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© 2006 American Public Health Association
DOI: 10.2105/AJPH.2004.051193
RESEARCH AND PRACTICE |
At the time of the study, Kate A. Levin and Alastair H. Leyland were with the Medical Research Council’s Social and Public Health Sciences Unit, University of Glasgow, Scotland.
Correspondence: Requests for reprints should be sent to Kate A. Levin, Dental Health Services Research Unit, The Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF (e-mail: klevin{at}chs.dundee.ac.uk).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We sought to describe the pattern and magnitude of urban–rural variation in ischemic heart disease (IHD) in Scotland and to examine the associations among IHD health indicators, level of rurality, and degree of socioeconomic deprivation.
Methods. We used routine population and health data on the population aged 40–74 years between 1981 and 1999 and living in 826 small areas (average population=5600) in Scotland. Three IHD health indicators—mortality rates (deaths per 100000 population), rates of continuous hospital stays (discharges per 100000 population), and rates of mortality in the hospital or within 28 days of discharge (MH+) were analyzed with multilevel Poisson models. A 4-level rurality classification was used: urban areas, remote small towns, accessible rural areas, and remote rural areas.
Results. Rates of mortality, continuous hospital stays, and MH+ increased with area socioeconomic deprivation. After adjustment for population age, gender, and deprivation, the relative risk of IHD mortality in remote rural areas was similar to that of urban areas in 1981; the relative risk of a continuous hospital stay was significantly lower (relative risk [RR] = 0.70; 95% confidence interval [CI] = 0.64, 0.76) and the relative risk of MH+ was higher (RR=1.18; 95% CI=1.04, 1.35) in remote rural areas. Mortality and MH+ declined for all ruralities over time. However, MH+ remains highest in remote rural areas and remote towns.
Conclusions. Low standardized ratios of IHD continuous hospital stays and mortality in remote rural areas mask health problems among rural populations. Although absolute and relative differences between urban and rural rates of MH+ have diminished, the relative risk of MH+ remains high in remote rural areas.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Ischemic heart disease (IHD) mortality has declined in western Europe since the 1970s. By the mid-1990s, IHD had ceased to be the most common cause of death in Scotland.1 Nevertheless, in 2000 IHD accounted for 22% of deaths in Scotland, and the Scottish IHD mortality rate was the second highest in western Europe.2 Decreases in IHD mortality between 1981 and 1999 were substantially smaller in Scotland than in England and Wales, a decrease of 30% for men and 22% for women in Scotland, compared with decreases of 43% and 38% for men and women, respectively, in England and Wales.3 This discrepancy has created widening inequalities in IHD mortality within Great Britain, and may partly be caused by geography: 89% of the land area of Scotland is rural.4 Previous studies have demonstrated urban–rural differences in rates of IHD mortality and of hospital admissions for IHD in Norway,5 Australia,6 and Sweden,7 primarily owing to differences in the relation between level of rurality and socioeconomic deprivation, differences in lifestyle between levels of rurality, and the demography of differing rurality categories. Furthermore, urban–rural differences have been observed in other causes of mortality in Scotland.8,9
Mortality is used as a health indicator but is not necessarily a proxy for morbidity. Hospital admissions or physician consultations may also serve as indicators, but low rates of admissions or consultations may reflect poor provision or use of services but may be misinterpreted as reflecting good health. Particularly in rural areas, there is an inverse relation between distance from services and use of services, but "what is not clear from studies is the degree to which decreased use of primary care with increasing distance represents unmet need."10(p18) Because of cultural differences in interpretation of the term limiting long-term illness, self-reported health as a health indicator has also been criticized as a tool for the study of urban–rural health inequalities.11
The benefits of including a range of health measures to examine urban–rural inequalities have been discussed elsewhere.12,13 The choice of indicator is particularly important for rural small-area studies.14 Norris15 suggested lives saved per 1000 patients treated as an indicator of hospital and ambulance service performance for acute myocardial infarction that is sensitive to patient delay in seeking treatment, ambulance service performance, and hospital performance. Mortality in the hospital or within 28 days of discharge (MH+) is also affected by all of these factors and has been proposed as a reasonable indicator of IHD case fatalities16 and a recommended measure for monitoring heart disease.
We examined the pattern and magnitude of urban–rural variation in IHD in Scotland using 3 health indicators—mortality, hospital admission, and MH+—and analyzed the associations of these indicators during the period 1981–1999. These indicators were used to compare areas of varying degrees of rurality on the incidence and successful treatment of IHD, thus creating profiles of IHD for areas belonging to different rurality categories.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Scotland has a population of approximately 5 million. The country is split into 895 postcode sectors; these are grouped roughly into 56 local government districts, nested within 15 health boards. Postcode sectors whose boundaries crossed local government districts were assigned to the district that housed the largest number of residents. Data confidentiality concerns dictated that population data be aggregated into age/gender groups within each postcode sector; therefore, our analysis was conducted with these aggregated groups. One health board (Grampian) was excluded from our analysis because of boundary changes that occurred in 1996. Interpolation and extrapolation of census data for 1981 and 1991 and of General Register Office for Scotland estimates for 1999, with estimates by age, gender, and health board for the intervening years, yielded disaggregated population data stratified by age, gender, and postcode sector for 1982–1990 and 1992–1998.
The data used in this analysis were IHD mortality data from the General Register Office for Scotland and hospital discharge data collected and linked to mortality data by the Information and Statistics Division of the National Health Service in Scotland. An episode of IHD was defined as 1 continuous hospital stay for which the diagnosis at discharge included International Classification of Diseases, Ninth Revision, codes 410–414.17 These IHD episodes were collated for each postcode sector into 7 five-year age groups of men and women aged 40–74 years. Men and women younger than 40 years were excluded because of the small number of IHD episodes experienced in this age group. Number of continuous hospital stays and number of patients—or 1-year admissions—were analyzed; some patients were possibly counted more than once when measuring continuous hospital stays. Length of stay was calculated by subtracting the date of admission (from the first record in a continuous stay) from the date of discharge (from the last record in the continuous stay). Average length of continuous hospital stay for each age–gender group within a postcode sector was truncated to a maximum of 60 days.16 MH+ was defined as death from any cause in the hospital or within 28 days of discharge after the last episode of any stay that involved at least 1 principal diagnosis of IHD. Emergency admissions were usually observed in Accident and Emergency departments and would not normally be recorded unless the patients were transferred into another specialty department. Therefore, emergencies in which people died en route to the hospital or in the emergency room were included only in the mortality analysis.
We used the 1991 Carstairs area deprivation indicator,18 a continuous variable assigned at the postcode sector level, to categorize levels of socioeconomic deprivation. The Carstairs indicator was derived from 4 variables—lack of car ownership, low social class, male unemployment, and overcrowding—and the 1991 Carstairs score ranged from –7.54 (most affluent) to 12.87 (most deprived).
Postcode sectors were classified into 4 categories by rurality: urban areas (
10000 population), remote small towns (3000–10000 population, > 30-minute drive from a settlement of 10000 population), accessible rural areas (< 3000 population, 
30-minute drive from a settlement of 10000 population), and remote rural areas (< 3000 population, > 30-minute drive from a settlement of 10000 population). This classification was derived from that used in the Scottish Household Survey19 and has previously been used to show urban–rural differences in suicides in Scotland.9 The rurality of a postcode sector was assumed to be constant during 1981–1999.
We used aggregated 1981–1999 data to calculate crude rates and standardized ratios across rurality categories for mortality, hospital admissions, and MH+; the standard population was the 1991 population of Scotland (excluding Grampian) aged 40–74 years.
A multilevel Poisson regression analysis20 was conducted using MLwiN,21 with adjustment for age, gender, and deprivation, to study the associations among deprivation, rurality, and IHD during 1981–1999. The models had 4 levels: health boards (14), local government districts (51), postcode sectors (826), and age and gender groups (14). (The age and gender groups formed a pseudolevel that enabled the estimation of separate mortality rates and different variances within each group.)
One-year rates of admission (number of patients admitted at least once in a 1-year period per 100 000 population) and rates of continuous hospital stays (number of hospital discharges separated by more than 28 days from a later admission per 100 000 population) are similar measures. However, stays in rural areas may be longer than in urban areas owing to greater distances between homes and health care services. Shorter distances would result in higher readmission rates in urban areas and therefore the same 1-year rates of admission as in rural areas but higher rates of continuous hospital stays. One-year rates of admission might provide a better indicator of disease incidence, but rates of continuous stays measure hospital use. Therefore, both were analyzed—as a health indicator and as a measure of the population at risk when MH+ is investigated—although we present only rates of MH+ per continuous hospital stays.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Table 1
shows higher deaths, rates of continuous hospital stays, MH+s, and longer stays in total in urban areas. This finding is not surprising, because 56% of the population of Scotland lives in urban areas. When crude rates were compared across rurality categories, a different picture emerged, with higher mortality and rates of continuous hospital stay, lower rates of MH+, and shorter stays among urban areas than among remote small towns and remote rural areas. Rates of MH+ per 1-year admissions (results not presented) followed a similar pattern across rurality categories, although all such rates were higher than rates of MH+ per continuous stay.
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The population of remote rural Scotland is relatively older than the general population. The higher rate of MH+ in remote rural areas might result from a relatively more vulnerable and higher-risk population. However, when indirectly standardized by age and gender, standardized ratios of MH+ are highest in remote rural areas and remote small towns (Table 1
). Standardized mortality ratios fell with increasing rurality, with the lowest ratios in remote rural areas. Hospital discharges also fell sharply with increasing rurality. Indirectly standardized ratios of continuous hospital stays and 1-year ratios of admission were lower in remote rural areas than in urban areas. These findings suggest a relatively healthy population in remote rural Scotland. However, ratios of MH+ were high in these areas.
Figure 1a shows that mortality was consistently highest in urban areas and that mortality decreased from 1981 to 1999 for all categories of rurality, with the smallest relative decreases occurring in urban areas (Table 1). Rates of continuous stay remained highest in urban areas and lowest in remote rural areas and increased for all rurality categories (Figure 1b). The increase in rates of continuous hospital stay (and 1-year rates of admission) was greatest in remote rural areas. Rates of MH+ decreased for all rurality categories (Figure 1c). Decreases in rates of MH+ per stay were greatest in remote rural areas, although small numbers in these areas suggest a less clear trend. The decrease in lengths of stay was consistent across all rurality categories except for a smaller decrease in remote small towns (Figure 1d). However, stays in the hospital were longest in remote rural areas for almost all of the period observed.
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Table 2
presents estimates from multilevel models for each indicator. After we adjusted for age, gender, socioeconomic deprivation, and time, the relative risk of mortality decreased with time, with the greatest decreases occurring in remote rural areas. The relative risk of continuous hospital stays increased with time, with the greatest increases occurring in remote rural areas. In 1981, the relative risk of MH+ (from the multilevel models) in remote small towns and remote rural areas was significantly higher than that in other areas. Between 1981 and 1999, these differences diminished, and the relative risk of MH+ decreased for all rurality categories. Rates of MH+ per 1-year admission followed a similar pattern across rurality categories and over time.
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Socioeconomic deprivation was significant in all 3 models, with risk of mortality, rates of continuous hospital stays, and rates of MH+ increasing as deprivation increased. The impact of deprivation on mortality and rates of continuous hospital stays, however, was greater than the impact of deprivation on rates of MH+. Table 3
shows that the greatest proportion of the residual variation at the area level resulted from differences among postcode sectors for both mortality (50%) and rates of continuous hospital stays (47%). For rates of MH+, however, only 15% of the variation was at the postcode sector level, with 58% (because of rounding, percentages do not correspond exactly to the numbers in the table) resulting from unexplained differences between health boards.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Rates of IHD mortality have declined throughout Scotland between 1981 and 1999. This trend is because of medical advances and reductions in primary and secondary risk factors, including smoking, high blood cholesterol levels, and high blood pressure. Half of the decline in coronary mortality in Scotland, and half of a parallel decline in the United States between 1980 and 1990, has been attributed by Capewell et al.22 and Hunink et al.23 to reductions in these risk factors. Critchley and Capewell24 suggested that UK government targets to reduce coronary heart disease by 28000 by 2010 could be achieved through a reduction of major risk factors alone.
Although rates of mortality and of continuous hospital stay are relatively low in remote rural areas, the relative risk of MH+ is greater in such areas than in urban Scotland. Even when the more conservative measure of 1-year admissions is used as the denominator for MH+ rates, rates of MH+ for remote rural areas remain higher than for urban areas. Increases in rates of stay (Table 1) were greater than the increases in 1-year rates of admission. These changes, along with decreasing lengths of stay, suggest that a pattern of a small number of relatively long stays per admission has been replaced since 1981 by a pattern of a large number of relatively short stays. Rates of continuous hospital stay have increased in remote rural areas. However, relative decreases in length of continuous hospital stay have been roughly the same in urban and remote rural areas.
Three possible reasons related to patient behavior, diagnosis, referral, and management exist for the low standardized ratios of mortality and hospital discharge and high rates of MH+ in remote rural areas. First, in rural areas delays may occur in patient referral or, in the case of emergencies, delays in the provision of treatment. Such delays may be delays in a patient receiving treatment after presentation at a general practitioner, or in the case of an emergency, after calling for help and/or admission to a hospital. This is a delay in the provision of service. Second, rural inhabitants may delay before contacting health services. This is a delay caused by patient behavior, resulting in presentation at more advanced stages of heart disease. Cancer patients living in rural areas have more advanced stages of disease at diagnosis,8,25 and settlement remoteness confers a greater disadvantage than does small settlement size.26 We found that this disadvantage may also hold for IHD. Delay in contacting health services is of primary concern in the case of patients living in remote areas. The median door-to-needle time—the time required for a patient to receive thrombolytic treatment after arrival at a hospital—in the United Kingdom was halved during the 1990s.27 However, the resulting reduction in delay from the onset of symptoms to treatment was small because of increases in patient-caused delays.28 Early thrombolytic treatment is known to reduce premature acute myocardial infarction mortality and subsequent morbidity rates; therefore, delay in presentation affects patient survival of acute myocardial infarction and hence IHD. A number of social or cultural factors, including level of knowledge and distance to the nearest health service, may influence delay. Third, significant differences among different rurality categories may exist in provision of care or aftercare and length of stay in the hospital. Shorter continuous hospital stays may result in higher mortality rates after discharge because of insufficient treatment, whereas longer stays, particularly very long stays, increase the chance of mortality in the hospital. Hospital policies regarding beds and patient stays clearly influence this outcome.
These explanations suggest that IHD mortality may be avoidable. Other possible explanations for high rates of MH+ do not suggest avoidable mortality. The first is that IHD manifests itself in a number of forms, some more lethal than others. Rural inhabitants admitted to hospitals may have higher rates of acute myocardial infarction than other populations; the hospital discharge data we used do not detail the type of IHD. Rates of co-morbidities and complications may be higher in the rural than in the urban population. A second possibility is that diagnostic coding might vary systematically across rurality categories, resulting in deceptively high rates of MH+ in rural areas. However, such false positives are unlikely, because the data collected by the Information and Statistics Division in Scotland are considered to be of high quality.29
The multilevel models showed that, unlike mortality rates or hospital discharge rates, rates of MH+ have little to do with socioeconomic deprivation, and much of the variation among categories of rurality is among health boards. Moreover, populations served by rural boards have higher rates of MH+ compared with those served by urban boards. Multilevel analysis is able to attribute variation to different levels,30 and allowed us to distinguish between differences arising at the administrative (health board) level and small-area variation.
The socioeconomic deprivation indicator used in this study, the Carstairs index, has been criticized for being biased toward urban communities.31 This index includes components, such as car nonownership and overcrowding, that may be inappropriate for the measurement of rural deprivation. If the Carstairs indicator measured deprivation in urban areas but not in rural areas, the impact of deprivation on IHD in rural areas may have been underestimated, possibly resulting in an overestimation of the effect of rurality category on all 3 health outcomes.
The main limitation of this study was in the interpretation of findings. We have summarized the possible interpretations of our findings. However, further research is needed to ascertain whether the urban–rural differences result from differences in patient-caused delay, management of patients, or quality of health care.
It is clear from this study that much of the variation in rates of MH+ among populations served by different health boards remains unexplained, even when demographics, socioeconomic status, and rurality are taken into account. Rates of MH+ are particularly high in areas served by rural health boards. The target recommended by the National Services Framework32—60 minutes as the maximum time between a call for help and receipt of thrombolytic treatment—is unlikely to be achievable in remote rural Scotland unless prehospital delivery of drugs becomes common practice. The Remote and Rural Areas Resource Initiative, funded by the National Health Service of Scotland to develop healthcare services and support for professional staff in remote and rural parts of Scotland, has initiated projects to train general practitioners and paramedics in the administration of prehospital thrombolysis. Benefit in pre-hospital treatment particularly is conferred when people live some distance from the nearest hospital,33,34 and general practitioners can help in the management of patients with suspected acute myocardial infarction.35 Having general practitioners who are located more than 30 minutes’ traveling time from any hospital provide thrombolysis has been associated with increased survival36 and has been shown to be cost effective37; methods of motivating general practitioners to do so are needed. Such provision may improve rates of MH+ in remote areas of Scotland, particularly in areas served by rural boards, where rates of MH+ are high.
Health promotion initiatives encouraging a healthy lifestyle will aid in reducing rates of of IHD. The National Services Framework32 established the need to target the population most at risk for IHD. In rural areas, programs must be tailored to the needs of rural communities. Information about symptoms, disease management, and access to services, including the first point of contact, would be particularly useful in the rural context, not only for the public but also for health care professionals, and can be provided by advice lines, outreach support groups, and Web sites.38
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Acknowledgments |
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This study was funded by the Chief Scientist Office of the Scottish Executive, Department of Health.
Human Participant Protection
No protocol approval was needed for this study.
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Footnotes |
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Peer Reviewed
Contributors
K. A. Levin originated the study, carried out the analysis, interpreted findings, and led the writing. A. H. Leyland assisted with writing, analysis, and interpretation.
Accepted for publication December 24, 2004.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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