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Thierry Lang, Ignoring social factors in clinical decision rules: a contribution to health inequalities?, European Journal of Public Health, Volume 15, Issue 5, October 2005, Page 441, https://doi.org/10.1093/eurpub/cki156
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Much work has been published on health inequalities and the health-care system. Ignoring the fact that it is risky to summarize a literature review in a single sentence, I would suggest that most publications on this subject have focused on the conditions of primary access to care. Far fewer papers have investigated the next step: what happens when patients have had a first contact with the health-care system. While data are more sparse, they are, however, concordant: entering the health-care system does not mean that each person will receive the same care and/or the same quality of care for a given disease. Social differences in delivery of preventive services, frequency of negative health effects or quality of disease control under treatment have been reported.1 Whether primary or secondary access to care is concerned, the hypothesis is, however, that the same medical decision rules should apply to all patients, whatever their social context.
Some mechanisms should be examined in relation to clinical decision making, since they would not mean ‘merely’ ignoring health inequalities and thus missing an opportunity to correct them, but would in fact worsen them.2 Some guidelines might indeed aggravate the ‘inverse care law’ by adding medical misconceptions to the many causes of health inequalities. The debate surrounding the concept of cardiovascular risk estimates for decision making when treating arterial hypertension may be a good illustration. According to this concept, the decision to treat hypertension would not be based on blood pressure (BP) threshold, but on the patient's estimated absolute cardiovascular risk, assessed by age, sex, BP level, tobacco consumption, cholesterol level, high-density lipoprotein cholesterol, glucose intolerance and left ventricular hypertrophy.3 The variables and equations used in the models are those available in international cardiovascular cohorts or databases and thus ignore the psychosocial context of the patients, although adverse psychosocial conditions were associated with a mean 2.7 increased risk of myocardial infarction and contributed to 35% of the population attributable risk in the recently published InterHeart Study, in line with previous reports.4
Ignoring psychosocial risk factors might indeed increase social disparities through a biased estimation of true cardiovascular risk, resulting in divergence between the true and the estimated cardiovascular risk. Let us consider two patients who consult for mild hypertension, with the same level of clinical and biological cardiovascular risk factors. Based on their cardiovascular risk estimate, the same decision concerning the treatment of hypertension would be taken. Let us now suppose that these two patients have very different lives. Mr A is a manual worker, has a low level of education, is socially isolated and his occupation is characterized by low job control and high demand. Mr B is a highly educated professional. Considering their psychosocial factors, the true cardiovascular risk of Mr A would in fact be much higher than the true risk of Mr B. Since BP increases with age in our society, at a given time both Mr A and Mr B would meet the criteria for treatment, based on their estimated risk. It is easy to see that, given the underestimation of the true risk of the disadvantaged patient, Mr A, he would start treatment later than a patient with no adverse psychosocial factors such as Mr B. The actual decision threshold for treatment would thus be higher for lower socioeconomic classes, among which psychosocial factors are more prevalent resulting in delayed access to effective care.
Introducing a more comprehensive picture of a patient's life for estimating his/her absolute cardiovascular risk thus appears as an urgent task in order to avoid perpetuating yet another cause of social health inequalities. This means that social, economic and psychological factors that predict long-term risk should be taken into account when assessing the patient's future health status. In other fields, such as rheumatology, the rules of prescription of costly drugs such as tumour necrosis factor blockers might be based, in the future, on the estimated progression of the patient's disability (A. Cantagrel, personal communication). Again, neglecting social factors with a negative impact on disability might increase health inequalities, since patients with adverse factors would have a true risk of disability higher than their calculated risk, and would be denied access to effective health care. It therefore seems important to examine clinical decision rules and see whether those that ignore social context may in fact contribute to increase social inequalities in health. Avoiding social health inequalities by design through clinical decision making would appear to be one of the tasks on our public health agenda.
References
de Gaudemaris R, Lang T, Chatellier G, et al. Socioeconomic inequalities in hypertension prevalence and care: the IHPAF Study.
De Backer G, Ambrosioni E, Borch-Johnsen K, et al. Third joint task force of European and other societies on cardiovascular disease prevention in clinical practice. European guidelines on cardiovascular disease prevention in clinical practice.
Lombrail P, Pascal J, Lang T. Accès au système de soins et inégalités sociales de santé: que sait-on de l'accès secondaire?
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