Mortality from cardiovascular disease is too high outside capital cities

The demonstration of social and geographic gradients in death rates is not new.^2,3 The findings of Sexton and Sexton are disturbing -- what could be the explanation? What can we do about them?

There are two reasons for excess CHD deaths -- risk factors among the population and inadequacies in the level of medical care provided. A combination of changes in these factors has been found to be the explanation for the recent decline in CHD deaths seen in Australia.⁴Sexton and Sexton allude to differences in socioeconomic status between urban and rural areas, which together with higher levels of unemployment outside capital cities may be part of the "explanation" of the higher CHD mortality. Their report does not examine separately death rates in Aboriginal people, and, while these are likely to contribute to the overall picture, Indigenous people constitute too small a proportion of the total population for this to be the whole explanation. Data on risk factor levels are scarce outside capital cities, but some limited data discussed in the report suggest that differences in risk factor levels mirror the excess rural mortality.

The strength of the article by Sexton and Sexton is the demonstration of a widening of the mortality gap over time. There have been major changes in the provision of medical care for patients with heart disease between 1986 and 1996, and it seems most appropriate to focus here on the level of healthcare provided in and outside capital cities. The data from Sexton and Sexton do not allow us to distinguish between disease incidence and case fatality, but other data indicate that there are differences in case fatality and in medical care for acute myocardial infarction (AMI) between metropolitan and non-metropolitan hospitals.^5,6 There are differences in the types of hospital in and outside capital cities and in the distribution of specialist cardiologists. There is ample evidence that hospital type and size and the speciality of the treating physician are related to the outcome and the practice of evidence-based care for patients with CHD.^7-10 A recent report in this Journal found that the evidence-based use of drugs after AMI was lower among doctors in smaller non-metropolitan hospitals in New South Wales.⁷

It is not beyond credibility to suggest that at least part of the reason for the widening geographic gradient in CHD deaths in Australia is differential levels of care for those with the disease. Rural areas have smaller hospitals and fewer cardiologists (who prefer to have access to investigative facilities, which have become such an important part of their speciality). We must find solutions to the need to practise evidence-based care and prevention throughout the Australian healthcare system, irrespective of access to specialist services and tertiary care facilities.

Guidelines and clinical pathways have been promulgated as a response to the demonstration of variations in medical care, and may have an impact on changing patterns of care.^11,12 However, the solution to the structural inequalities in the provision of care is likely to be much more complex than the use of these clinical decision aids, especially given the relatively small impact they might be expected to have.¹² Do we just accept that people who live outside capital cities in a large country where the population is thinly spread will inevitably have less access to high quality medical care (as they have less access to many other resources such as the arts and retail outlets)? These are fundamental questions about societal expectations. Where is the consumer pressure for change? What is the responsibility of the health professions for the health of the whole of the population, and how is this expressed?

A number of these questions were discussed at the recent Federal Government Regional Australia Summit, at which, despite the comment that "There are no easy solutions facing regional Australia", a number of key priorities and proposed strategies were identified.¹³ For example, two of the key priorities under the health theme are: "Regional, rural and remote communities require improved and expanded access to healthcare services . . ." and "Resource allocation for regional, rural and remote communities must be equitable in terms of health need relative to the urban population." One of the proposed strategies to achieve this latter priority is "A health services plan will be established to set optimal levels of services for communities of different sizes. The Commonwealth Health Department will act as broker for funding to any community which wishes to invoke those benchmarks." Maybe the demonstration of a reduced geographic gradient for CVD deaths could be a future marker of the success of this and other interventions.

Richard F Heller
Professor of Community Medicine and Clinical Epidemiology
Centre for Clinical Epidemiology and Biostatistics
Faculty of Medicine and Health Sciences
The University of Newcastle, Newcastle, NSW

1. Sexton PT, Sexton T-L H. Excess coronary mortality among Australian men and women living outside the capital city statistical divisions. Med J Aust 2000; 172: 370-374.
2. Taylor R, Chey T, Bauman A, Webster I. Socio-economic, migrant and geographic differentials in coronary heart disease occurrence in New South Wales, Australia. Aust N Z J Public Health 1999; 23: 20-26.
3. Marmot M, Ryff CD, Bumpass LL, et al. Social inequalities in health: next questions and converging evidence. Soc Sci Med 1997; 44: 901-910.
4. Dobson AJ, McElduff P, Heller R, et al. Changing patterns of coronary heart disease in the Hunter Region of New South Wales, Australia. J Clin Epidemiol 1999; 52: 761-771.
5. Huy Dinh Vu, Heller RF, Lim LLY, et al. Hospital mortality after acute myocardial infarction is lower in metropolitan than non-metropolitan regions. J Epidemiol Commun Health. In press.
6. Lim L, O'Connell R, Heller R. Differences in management of heart attack patients between metropolitan and regional hospitals in the Hunter Region of Australia. Aust N Z J Public Health 1999; 23: 61-66.
7. Lim LLY, Heller RF, O'Connell R, D'Este C. Stated and actual management of acute myocardial infarction among different specialties. Med J Aust 2000; 172: 208-212.
8. Chen J, Radford MJ, Wang Y, et al. Do "America's best hospitals" perform better for acute myocardial infarction? N Engl J Med 1999; 340: 286-292.
9. Jollis JG, Delong ER, Peterson ED, et al. Outcome of acute myocardial infarction according to the speciality of the admitting physician. N Engl J Med 1996; 335: 1880-1887.
10. Weitzman S, Cooper L, Chambless L, et al. Gender, racial, and geographic differences in the performance of cardiac diagnostic and therapeutic procedures for hospitalised acute myocardial infarction in four states. Am J Cardiol 1997; 79: 722-726.
11. Kitchiner DJ, Bundred PE. Clinical pathways [editorial]. Med J Aust 1999; 170: 54-55.
12. Gupta L, Ward JE, Hayward RS. Clinical practice guidelines in general practice: a national survey of recall, attitudes and impact. Med J Aust 1997; 166: 69-72.
13. Regional Australia Summit communiquŽ. Presentation of the summit recommendations. <http://www.dotrs.gov.au/regional/summit/communique.htm> (Accessed 23 March 2000).

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