Urban/Rural inequalities in Ischaemic Heart Disease and their association with deprivation

Background:
Ischaemic heart disease (IHD) mortality has been
declining in the UK since the 1970s. Nevertheless, it accounted for
22% of deaths in Scotland in 2000. Until recently rural areas were
regarded as healthy. However, results from studies using health indi-
cators are easy to misinterpret. An area with low GP consultation rates
due to lack of resources or poor access to services, for example, may
be misinterpreted as a healthy area. One solution might be to
incorporate a range of health measures when assessing urban–rural
inequalities.
Objectives:
To describe the pattern and magnitude of urban/rural
variation in IHD in Scotland using three health indicators and to exam-
ine the relationship between health, rurality, and deprivation.
Data and Methods:
Scotland was split into eight geographies and
three IHD health indicators. Mortality, hospital admissions, and
mortality within 28 days of admission to hospital (MWAH) were
investigated using 1986–95 data for all of Scotland. Multilevel
Poisson models, adjusting for age and sex, were created. The
Carstairs Index was included in the models to investigate the relation-
ship between rurality and deprivation for each of the health indicators.
Results:
Adjusting for age, sex, and deprivation, the area
described as very remote rural has lower IHD mortality than that of
urban Scotland (RR=0.96), however, this difference is not significant
at the 95% level. Adjusting for age, sex, and deprivation, hospital
admissions are significantly lower in rural areas relative to urban
areas (RR=0.71, 0.63, 0.80). MWAH shows significantly higher rela-
tive risk in the most rural area than in urban areas (RR=1.10, 1.01,
1.20). The Carstairs Index is significant in all three models, with dep-
rivation being associated with unfavourable outcomes. There is also a
significant interaction between Carstairs and rurality in all three mod-
els. Deprived urban areas experience significantly greater IHD
mortality and hospital admissions than their affluent counterparts. In
rural areas deprivation has a weaker effect on these health indicators.
Conclusions:
Approximately equal mortality from IHD in urban
and rural areas masks the fact that hospital admissions are lower and
MWAH is higher in rural areas. This suggests that there may be differ-
ences in diagnosis and/or the provision of care between urban and
rural areas. Association with deprivation is weaker in rural than in
urban areas. The Carstairs Index may be measuring different phenom-
ena in urban and rural areas; alternatively sociocultural differences
and health services produce more equitable outcomes in rural areas.