-Shlomo,
email y.ben-shlomo@bristol.ac.uk
References
1. Richards HM, Reid ME, Watt GCM. Socioeconomic variations in
responses to chest pain: qualitative study. BMJ 2002;324:1308-1311.
2. Chaturvedi N, Rai H, Ben-Shlomo Y. Lay diagnosis and health-care
-seeking behaviour for chest pain in South Asians and Europeans. Lancet
1997;350:1578-1583.
3. Adamson J, Donovan J, Chaturvedi N, Ben-Shlomo Y. Open SESAME - the
impact of socioeconomic status on health care seeking behaviour. Journal
of Epidemiology and Community Health 2000;54 (Supplement):A23.
4. Richards H, McConnachie A, Morrison C, Murray K, Watt G. Social and
gender variation in the prevalence, presentation and general practitioner
provisional diagnosis of chest pain. Journal of Epidemiology &
Community Health 2000;54:714-718.
Table: Odds ratio (adjusted for gender) for presenting to general practitioner by area deprivation score and Rose angina grade from Glasgow Monica Project* Deprivation category 1, 2 (least deprived) 3,4,5 6,7 (most deprived) p-value for trend Rose angina II 1.00 1.05 0.85 0.66 Rose angina I 1.00 1.36 2.69 0.0005 Rose angina I & II 1.00 1.51 2.10 0.002 * Data re-analysed from Richards et al4 adjusting for gender but without adjustment for age group as data not available
Competing interests: Table: Odds ratio (adjusted for gender) for presenting to general practitioner by area deprivation score and Rose angina grade from Glasgow Monica Project*Deprivation category1, 2 (least deprived) 3,4,5 6,7 (most deprived) p-value for trendRose angina II 1.00 1.05 0.85 0.66Rose angina I 1.00 1.36 2.69 0.0005Rose angina I & II 1.00 1.51 2.10 0.002* Data re-analysed from Richards et al4 adjusting for gender but without adjustment for age group as data not available
Emergency room chest pain presentations among the uninsured vs. the insured
First and foremost, I would like to commend the study by Richards,
Reid, and Watt. I believe that their study gives us good insight at chest
pain presentations along the lines of socioeconomic status.
With my experience in a large American inner city emergency room , I
have noticed interesting trends among chest pain patients in regards to
patients who are insured versus the uninsured.
Most patients take chest pains very seriously. I've noticed that the
patients who do not have health insurance seem to present their cases to
the emergency room for a number of reasons. Among these reasons:
1. No health insurance means it is difficult to seek medical care
from a primary care practitioner.
2. The uninsured patients will usually only come to the emergency
room for services if they are in great fear of MI, or if the pain is
disrupting their normal activities.
Patients that do have health insurance tend to come to the emergency
room for chest pains for a number of reasons:
1. Advice from their physician to seek medical services at chest pain
onset.
2. Relief of pain.
3. Assumption that the they should utilize their health insurance for
any pains associated with chest.
Insured patients have access to regular medical care from primary
care practitioners. They are usually educated about proper health
maintenance and illness prevention. This education, in the long run, will
save the insurance companies and the hospital money from possible future
emergency room expendatures.
The uninsured do not have this access to prevention techniques and
medical education. They will tend to "shake off" the pain (wait for it to
go away) in large part because they do not want to get stuck with a hefty
bill from the emergency room. Other uninsured do not trust the medical
field, due to some belief that they are treated unequally by medical staff
due to lack of insurance coverage.
These are just general observations that I picked up at the emergency
room where I am at. When it comes to chest pains, immediate medical
attention should be given to the patient, whether insured or uninsured.
More illness prevention on behalf of all patients will reduce the rates of
chest pains to emergency rooms, and in the long run, make the society more
equal when it comes to health care equality.
Competing interests: No competing interests