Socioeconomic status and prescribing of hormone replacement therapy in general practice: a cross-sectional study of practice-level data in England

Problem

Prescribing rates of various drugs in general practice are associated with socioeconomic deprivation, but until now evidence has been lacking around its relationship with rates of hormone replace therapy (HRT) prescribing in women. Concerns have been raised that women from more deprived backgrounds are less likely to be receiving HRT treatment and its associated benefits.We aimed to investigate the association between general practice HRT prescription rates and socioeconomic deprivation in England.

Approach

In this cross-sectional study, monthly primary care prescribing data for 2018, as well as practice age and sex profiles, were downloaded from NHS digital. Practice-level Index of Multiple Deprivation (IMD) scores – a marker of socioeconomic deprivation – were obtained from Public Health England. Quality Outcomes Framework (QOF) data for 2017/18 were obtained for the proportions of patients of each practice with a diagnosis or risk factor that may influence decisions around HRT prescribing. Practice-level prescribing rate was defined as the number of items of HRT prescribed per 1000 registered female patients over the age of 40 years. The association between IMD score and HRT prescribing rate was tested using univariate and multivariate Poisson regression. Multivariate analyses adjusted for the practice proportions of obesity, smoking, hypertension, diabetes, coronary heart disease and cerebrovascular disease, as well as practice list size. The analysis was repeated for (1) only oral and (2) only transdermal preparations.

Findings

The overall rate of HRT prescribing was 29% lower in practices from the most deprived quintile compared with the most affluent (Incidence rate ratio [IRR] 0.71, 95% CI 0.68-0.73). After adjusting for all cardiovascular disease outcomes and risk factors, the prescribing rate in the most deprived quintile was still 18% lower than in the least deprived quintile (adjusted IRR 0.82, 95% CI 0.77-0.86). In more deprived practices, there was a significantly higher tendency to prescribe oral HRT over transdermal preparations (p < 0.001).

Consequences

This study has highlighted inequalities associated with HRT prescription. This may reflect a large unmet need in terms of post-menopause care in areas of deprivation. Further research is needed to confirm these results with individual-level patient datasets, and to identify the underlying factors from patient and GP perspectives that may explain this.