Unmet health needs in patients with coronary heart disease: implications and potential for improvement in caring services

Medical professionals tend to focus on a medical model of health care. This ignores the more comprehensive approach which addresses 'the state of physical, mental and social well being'. Defining health needs is difficult, so it is not surprising that numerous definitions have been proposed in the past. Classifying needs in a sociologic environment as 'normative', felt', expressed', and 'comparative', remains one of the best, [1] despite its ignoring cost-effectiveness as a major determinant of healthcare provision. 'Ability to benefit from health care services' is a definition of 'needs'.[2] which minimises the role of lay individuals, focusing on 'health care' rather than 'health' [3] and is constrained by existing healthcare facilities. Additionally, benefit from healthcare may be affected inversely by the severity of disease.[4]

Geographic variations, socio-economic status and the knowledge base and attitude of the population may influence demand for health care, while medical guidelines and effectiveness of interventions may affect health care availability. Ideally, the provision of health care services should meet most of the populations' needs but these may not be constant, so health needs assessment (HNA) surveys are necessary both locally and nation-wide to establish what services are required to match these needs.

The medical model of health care has led to major improvement in health in the Western world but resolving the clinical aspects of an illness ignores the impact on quality of life in the patient's social context, generating unmet need. We identified several areas which warrant further investigation and implications for clinical practice.

Accommodation was a major concern for many, adversely affecting health-related quality of life in one in five patients, independent of age and diagnosis or existing house size. Social problems were common but two in particular are worthy of attention. First, living alone created difficulties. This is a timely reminder that the family environment should be considered when medical treatment is offered. [25] Second was social isolation, a major psychological factor that has been acknowledged as important aid to survival following an acute myocardial infarction, particularly in vulnerable groups like elder patients or women. [9, 26] One-third of our patients assumed that a wider social circle might help them to cope with and better overcome their illness. Being in employment facilitates social contact, and our non-working groups, whether retired or not were 10 times more likely to request improved social communication. In this respect, attendance at post-myocardial infarction rehabilitation groups assumed greater importance, especially for lower socio-economic groups who are notoriously poor at accepting invitations for cardiac rehabilitation; [27] in addition, the role of the traditional outpatient appointment becomes more important for some as a social rather than medical event. Overall individual patients' social needs and physical needs scores correlated "moderate to high" [28] with all HRQL components, which supports the construct validity of the needs assessment questionnaire.

The impact of socio-economic status on health, as well as on equity of access [29] have been known for many years. [30] In line with other reports [29], knowing how to get the best out of the medical services and gaining access to healthcare facilities, particularly gaining information about illness or discussing concerns about diagnosis or prognosis, is directly related to socio-economic status. The impact of socio-economic status, although not universal,.[31] highlights the difficulty of ensuring equity of access to standard care for everyone in the community. One way to tackle this is to identify vulnerable patients and communities and target these.

We confirmed age and gender differences in health related quality of life reported by others. [32] Quality of life was perceived to be worse in older patients. In addition to gender variations in etiological factors and the well-known excess of coronary heart disease in men, differences in access to diagnostic and treatment procedures have been reported. [33] Our results – similar to other studies[34] – indicate that women had worse quality of life in all domains, which per se contribute to lower survival chances. Women also required more help needs and social support consistent with evidence from other studies. [25, 35]

The needs expressed by our patient population identifies areas for potential improvements in health care that are usually not directly related to physical conditions and therefore are generally ignored by healthcare professionals. If assessing needs leads to genuine change in the current healthcare services [36] where health is the ultimate concept of well-being, meeting social, physical, transport and housing needs ought to provide a more comprehensive health care, and improve the outcome, for patients.

Establishing need presents problems and the Nottingham Health Needs Assessment was developed for this study because health needs analysis is a relatively new approach to ascertaining attitudes to health and so there was no 'off the shelf' valid and reliable needs assessment instrument available for cardiac patients. The tool, however, showed acceptable psychometric properties (table 1) and therefore we propose to test this instrument more widely to assess its generalisability against a background of a wide range of patient demography, illnesses and socio-economic and geographic settings.

Based on an analysis of a pilot study and experience gained in routine clinical visits, we had expected that our patients might have common social health needs as well as specific health needs relating to their illness. What surprised us was the depth of the underlying current of major deficiencies in social or health service provision which generated considerable dissatisfaction with quality of life, despite satisfactory resolution of presenting symptoms. Resolving social and environmental issues remains an important issue in the era of ever-increasing medical technology, not least in coronary heart disease.