Is publicly funded health care really distributed according to need? The example of cardiac rehabilitation in the UK.

OBJECTIVES: To demonstrate the importance of measuring both the horizontal and vertical components of equity in order to examine whether patients are receiving the health care that they need. DESIGN: A theoretical demonstration followed by analysis of a prospectively collected national random sample of acute cardiac admissions to 94 hospitals in the UK. PATIENTS: 1064 patients under 70 years old. ANALYSIS: The association between use of cardiac rehabilitation and gender (after adjusting for clinical need) was measured using multivariable analysis with effect modification. RESULTS: Hypertensive males were nearly twice as likely to undergo rehabilitation compared to hypertensive females (OR 1.76, 95% CI 1.03-3.02). Hyertensive patients were less likely to undergo rehabilitation than normotensive patients (OR 0.67, 95% CI 0.50-0.89) but this treatment difference did not apply in the same way to both men and women. Hypertensive women were half as likely to undergo rehabilitation compared with normotensive women (OR 0.48, 95% CI 0.30-0.78), whereas hypertensive men were as likely as normotensive men to receive rehabilitation (OR 1.00. 95% CI 0.63-1.60). CONCLUSIONS: Horizontal inequity was demonstrated because male and female hypertensive patients with equal needs were not treated equally. There was also vertical inequity because although patients with hypertension were treated differently to normotensive patients, this treatment difference was not the same for men and women.