Exploring inequalities and inequities in the receipt of heart attack care for people with chronic kidney disease

: a mixed methods study

Abstract

Amongst people who suffer an acute coronary syndrome (ACS) event, one in three has chronic kidney disease (CKD). Despite an elevated mortality risk, the CKD population have historically been less likely to receive guideline-directed therapies for ACS, than those without kidney disease. The reasons for these disparities are unclear. This work aimed to summarise and quantify disparities in receipt of ACS care between people with and without CKD and start to understand the drivers of such variation.

A mixed methods study was undertaken. Systematic reviews and meta-analyses aimed to summarise prior research relating to the relative use of invasive ACS management between people with and without CKD. Retrospective English cohort data was analysed to provide granular data on the relationship between CKD severity and the receipt and outcome of ACS care. Finally, a multi-centre qualitative interviews were conducted to understand the process of ACS treatment decision-making by patients with CKD and clinicians.

The study found that individuals with CKD are approximately half as likely to receive invasive ACS management as those without kidney disease. This finding cannot be explained by variation in demographics or comorbidity, suggesting it is underlain by the kidney function per se. Variation is likely to be driven by clinicians: despite holding strong health preferences, patients have minimal involvement in inpatient ACS decision-making. Clinicians reported a bias towards conservative treatment recommendations for people with CKD due to a fear of causing harm via more “aggressive” management. Optimising guidelines, encouraging more inclusive population-based research and promoting collaborative working between clinicians may counter this bias.

Absence of adequate system and clinician-level support for higher-risk ACS treatment decisions contributes to fear-driven conservatism for people with CKD. Improving these support systems could optimise treatment decision-making by clinicians, reduce the gap between practice and guidelines and potentially lower associated morbidity and mortality.

Date of Award	18 Mar 2025
Original language	English
Awarding Institution	University of Bristol
Supervisor	Lucy E Selman (Supervisor), Pippa K Bailey (Supervisor), Yoav Ben-Shlomo (Supervisor), Fergus J Caskey (Supervisor) & Thomas W Johnson (Supervisor)