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

Background:Ischaemic heart disease (IHD) mortality has beendeclining in the UK since the 1970s. Nevertheless, it accounted for22% of deaths in Scotland in 2000. Until recently rural areas wereregarded as healthy. However, results from studies using health indi-cators are easy to misinterpret. An area with low GP consultation ratesdue to lack of resources or poor access to services, for example, maybe misinterpreted as a healthy area. One solution might be toincorporate a range of health measures when assessing urban–ruralinequalities.Objectives:To describe the pattern and magnitude of urban/ruralvariation 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 andthree IHD health indicators. Mortality, hospital admissions, andmortality within 28 days of admission to hospital (MWAH) wereinvestigated using 1986–95 data for all of Scotland. MultilevelPoisson models, adjusting for age and sex, were created. TheCarstairs 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 areadescribed as very remote rural has lower IHD mortality than that ofurban Scotland (RR=0.96), however, this difference is not significantat the 95% level. Adjusting for age, sex, and deprivation, hospitaladmissions are significantly lower in rural areas relative to urbanareas (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 asignificant interaction between Carstairs and rurality in all three mod-els. Deprived urban areas experience significantly greater IHDmortality and hospital admissions than their affluent counterparts. Inrural areas deprivation has a weaker effect on these health indicators.Conclusions:Approximately equal mortality from IHD in urbanand rural areas masks the fact that hospital admissions are lower andMWAH is higher in rural areas. This suggests that there may be differ-ences in diagnosis and/or the provision of care between urban andrural areas. Association with deprivation is weaker in rural than inurban areas. The Carstairs Index may be measuring different phenom-ena in urban and rural areas; alternatively sociocultural differencesand health services produce more equitable outcomes in rural areas