Boyd, J.

Capewell, S.

Chalmers, J.

Finlays, A.

MacIntyre, K.

McMurray, J.

Pell, J.

Redpath, A.

Stewart, S.

English

PubMed

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Relation between socioeconomic deprivation and death from a first myocardial infarction in Scotland: population based analysis

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We thank the midwives for enthusiastically sharing their knowl›edge and experience and Peter Hope and Pat Townshend forcomments on an earlier draft of the paper.Contributors: PA initiated the study, was involved in all itsaspects, and is the guarantor; ER contributed to study design,interpretation of data, and writing of the paper; NTF and MJRcontributed to many discussions on vitamin K and to writing thepaper.Funding: Data collection was funded by a nursing researchfellowship awarded to PA by the Smith and NephewFoundation. Other aspects of the study were funded by the Leu›kaemia Research Fund.Competing interests: None declared.1 Golding J, Greenwood R, Birmingham K, Mott M. Childhood cancer,intramuscular vitamin K, and pethidine given during labour. BMJ1992;305:341›6.2 Ekelund H, Finnstrom O, Gunnarskog J, Kallen B, Larsson Y.Administration of vitamin K to newborn infants and childhood cancer.BMJ 1993;307:89›91.3 Klebanoff MA, Read JS, Mills JL, Shiono PH. The risk of childhood can›cer after neonatal exposure to vitamin K. N Engl J Med 1993;329:905›8.4 Olsen JH, Hetz H, Blinkenberg K, Verder H. Vitamin K regimens andincidence of childhood cancer in Denmark. BMJ 1994;308:895›6.5 Von Kries R, Göbel U, Hachmeister A, Kaletsch U, Michaelis J. Vitamin Kand childhood cancer: a population based case›control study in LowerSaxony, Germany. BMJ 1996;313:199›203.6 Ansell P, Bull D, Roman E. Childhood leukaemia and intramuscular vita›min K: findings from a case›control study. BMJ 1996;313:204›5.7 McKinney PA, Juszczak E, Findlay E, Smith K. Case›control study ofchildhood leukaemia and cancer in Scotland: findings for neonatal intra›muscular vitamin K. BMJ 1998; 316:173›7.8 Passmore SJ, Draper G, Brownhill P, Kroll M. Ecological studies ofrelation between hospital policies on neonatal vitamin K administrationand subsequent occurrence of childhood cancer. BMJ 1998;316:184›9.9 Passmore SJ, Draper G, Brownhill P, Kroll M. Case›control studies of rela›tion between childhood cancer and neonatal vitamin K administration.BMJ 1998;316:178›84.10 Parker L, Cole M, Craft AW, Hey EN. Neonatal vitamin K administrationand childhood cancer in the north of England: retrospective case›controlstudy. BMJ 1998;316:184›93.11 Barton JS, McNinch AW, Tripp JH. Oral vitamin K prophylaxis andfrequency of late vitamin K deficiency bleeding. Lancet 1994;343:1168.12 National Childbirth Trust. Parents’ rights denied over vitamin K. Report tothe Department of Health. London: NCT, 1994.13 Department of Health. Vitamin K for newborn babies. Letter from the chiefmedical and nursing officers of England to all doctors, regional directorsof public health, district nursing officers, midwives and health visitors.London: Stationery Office, 1998. (PL/CNO/998/4.)14 Royal College of Midwives. Position paper 13b: vitamin K. RCM MidwivesJournal 1999;2(8):252›3.15 Department of Health. NHS hospital and community health servicesnon›medical workforce census England: 30 September 1998. Detailed results.Leeds: NHS Executive, 1999.16 Scottish health statistics 2000. Edinburgh: ISD Scotland, 2000:table P3.8.on www.show.scot.nhs.uk/isd/Scottish_Health_Statistics/SHS2000/home.htm (accessed 23 March 2001).17 Health Statistics and Analysis Unit, National Assembly for Wales,personal communication, 2000.18 Project Support Analysis Branch, Northern Ireland Assembly, personalcommunication, 2000.19 Barton JH, Tripp JS, McNinch AW. Neonatal vitamin K prophylaxis in theBritish Isles: current practice and trends. BMJ 1995;310:632›3.20 Handel J, Tripp JH. Vitamin K prophylaxis against haemorrhagic diseaseof the newborn in the United Kingdom. BMJ 1991;303:1109.21 Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveyspublished in medical journals. J Clin Epidemiol 1997;50:1129›36.(Accepted 8 March 2001)Relation between socioeconomic deprivation and deathfrom a first myocardial infarction in Scotland: populationbased analysisKate Macintyre, Simon Stewart, James Chalmers, Jill Pell, Alan Finlayson, James Boyd,Adam Redpath, John McMurray, Simon CapewellHealth policy now explicitly addresses the increasinginequalities arising within many countries.1 Although itis generally accepted that socioeconomic factors influ›ence the overall rates of coronary heart disease events,2studies of case fatality after admission to hospital foracute myocardial infarction show only modestsocioeconomic gradients.3 By focusing on those whosurvive to reach hospital, however, such studies mayunderestimate the true influence of socioeconomicdeprivation. Reports suggest that around 70›80% ofdeaths within 30 days of a myocardial infarction occurbefore admission to hospital, and this proportionincreases with age.4 We therefore examined the effectof socioeconomic deprivation not only on case fatalityin patients admitted with myocardial infarction butalso on the risk of death before admission.Participants, methods, and resultsData were obtained from the Scottish MorbidityRecord and General Register Office on all Scottishresidents for whom a first myocardial infarction (code410, international classification of diseases, 9threvision) was the principal cause of death or admissionto hospital between 1986 and 1995. This database islinked to the Registrar General’s data on death certifi›cates, with an accuracy of 98%. In a 1% sample ofrecords checked in 1994, acute myocardial infarctionas a principal diagnosis was 97% accurate. Firstmyocardial infarction was defined as no previousadmission for this event since 1981. Postcodes wereused to assign a Carstairs deprivation category to eachindividual, from 1 (least deprived) to 5 (mostdeprived).3 These categories are derived from 1991What is already known on this topicNeonatal administration of vitamin K by the intramuscular route iseffective in the prevention of haemorrhagic disease in newborn babiesbut has been suggested as a possible risk factor for leukaemia in childrenA written record confirming that vitamin K has (or has not) been givenis often not found, and some research groups have attempted toimpute a child’s vitamin K status from hospital policyNothing is known about how midwives interpret and implementvitamin K policiesWhat this study addsEarlier hospital policies were open to individual interpretation andthey were not always followedThere is considerable variation in current vitamin K policies andmidwifery practice in the United Kingdom and no clear consensus onwhich babies should receive vitamin K intramuscularlyA table showingmortality per 1000men and womenappears on theBMJ’s websitePapersDepartment ofPublic Health,University ofGlasgow, GlasgowG12 8QQKate Macintyreresearch fellowClinical ResearchInitiative in HeartFailure, Universityof Glasgow,Glasgow G12 8QQSimon StewartNational HeartFoundation ofAustralia postdoctoraloverseas researchfellowJohn McMurrayprofessorcontinued overBMJ 2001;322:1152–31152 BMJ VOLUME 322 12 MAY 2001 bmj.comcensus data on four variables: overcrowding, theproportion of residents unemployed, those who do nothave a car, and those who belong to a low occupationalsocial class. Population rates were calculated by usingthe population structure by age, sex, and deprivationcategory.Between 1986 and 1995 in Scotland, 44 465 men(mean age (SD 11) 71.1) and 38 710 women (meanage (SD 10) 77.7) died before being admitted tohospital after a first myocardial infarction. A further68 626 men and 49 123 women were admitted to hos›pital, of whom 22.3% (95% confidence interval 22.1%to 22.6%) died within 30 days. There was asocioeconomic gradient in all three parameters, whichwas greater in younger age groups (figure). The popu›lation based mortality in deprivation category 5 wasmore than twice that of category 1 in people agedunder 65 (see table on website). Overall there wereabout 2000 excess deaths in the least affluent categorycompared with the most affluent (comparing thedifferential in observed over expected deaths in eachdeprivation category).CommentSocioeconomic deprivation has a profound effect onthe risk of having a first myocardial infarction, thechance of reaching hospital alive, and the probabilityof surviving the first month. The effect of socioeco›nomic deprivation is greatest in women, with a twofoldincrease in death before reaching hospital in thoseunder 65. The most deprived members of societyunder 65 have twice the risk of a first myocardialinfarction and death before reaching hospital.Younger deprived men and women admitted tohospital are 20% more likely to die within the firstmonth. One limitation of the study is that deprivationcategory is based on postcode rather than personalcharacteristics.How socioeconomic deprivation increases theserisks is probably multifaceted. The inverse care law isimportant but is only the last stage in a long sequenceof events extending from the intrauterine period.5To attain real equality requires strategies that targetthe wider determinants of health throughout anindividual’s life. As around 40% of people who experi›ence a first myocardial infarction do not survive toreach hospital, the potential of acute treatment toreduce mortality is limited. Reducing mortalityfrom heart disease requires a focus on primaryprevention that explicitly addresses socioeconomicinequalities.Contributors: KM designed the study, performed the analysesand interpretation, and wrote the first and final draft of thepaper. SS, JMcM, SC, JP, and JC contributed to the design andinterpretation and assisted with drafting the paper. AF, JB, andAR extracted the data and contributed to the interpretation anddrafting of the paper. KM, JMcM, and SC will act as guarantorsfor the paper.Funding: British Heart Foundation.Competing interests: None declared.1 National Heart Forum. Social inequalities in coronary heart disease: opportu›nities for action. London: Stationery Office, 1999.2 Morrison C, Woodward M, Leslie W, Tunstall›Pedoe H. Effect ofsocioeconomic group on the incidence of management of and survivalafter myocardial infarction and coronary death; analysis of communitycoronary event register. BMJ 1997;314:541›6.3 Capewell S, Kendrick S, Boyd J, Juszczak E, Clarke J. Measuringoutcomes: one month survival after acute myocardial infarction in Scot›land. Heart 1996;76:70›5.4 Tunstall›Pedoe H, Morrison C, Woodward M. Sex differences in myocar›dial infarction and coronary deaths in the Scottish MONICA populationof Glasgow 1985 to 1991. Circulation 1996;93:1981›92.5 Barker DJP. Fetal origins of coronary heart disease. BMJ 1995;311:171›4.(Accepted 27 October 2000)Mortality rate per 10001 3 52 40510152025< 65 years 65-75 years > 75 yearsIn hospital30 day case fatalityOut of hospital deaths1 3 52 404080120160Deprivation category1 3 52 4050100150200250Rates per 1000 population of hospital admission for myocardial infarction, deaths beforeadmission, and deaths within 30 days, by deprivation category 1986›95 (1=least deprived,5=most deprived)Email submissions from outside the United KingdomWe offer an email submission service for authors fromoutside the UK. The address is papers@bmj.comIdeally our email server would link seamlessly with ourmanuscript tracking system, but for now it does not,which is why we are offering the service only toauthors outside the UK. Most post in the UK arrivesthe next day, so UK authors have the least to gain inspeed of delivery from email delivery. As soon as oursystems improve we will invite email submissions fromeveryone.If you choose to send your submission by email pleasewould you send the text and any tables and figures asattached files, together with a covering letter giving allyour contact details (postal address, phone, fax, andemail address). We can read files created with mostword processing, graphics, and spreadsheetprograms.When your submission is received in our email boxyou will receive an automatic acknowledgment to showthat it has arrived. If the submission is incomplete wewill contact you and ask you to resend the missinginformation.Once the submission is complete we will register it onour manuscript tracking system and you will receive astandard acknowledgment in the post.Letters to the editor should continue to be sent direct tobmj.com as rapid responses or to letters@bmj.comPapersInformation andStatistics Division,EdinburghEH5 3SQJames ChalmersconsultantAlan Finlaysonsenior healthinformation scientistJames Boydprincipal statisticianAdam Redpathprincipal statisticianGreater GlasgowHealth Board,Glasgow G3 8RHJill PellconsultantDepartment ofPublic Health,University ofLiverpool,Liverpool L69 3GBSimon CapewellprofessorCorrespondence to:J McMurrayJ.McMurray@bio.gla.ac.uk1153BMJ VOLUME 322 12 MAY 2001 bmj.com

K.  Macintyre

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Relation between socioeconomic deprivation and death from a first myocardial infarction in Scotland: population based analysis

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