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Population need for coronary revascularisation: are national targets for England credible?
  1. R M Martin1,
  2. H Hemingway2,*,
  3. D Gunnell1,
  4. K R Karsch3,
  5. A Baumbach3,
  6. S Frankel1
  1. 1Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol, UK
  2. 2Department of Research and Development, Kensington & Chelsea and Westminster Health Authority, London, UK
  3. 3Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, UK
  4. *Also the Department of Epidemiology and Public Health, UCL Medical School, London, UK
  1. Correspondence to:
    Dr R M Martin, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol, BS8 2PR, UK;


Objective: To estimate the need for coronary revascularisation, by using an incidence of indications approach, among 45–84 year olds with stable angina, unstable angina, and acute myocardial infarction.

Design: Modelling exercise. Six key steps along the pathway of care from initial diagnosis in primary or secondary care to revascularisation were defined and the frequency of indications estimated using routine data from hospital admissions and data from studies in the general population, and primary and secondary care.

Setting and patients: Mid-1998 population of England.

Intervention: Coronary revascularisation.

Main outcome measure: Ability to benefit (need), defined by randomised trials, expert panel ratings from the ACRE (appropriateness of coronary revascularisation) study, or by informal consensus.

Results: The need for coronary revascularisation was estimated to be 92 000 procedures, equivalent to a rate of 1861 per million population. Overall, the model of need exceeded current provision by 3.3:1, although among people aged 75 years and over the ratio was 7.7:1. A plausible upper estimate of need—obtained by assuming that 90% of patients with stable angina were referred from primary care and that angiography would be performed in 65% of patients with acute myocardial infarction and 75% of patients with unstable angina—was 2626 per million population.

Conclusions: The national target of 1500 revascularisation procedures per million population is credibly related to population need, although upper estimates of need are considerably higher. Better understanding is required of the benefits of referring patients with specific indications from primary care. The greatest relative increase in provision is required for those aged 75 and older, among whom trial evidence of benefit is scant.

  • needs assessment
  • models, theoretical
  • coronary revascularisation
  • coronary disease
  • ACRE, appropriateness of coronary revascularisation
  • ENACT, European Network for Acute Coronary Treatment
  • HES, hospital episodes statistics
  • ICD-10, International classification of diseases, 10th revision
  • MSGP4, 4th national morbidity survey in general practice
  • OXMIS, Oxford myocardial infarction incidence study
  • TACTICS-TIMI 18, treat angina with Aggrastat and determine cost of therapy with an invasive or conservative strategy-thrombolysis in myocardial infarction 18

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