Excess coronary mortality among Australian men and women living outside the capital city statistical divisions

Long-term exposure to air pollution increases hip fracture incidence rate and related mortality: analysis of National Hip Fracture Database

To explore the association of air pollution and hip fracture and related mortality in the UK. The average levels of PM2.5, PM10, and NO2 exhibited a positive association with hip fracture and short-term mortality while O₃ did not. Our study highlights the association of air pollution and hip fracture.

INTRODUCTION

Until now, the influence of air pollution on bone mineral density and associated fractures has drawn little attention, and the consequences are controversial. To investigate the association between air pollution and hip fracture incidence and related short-term mortality.

METHODS

We constructed a cohort of all the National Hip Fracture Database beneficiaries (513,540 patients) in the UK from 2013 to 2018. Per year averages of PM_2.5, PM₁₀, O₃, NO₂, and SO₂ were estimated according to the person's residence. The incidence rate ratio with 95% confidence interval and all-cause mortality within 30-day post-fracture (ACM30D) rate ratios were estimated using generalized additive models.

RESULTS

The average levels of PM_2.5, PM₁₀, and NO₂ exhibited a positive association with the incidence rate of hip fracture (IHF) and ACM30D. Whereas, this association was negative for O₃ levels. Each increase of 5 μg per cubic meter in PM_2.5, PM₁₀, and NO₂ leads to 9.5%, 9.2%, and 4.1% higher hip fracture rate, respectively, and also 9.3%, 8.3%, and 2.9% higher ACM30D, respectively. When we restricted the analysis to low-level exposure of air pollutants, similar results were obtained.

CONCLUSION

Our study found a moderate, positive association between IHF, ACM30D, and the levels of specific air pollutants in the entire National Hip Fracture Database population. A reduction in the levels of PM_2.5, PM₁₀, and NO₂ may decrease the hip fracture incidence rate and associated short-term mortality in older adults. Our study highlights the influence of air pollution on hip fracture.

Prevalence and factors associated with lipid-lowering medications use for primary and secondary prevention of cardiovascular diseases among Malaysians: the REDISCOVER study

Background

Lipid-lowering medications (LLM) are commonly used for secondary prevention, as well as for primary prevention among patients with high global cardiovascular risk and with diabetes. This study aimed to determine the prevalence of LLM use among high-risk individuals [participants with diabetes, high Framingham general cardiovascular (FRS-CVD) score, existing cardiovascular disease (CVD)] and the factors associated with it.

Methods

This is a cross-sectional analysis from the baseline recruitment (years 2007 to 2011) of an ongoing prospective study involving 11,288 participants from 40 rural and urban communities in Malaysia. Multiple logistic regression was used to identify characteristics associated with LLM use.

Results

Majority (74.2%) of participants with CVD were not on LLM. Only 10.5% of participants with high FRS-CVD score, and 17.1% with diabetes were on LLM. Participants who were obese (OR = 1.80, 95% CI: 1.15–2.83), have diabetes (OR = 2.38, 95% CI: 1.78–3.19), have hypertension (OR = 2.87, 95% CI: 2.09–3.95), and attained tertiary education (OR = 2.25, 95% CI: 1.06–4.78) were more likely to be on LLM. Rural residents had lower odds of being on LLM (OR = 0.58, 95% CI: 0.41–0.82). In the primary prevention group, participants with high FRS-CVD score (OR = 3.81, 95% CI: 2.78–5.23) and high-income earners (OR = 1.54, 95% CI: 1.06–2.24) had higher odds of being on LLM.

Conclusions

LLM use among high CVD-risk individuals in the primary prevention group, and also among individuals with existing CVD was low. While CVD risk factors and global cardiovascular risk score were positively associated with LLM use, sociodemographic disparities were observed among the less-educated, rural residents and low-income earners. Measures are needed to ensure optimal and equitable use of LLM.

Trends in Ischaemic Heart Disease in Australia, 2001-2015: A Comparison of Urban and Rural Populations

OBJECTIVE

Ischaemic heart disease (IHD) is a major source of disease burden worldwide. Recent trends show incidence is declining but it is unclear whether the trends are similar in urban and rural populations. This study examines the trends of IHD events (i.e. hospitalisations and deaths) in New South Wales, Australia by rurality.

METHODS

This was a retrospective analysis of linked administrative data for hospitalisation and death records across NSW between 2001 and 2015. Participants were NSW residents aged 15-105 years who died or were hospitalised with a principal diagnosis of IHD. The main outcome measures were annual age-standardised mortality and hospitalisations for IHD by calendar year and rurality.

RESULTS

Between 2001 and 2015, age-standardised annual IHD hospitalisations declined in urban areas from 587 to 260 and in rural areas from 766 to 395 per 100,000 people. The annual decline in hospitalisations was greater in urban than rural areas, with Annual Percentage Change (APC) of -5.6% (95% CI, -6.1%, -5.0%) and -4.5% (95% CI, -5.0%, -4.0%), respectively (p=0.012). Ischaemic heart disease mortality declined at a similar rate in urban and rural regions (APC -7.6% and -6.7% per annum, p=0.28). Absolute inequalities in IHD deaths persisted until 2015 when there were 49 (urban) and 70 (rural) IHD deaths per 100,000 people.

CONCLUSIONS

Ischaemic heart disease hospitalisations and mortality have declined considerably between 2001 and 2015 in both rural and urban areas, yet inequalities persist, suggesting more intensive preventive efforts are required to further reduce the burden of IHD in rural populations.

Hypertension, white-coat hypertension and masked hypertension in Australia: findings from the Australian Diabetes, Obesity, and Lifestyle Study 3

BACKGROUND AND METHOD

The Australian Diabetes, Obesity, and Lifestyle Study is a national, population-based examination of ∼11 000 adults with a third follow-up phase at 12 years. The aim was to use ambulatory blood pressure monitoring (ABPM) in a subsample (n = 508) of the main Australian Diabetes third follow-up cohort to determine the proportion with established, masked or white-coat hypertension in city and regional centers and the effectiveness of diagnosis and treatment.

RESULTS

Mean age was 58.9 years, BMI was 27.6 kg/m with 53% women. The mean clinic BP was 127/73 mmHg and mean 24-h BP was 121/73 mmHg. Using regression analysis estimations, the predicted ABPM daytime equivalent for the hypertension threshold values of 140/90 mmHg were 136/90 mmHg. There were 43% classified as hypertensive due to either ABPM 24-h more than 130/80 mmHg (17%) or taking antihypertensive therapy (25%). Ambulatory SBP/DBP were higher in men (24-h + 6.4/4.9 mmHg, P < 0.001) compared with women. There was only 3% with white-coat but 21% with masked hypertension indicating 24% misdiagnosis. Based on ABPM, 9% were treated and still hypertensive, which was three times more common in men (14%) than women (4%). Thus 36% had not reached target. There were no differences between urban and rural participants. Based on ABPM, nearly half the participants were hypertensive while only a quarter were taking antihypertensive therapy.

CONCLUSION

The findings highlight the importance of out-of-office BP assessments and the considerable gaps in effectively diagnosing and treating hypertension.

Quantifying the role of modifiable risk factors in the differences in cardiovascular disease mortality rates between metropolitan and rural populations in Australia: a macrosimulation modelling study

OBJECTIVES

The study aimed (1) to quantify differences in modifiable risk factors between urban and rural populations, and (2) to determine the number of rural cardiovascular disease (CVD) and ischaemic heart disease (IHD) deaths that could be averted or delayed if risk factor levels in rural areas were equivalent to metropolitan areas.

SETTING

National population estimates, risk factor prevalence, CVD and IHD deaths data were analysed by rurality using a macrosimulation Preventable Risk Integrated Model for chronic disease risk. Uncertainty analysis was conducted using a Monte Carlo simulation of 10 000 iterations to calculate 95% credible intervals (CIs).

PARTICIPANTS

National data sets of men and women over the age of 18 years living in urban and rural Australia.

RESULTS

If people living in rural Australia had the same levels of risk factors as those in metropolitan areas, approximately 1461 (95% CI 1107 to 1791) deaths could be delayed from CVD annually. Of these CVD deaths, 793 (95% CI 506 to 1065) would be from IHD. The IHD mortality gap between metropolitan and rural populations would be reduced by 38.2% (95% CI 24.4% to 50.6%).

CONCLUSIONS

A significant portion of deaths from CVD and IHD could be averted with improvements in risk factors; more than one-third of the excess IHD deaths in rural Australia were attributed to differences in risk factors. As much as two-thirds of the increased IHD mortality rate in rural areas could not be accounted for by modifiable risk factors, however, and this requires further investigation.

Broadening the Reach of Cardiac Rehabilitation to Rural and Remote Australia

BACKGROUND

Cardiac rehabilitation (CR) has an evidence base but traditional models may not readily apply to people living in rural and remote regions.

AIM

: To outline published comprehensive and non-hospital based CR models used for people discharged from hospital after a cardiac event that have potential relevance to those living in rural and remote areas in Australia.

METHODS

The PubMed database was searched using Medical subject headings (MeSH) terms and the key word 'cardiac rehabilitation' limited to clinical trials. Articles were retrieved if they included at least two components of CR and were not based in an outpatient setting.

RESULTS

No CR models specifically developed for rural and remote areas were identified. However, 14 studies were found that outlined 11 non-conventional comprehensive CR models. All provided CR in a home-based setting. Health professionals provided support via telephone contact or home visits, and via resources such as the Heart Manual. Reported outcomes from these CR programs varied: ranging from an increase in knowledge of risk factors, to improvements in physical activity, decreased risk factor profile, improved psychological and social functioning and reductions in health service costs and mortality.

CONCLUSION

Home-based, CR models have the most substantive evidence base and, therefore the greatest potential to be developed and made accessible to eligible people living in rural and remote areas.

How well do patients understand written instructions?: health literacy assessment in rural and urban rheumatology outpatients

The aim of this study was to assess health literacy (word recognition and comprehension) in patients at a rural rheumatology practice and to compare this to health literacy levels in patients from an urban rheumatology practice.Inclusion criteria for this cross-sectional study were as follows: ≥18-year-old patients at a rural rheumatology practice (Mid-North Coast Arthritis Clinic, Coffs Harbour, Australia) and an urban Sydney rheumatology practice (Combined Rheumatology Practice, Kogarah, Australia). Exclusion criteria were as follows: ill-health precluding participation; poor vision/hearing, non-English primary language. Word recognition was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM). Comprehension was assessed using the Test of Functional Health Literacy in Adults (TOFHLA). Practical comprehension and numeracy were assessed by asking patients to follow prescribing instructions for 5 common rheumatology medications.At the rural practice (Mid-North Coast Arthritis Clinic), 124/160 patients agreed to participate (F:M 83:41, mean age 60.3 ± 12.2) whereas the corresponding number at the urban practice (Combined Rheumatology Practice) was 99/119 (F:M 69:30, mean age 60.7 ± 17.5). Urban patients were more likely to be born overseas, speak another language at home, and be employed. There was no difference in REALM or TOFHLA scores between the 2 sites, and so data were pooled. REALM scores indicated 15% (33/223) of patients had a reading level ≤Grade 8 whereas 8% (18/223) had marginal or inadequate functional health literacy as assessed by the TOFHLA. Dosing instructions for ibuprofen and methotrexate were incorrectly understood by 32% (72/223) and 21% (46/223) of patients, respectively.Up to 15% of rural and urban patients had low health literacy and <1/3 of patients incorrectly followed dosing instructions for common rheumatology drugs.There was no significant difference in word recognition, functional health literacy, and numeracy between rural and urban rheumatology patients.

A comparison of Australian rural and metropolitan cardiovascular risk and mortality: the Greater Green Triangle and North West Adelaide population surveys

OBJECTIVES

Cardiovascular (CVD) mortality disparities between rural/regional and urban-dwelling residents of Australia are persistent. Unavailability of biomedical CVD risk factor data has, until now, limited efforts to understand the causes of the disparity. This study aimed to further investigate such disparities.

DESIGN

Comparison of (1) CVD risk measures between a regional (Greater Green Triangle Risk Factor Study (GGT RFS, cross-sectional study, 2004-2006) and an urban population (North West Adelaide Health Study (NWAHS, longitudinal cohort study, 2004-2006); (2) Australian Bureau of Statistics (ABS) CVD mortality rates between these and other Australian regions; and (3) ABS CVD mortality rates by an area-level indicator of socioeconomic status, the Index of Relative Socioeconomic Disadvantage (IRSD).

SETTING

Greater Green Triangle (GGT, Limestone Coast, Wimmera and Corangamite Shires) of South-Western Victoria and North-West Adelaide (NWA).

PARTICIPANTS

1563 GGT RFS and 3036 NWAHS stage 2 participants (aged 25-74) provided some information (self-administered questionnaire +/- anthropometric and biomedical measurements).

PRIMARY AND SECONDARY OUTCOME MEASURES

Age-group specific measures of absolute CVD risk, ABS CVD mortality rates by study group and Australian Standard Geographical Classification (ASGC) region.

RESULTS

Few significant differences in CVD risk between the study regions, with mean absolute CVD risk ranging from approximately 1% in the age group 35-39 years to 14% in the age group 70-74 years. [corrected]. Similar mean 2003-2007 (crude) mortality rates in GGT (98, 95% CI 87 to 111), NWA (103, 95% CI 96 to 110) and regional Australia (92, 95% CI 91 to 94). NWA mortality rates exceeded that of other city areas (70, 95% CI 69 to 71). Lower measures of socioeconomic status were associated with worse CVD outcomes regardless of geographic location.

CONCLUSIONS

Metropolitan areas do not always have better CVD risk factor profiles and outcomes than rural/regional areas. Needs assessments are required for different settings to elucidate relative contributions of the multiple determinants of risk and appropriate cardiac healthcare strategies to improve outcomes.

Potential of pharmacists to help reduce the burden of poorly managed cardiovascular risk

INTRODUCTION

Rural areas require better use of existing health professionals to ensure capacity to deliver improved cardiovascular outcomes. Community pharmacists (CPs) are accessible to most communities and can potentially undertake expanded roles in prevention of cardiovascular disease (CVD).

OBJECTIVE

This study aims to establish frequency of contact with general practitioners (GPs) and CPs by patients at high risk of CVD or with inadequately controlled CVD risk factors.

DESIGN, SETTING AND PARTICIPANTS

Population survey using randomly selected individuals from the Wimmera region electoral roll and incorporating a physical health check and self-administered health questionnaire. Overall, 1500 were invited to participate.

RESULTS

The participation rate was 51% when ineligible individuals were excluded. Nine out of 10 participants visited one or both types of practitioner in the previous 12 months. Substantially more participants visited GPs compared with CPs (88.5% versus 66.8%). With the exception of excess alcohol intake, the median number of opportunities to intervene for every inadequately controlled CVD risk factor and among high risk patient groups at least doubled for the professions combined when compared with GP visits alone.

CONCLUSION

Opportunities exist to intervene more frequently with target groups by engaging CPs more effectively but would require a significant attitude shift towards CPs. Mechanisms for greater pharmacist integration into primary care teams should be investigated.

Cardiovascular disease in women: implications for improving health outcomes

OBJECTIVE

To collate data on women and cardiovascular disease in Australia and globally to inform public health campaigns and health care interventions.

DESIGN

Literature review.

RESULTS

Women with acute coronary syndromes show consistently poorer outcomes than men, independent of comorbidity and management, despite less anatomical obstruction of coronary arteries and relatively preserved left ventricular function. Higher mortality and complication rates are best documented amongst younger women and those with ST-segment-elevation myocardial infarction. Sex differences in atherogenesis and cardiovascular adaptation have been hypothesised, but not proven. Atrial fibrillation carries a relatively greater risk of stroke in women than in men, and anticoagulation therapy is associated with higher risk of bleeding complications. The degree of risk conferred by single cardiovascular risk factors and combinations of risk factors may differ between the sexes, and marked postmenopausal changes are seen in some risk factors. Sociocultural factors, delays in seeking care and differences in self-management behaviours may contribute to poorer outcomes in women. Differences in clinical management for women, including higher rates of misdiagnosis and less aggressive treatment, have been reported, but there is a lack of evidence to determine their effects on outcomes, especially in angina. Although enrolment of women in randomised clinical trials has increased since the 1970s, women remain underrepresented in cardiovascular clinical trials.

CONCLUSIONS

Improvement in the prevention and management of CVD in women will require a deeper understanding of women's needs by the community, health care professionals, researchers and government.

Suboptimal management of cardiovascular risk factors in coronary heart disease patients in primary care occurs particularly in women

BACKGROUND

Patients with established coronary heart disease (CHD) are at the highest risk of further events. Despite proven therapies, secondary prevention is often suboptimal. General practitioners (GPs) are in an ideal position to improve secondary prevention.

AIM

To contrast management of cardiovascular risk factors in patients with established CHD in primary care to those in clinical guidelines and according to gender.

METHODS

GPs throughout Australia were approached to participate in a programme incorporating a disease management software (mdCare) program. Participating practitioners (1258 GPs) recruited individual patients whose cardiovascular risk factor levels were measured.

RESULTS

The mdCare programme included 12,509 patients (58% male) diagnosed with CHD. Their mean age was 71.7years (intra-quartile range 66-78) for men and 74years (intra-quartile range 68-80) for women. Low-density-lipoprotein cholesterol was above target levels in 69% (2032) of women compared with 58% (2487) in men (P < 0.0001). There was also a higher proportion of women with total cholesterol above target levels (76%, 3592) compared with men (57%, 3787) (P < 0.0001). In patients who were prescribed lipid-lowering medication, 53% (2504) of men and 72% (2285) of women continued to have a total cholesterol higher than recommended target levels (P < 0.0001). Overall, over half (52%, 6538) had at least five cardiovascular risk factors (55% (2914) in women and 50% (3624) in men, P < 0.0001).

CONCLUSION

This study found less intensive management of cardiovascular risk factors in CHD patients, particularly among women, despite equivalent cardiovascular risk. This study has shown that these patients have multiple risk factors where gender also plays a role.

Cost effectiveness of a general practice chronic disease management plan for coronary heart disease in Australia

Background.The cost effectiveness of a general practice-based program for managing coronary heart disease (CHD) patients in Australia remains uncertain. We have explored this through an economic model. Methods.A secondary prevention program based on initial clinical assessment and 3 monthly review, optimising of pharmacotherapies and lifestyle modification, supported by a disease registry and financial incentives for quality of care and outcomes achieved was assessed in terms of incremental cost effectiveness ratio (ICER), in Australian dollars per disability adjusted life year (DALY) prevented. Results.Based on 2006 estimates, 263 487 DALYs were attributable to CHD in Australia. The proposed program would add $115 650 000 to the annual national heath expenditure. Using an estimated 15% reduction in death and disability and a 40% estimated program uptake, the program’s ICER is $8081 per DALY prevented. With more conservative estimates of effectiveness and uptake, estimates of up to $38 316 per DALY are observed in sensitivity analysis. Conclusions.Although innovation in CHD management promises improved future patient outcomes, many therapies and strategies proven to reduce morbidity and mortality are available today. A general practice-based program for the optimal application of current therapies is likely to be cost-effective and provide substantial and sustainable benefits to the Australian community. What is known about this topic?Chronic disease management programs are known to provide gains with respect to reductions in death and disability among patients with coronary heart disease. The cost effectiveness of such programs in the Australian context is not known. What does this paper add?This paper suggests that implementing a coronary heart disease program in Australia is highly cost-effective across a broad range of assumptions of uptake and effectiveness. What are the implications for practitioners? These data provide the economic rationale for the implementation of a chronic disease management program with a disease registry and regular review in Australia.

An ecological approach to understanding black-white disparities in perinatal mortality

Despite appreciable improvement in the overall reduction of infant mortality in the United States, black infants are twice as likely to die within the first year of life as white infants, even after controlling for socioeconomic factors. There is consensus in the literature that a complex web of factors contributes to racial health disparities. This paper presents these factors utilizing the socioecological framework to underscore the importance of their interaction and its impact on birth outcomes of Black women. Based on a review of evidence-based research on Black-White disparities in infant mortality, we describe in this paper a missing potent ingredient in the application of the ecological model to understanding Black-White disparities in infant mortality: the historical context of the Black woman in the United States. The ecological model suggests that birth outcomes are impacted by maternal and family characteristics, which are in turn strongly influenced by the larger community and society. In addition to infant, maternal, family, community and societal characteristics, we present research linking racism to negative birth outcomes and describe how it permeates and is embedded in every aspect of the lives of African American women. Understanding the contribution of history to the various factors of life of Black women in the United States will aid in developing more effective policies and programs to reduce Black infant mortality.

Chronic Disease Risk Factors in Rural Australia: Results From the Greater Green Triangle Risk Factor Surveys

The aim of this article was to assess the level and prevalence of major chronic disease risk factors among rural adults. Two cross-sectional surveys were carried out in 2004 and 2005 in the southeast of South Australia and the southwest of Victoria. Altogether 891 randomly selected persons aged 25 to 74 years participated in the studies. Surveys included a self-administered questionnaire, physical measurements, and a venous blood specimen for lipid analyses. Two thirds of participants had cholesterol levels ≥5.0 mmol/L. The prevalence of high diastolic blood pressure (≥90 mm Hg) was 22% for men and 10% for women in southeast of South Australia, and less than 10% for both sexes in southwest of Victoria. Two thirds of participants were overweight or obese (body mass index ≥25 kg/m2). About 15% of men and slightly less women were daily smokers. The abnormal risk factor levels underline the need for targeted prevention activities in the Greater Green Triangle region. Continuing surveillance of levels and patterns of risk factors is fundamentally important for planning and evaluating preventive activities.

Characteristics and blood pressure management in patients with and without diabetes in primary care in rural Victoria

AIMS/HYPOTHESIS

This study tested whether diabetic hypertensive patients receive more intensive BP management than hypertensive patients without diabetes.

METHODS

A 12 month retrospective review of BP management was undertaken among 2460 hypertensive patients (335 with diabetes), aged 40-79 years from randomly selected general practices in rural Australia.

RESULTS

Prevalent diagnosed cardiovascular disease (CVD) was commoner among diabetic than non-diabetic patients (27.2% vs. 16.0%, OR 1.82 (1.39-2.39)). The proportion with a BP<130/80 mmHg was low (22.9% vs. 18.6%, p=.069, respectively). BP was monitored more closely among diabetic patients (e.g. quarterly BP measurements in 18.2% vs. 10.5% respectively, p<.001), was treated with more anti-hypertensive agents (1.5+/-1.0 vs. 1.0+/-1.0, p<001) and was more likely to be associated with other CVD medications. Achievement of non-diabetic BP targets was associated with living in the regional centre (vs. smaller rural town: 1.21 (1.02-1.43)) and CVD (1.54 (1.21-1.95)), but not the presence of diabetes (0.94 (0.73-1.19)).

CONCLUSIONS

In this population, hypertension is more aggressively monitored and treated among diabetic than non-diabetic patients, but largely due to their CVD and not to the level recommended in guidelines. Commencing anti-hypertensive treatment earlier (e.g. at diagnosis) and recommending more agents (e.g. in combination) may be needed to improve BP control among diabetic patients on a population basis.

Impact on mortality following first acute myocardial infarction of distance between home and hospital: cohort study

Objective:

To investigate the effect of distance between home and acute hospital on mortality outcome of patients experiencing an incident myocardial infarction (MI).

Design:

Cohort study using a record linkage database.

Setting:

Tayside, Scotland, UK.

Patients:

10 541 patients with incident acute MI between 1994 and 2003 were identified from Tayside hospital discharge data and from death certification data.

Main outcome measures:

MI mortality in the community, all-cause mortality in hospital and all-cause mortality during follow-up.

Results:

4133 subjects died following incident MI in the community (that is, were not hospitalised), 6408 patients survived to be hospitalised and 1010 of these (15.8%) died in hospital. Of 5398 discharged from hospital, 1907 (35.3%) died during a median of 3.2 years of follow-up. After adjustment for rurality and other known risk factors, distance between home and admitting hospital was significantly associated with increased mortality both before hospital admission (adjusted odds ratio (OR), 2.05, 95% CI 1.00 to 4.21 for >9 miles and 1.46, 1.09 to 1.95 for 3–9 miles when compared to <3 miles) and after hospitalisation (adjusted hazard ratio (HR) 1.90, 1.19 to 3.02 and 1.27, 0.96 to 1.68). However, there was no effect of distance on in-hospital mortality (adjusted OR 0.95, 0.45 to 2.03 and 1.02, 0.66 to 1.58).

Conclusion:

The distance between home and hospital of admission may predict mortality in subjects experiencing a first acute MI. This association was found both before and after hospitalisation. Further studies are needed to explore the reasons for this association. However these data provide support for policies that locate services for acute MI closer to where patients live.

Patient delay in responding to symptoms of possible heart attack: can we reduce time to care?

In Australia, many deaths and significant cardiac disability result from delayed response to symptoms of heart attack. Although delays due to transport and initiation of reperfusion therapy in hospital may contribute to late treatment, the major component of delay is the time patients take in deciding to seek help. A critical examination of campaigns to shorten patient delay concludes that they were based on a factual, short-term, non-targeted approach that included education and mass media strategies. They achieved equivocal results. One randomised controlled trial has been conducted. Although this showed an improved understanding of heart attack symptoms, it did not shorten pre-hospital delays. The implications of these findings are that future campaigns to shorten patient delay are likely to be more effective if they address the psychosocial and behavioural blocks to action, are ongoing rather than short term, and focus on people at highest risk, including those with known or high risk of coronary heart disease, those in rural locations, and Indigenous Australians. The National Heart Foundation of Australia proposes a comprehensive strategy to incorporate this approach into its future campaigns to reduce patient delay for suspected heart attack.

Lessons for a national pharmaceuticals strategy in Canada from Australia and New Zealand

BACKGROUND

The provincial formulary review processes in Canada lead to the slow and inequitable availability of new products. In 2004, the exploration of a national pharmaceuticals strategy (NPS) was announced. The pricing policies of New Zealand and Australia have been suggested as possible models for the NPS.

OBJECTIVE

To compare health care indexes and health care use information from Canada, Australia and New Zealand.

METHODS

The 2006 Organisation for Economic Co-operation and Development health data were used to compare health and health care indexes from Canada, Australia and New Zealand between 1994 and 2002 to 2004. The principal focus of the evaluation was cardiovascular and respiratory disorders.

RESULTS

Although the mortality rate from acute myocardial infarction decreased in each country from 1994, it levelled off in New Zealand in 1997, 1998 and 1999. Between 1994 and 2003, the average length of hospital stay for any cause and for cardiovascular disorders was stable in Australia and Canada, but increased in New Zealand, while the rate of hospital discharges for cardiovascular diseases decreased in Canada and Australia, but strongly increased in New Zealand. Over the same period, sales of cardiovascular drugs decreased in New Zealand, while sharply increasing in Canada and Australia.

CONCLUSIONS

Although only circumstantial, our results suggest an association between decreasing cardiovascular drug sales and markers of declining cardiovascular health in New Zealand. Careful consideration must be given to the potential consequences of any model for an NPS in Canada, as well as to opportunities provided for discussion and input from health care professionals and patients.

Out‐of‐hospital cardiac arrest in Victoria: rural and urban outcomes

OBJECTIVE

To compare the survival rate from out-of-hospital cardiac arrest in rural and urban areas of Victoria, and to investigate the factors associated with these differences.

DESIGN

Retrospective case series using data from the Victorian Ambulance Cardiac Arrest Registry.

SETTING

All out-of-hospital cardiac arrests occurring in Victoria that were attended by Rural Ambulance Victoria or the Metropolitan Ambulance Service.

PARTICIPANTS

1790 people who suffered a bystander-witnessed cardiac arrest between January 2002 and December 2003.

RESULTS

Bystander cardiopulmonary resuscitation was more likely in rural (65.7%) than urban areas (48.4%) (P = 0.001). Urban patients with bystander-witnessed cardiac arrest were more likely to arrive at an emergency department with a cardiac output (odds ratio [OR], 2.92; 95% CI, 1.65-5.17; P < 0.001), and to be discharged from hospital alive than rural patients (urban, 125/1685 [7.4%]; rural, 2/105 [1.9%]; OR, 4.13; 95% CI, 1.09-34.91). Major factors associated with survival to hospital admission were distance of cardiac arrest from the closest ambulance branch (OR, 0.87; 95% CI, 0.82-0.92), endotracheal intubation (OR, 3.46; 95% CI, 2.49-4.80), and the presence of asystole (OR, 0.50; 95% CI, 0.38-0.67) or pulseless electrical activity (OR, 0.73; 95% CI, 0.56-0.95) on arrival of the first ambulance crew.

CONCLUSIONS

Survival rates differ between urban and rural cardiac arrest patients. This is largely due to a difference in ambulance response time. As it is impractical to substantially decrease response times in rural areas, other strategies that may improve outcome after cardiac arrest require investigation.

The effects of socioeconomic status, accessibility to services and patient type on hospital use in Western Australia: a retrospective cohort study of patients with homogenous health status

Background

This study aimed to investigate groups of patients with a relatively homogenous health status to evaluate the degree to which use of the Australian hospital system is affected by socio-economic status, locational accessibility to services and patient payment classification.

Method

Records of all deaths occurring in Western Australia from 1997 to 2000 inclusive were extracted from the WA mortality register and linked to records from the hospital morbidity data system (HMDS) via the WA Data Linkage System. Adjusted incidence rate ratios of hospitalisation in the last, second and third years prior to death were modelled separately for five underlying causes of death.

Results

The independent effects of socioeconomic status on hospital utilisation differed markedly across cause of death. Locational accessibility was generally not an independent predictor of utilisation except in those dying from ischaemic heart disease and lung cancer. Private patient status did not globally affect utilisation across all causes of death, but was associated with significantly decreased utilisation three years prior to death for those who died of colorectal, lung or breast cancer, and increased utilisation in the last year of life in those who died of colorectal cancer or cerebrovascular disease.

Conclusion

It appears that the Australian hospital system may not be equitable since equal need did not equate to equal utilisation. Further it would appear that horizontal equity, as measured by equal utilisation for equal need, varies by disease. This implies that a 'one-size-fits-all' approach to further improvements in equity may be over simplistic. Thus initiatives beyond Medicare should be devised and evaluated in relation to specific areas of service provision.

Point-of-care monitoring of anticoagulant therapy by rural community pharmacists: description of successful outcomes

Warfarin is a recognised high-risk drug for adverse events. Patients from rural and remote regions are at increased risk of these events because of problems of access to health care providers and services, and there is some reluctance to prescribe warfarin to patients in rural areas because of the difficulties in monitoring anticoagulated patients. The availability of portable international normalised ratio (INR) monitors is particularly attractive in rural or remote settings because of the lack of access to pathology services. Pharmacists and other health professionals in rural areas are ideally placed to assist general practitioners in the management of their anticoagulated patients through the use of portable INR monitors. The present article describes three cases of successful outcomes of pharmacist-assisted anticoagulation monitoring in the rural setting. Innovative service delivery models like these are needed to meet the needs of the increasing number of rural Australians requiring warfarin therapy.

Do people in rural and remote Queensland delay using health services to manage the episodes of incapacity?

The research project described in the present paper aimed to explore the types of self-reported management which families in relatively 'high', 'moderate' and 'low' medically resourced areas use for episodes of incapacity and the length of time from an initial symptom to the management behaviours. A telephone survey was conducted in rural and remote Queensland, Australia, to explore one or more types of management for the most recent incapacity episode of family members. A respondent indicated at least one type of management for any one episode. These included using a home remedy, self-treatment and an ambulatory doctor's visit. Data were analysed descriptively and analytically. Log transformations were used for all outcomes prior to using bivariate analyses which incorporated the correlation between observations to compare the time from initial symptom to management between groups. Among 394 households contacted, 270 provided information about 697 household members, 269 (38.5%) of whom had had at least one episode of incapacity in the previous 12 months. Among people in each of the three resourced areas, there was a significant difference in the length of time taken to visit accident and emergency (A&E) units. Men visited the units and consulted books earlier than women. Although age was not quite significantly related to the use of A&E units (P = 0.06), data suggested that people 35 years or older tended to take a longer time to use the services than the younger age groups. After taking into account that the members of the same household might take the same time from initial symptoms to management, people who were incapacitated and lived in areas with different levels of medical resources and gender were likely to be different in the time taken to use services at the A&E units.

Management of episodes of incapacity by families in rural and remote Queensland

People in rural and remote areas have relatively poor health, so limited availability of and accessibility to doctors are major health issues. This cross-sectional study was conducted in rural and remote areas of Central Queensland. Using telephone interviews, the study described the use of formal and informal health services by families in response to episodes of incapacity. An episode of incapacity was defined as inability to conduct ordinary activities for at least half a day due to new or continued illness. Of the 394 households contacted, 270 (68.5%) provided information about 698 household members, of whom 269 (38.5%) reported at least one episode of incapacity in the previous 12 months. The respondents could report more than one type of management of an illness episode. The management of the most recent episode in each member included 68% visiting doctors and 8.2% using services at an accident and emergency unit. Persons living in "least" medically resourced areas were more likely than persons in relatively "high" and "moderate" areas to consult doctors, but were also more likely to first consult books and delay their visits. They also consulted by telephone three times more frequently. Only 7% consulted other health practitioners including nurses and chemists, suggesting that these health practitioners were not used by families in rural and remote areas during episodes of incapacity. Increasing the availability and accessibility of medical care resources in rural and remote areas, using alternative delivery methods such as telemedicine, may meet the health needs of rural populations.

Fracture rates lower in rural than urban communities: the Geelong Osteoporosis Study

BACKGROUND

Urban and rural communities differ in the incidence of several diseases including coronary heart disease and some cancers. Lower hip fracture rates among rural than urban populations have been reported but few studies have compared rural and urban fractures at sites other than the hip.

OBJECTIVE

To compare total and site specific fracture rates among adult residents of rural and urban communities within the same population.

DESIGN AND SETTING

This is a population based study on osteoporosis in Australia. All fractures occurring in adult residents over a two year period were ascertained using radiological reports. The rural and urban areas are in close proximity, with the same medical, hospital, and radiological facilities permitting uniform fracture ascertainment.

MAIN OUTCOME MEASURES

All fracture rates were age adjusted and sex adjusted to the Australian population according to the 1996 census of the Australian Bureau of Statistics and described as the rate per 10 000 person years. The p values refer to the adjusted rate difference.

RESULTS

The hip fracture rate (incidence per 10 000 person years) was 32% lower (39 v 57, p<0.001), and the total fracture rate 15% lower (160 v 188, p=0.004) among rural than urban residents, respectively. The lower fracture rates in the rural population were also apparent for pelvic fractures.

CONCLUSION

In the older rural population, lower fracture rates at sites typically associated with osteoporosis suggest environmental factors may have a different impact on bone health in this community. If the national rate of hip fracture could be reduced to that of the rural population, the projected increase in hip fracture number attributable to aging of the population could be prevented.

The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction

OBJECTIVE

To evaluate the effects of quality improvement interventions on inhospital mortality after admission for acute myocardial infarction (AMI).

DESIGN

Before-and-after study (with concurrent controls) based on hospital discharge data from a routinely maintained, administrative database.

SETTING

All Queensland public hospitals, July 1991 - June 1999.

STUDY POPULATION

Patients with AMI admitted through the emergency department.

INTERVENTION

Development and promulgation of clinical practice guidelines at one hospital, combined with regular audit and feedback, commencing November 1995.

MAIN OUTCOME MEASURES

Inhospital mortality (adjusted for age, sex and comorbidities) for four-year periods before (1991-92 to 1994-95) and after (1995-96 to 1998-99) initiation of quality improvement interventions.

RESULTS

Before the intervention, the adjusted odds ratio (OR) for inhospital death at the intervention hospital was about the same as at other public hospitals (adjusted OR, 0.99; 95% CI, 0.80-1.24), but was more than 40% lower after the intervention (adjusted OR, 0.59; 95% Cl, 0.45-0.78). After the intervention, the risk of death at the intervention hospital was lower compared with hospitals with cardiologists as admitting practitioners (adjusted OR, 0.63; 95% CI, 0.48-0.83), with onsite revascularisation facilities (adjusted OR, 0.66; 95% CI, 0.49-0.88), and with large numbers (> or = 250 per year) of annual admissions of patients with AMI (adjusted OR, 0.72; 95% CI, 0.54-0.97).

CONCLUSIONS

Quality improvement interventions lower the risk of inhospital death in patients with AMI. Implementation of such interventions in all hospitals may confer a risk of death lower than that achieved by admitting all patients under the care of cardiologists, or to hospitals with revascularisation facilities or a high volume of admissions of patients with AMI.

Social disadvantage and variation in the incidence of end-stage renal disease in Australian capital cities

OBJECTIVE

To evaluate variation in the incidence of end-stage renal disease (ESRD) within Australian capital cities. To explore the relation between the incidence of ESRD and socioeconomic disadvantage.

METHODS

We obtained data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) regarding 5,013 patients from capital cities who started ESRD treatment between 1 April 1993 and 31 December 1998. We used the postcode at the start of treatment to calculate the average annual incidence of ESRD for each of 51 capital city regions using 1996 Census counts based on place of usual residence. We calculated standardised incidence ratios with 95% confidence intervals for each region. The standardised incidence ratios were examined in relation to the SEIFA Index of Relative Socio-economic Disadvantage (IRSD), derived from the 1996 Census. Low IRSD values indicate more disadvantaged areas.

RESULTS

There is significant variation in the standardised incidence of ESRD within capital cities. There was a significant correlation (r=-0.41, p=0.003) between the standardised incidence ratio for ESRD and the SEIFA IRSD.

CONCLUSIONS AND IMPLICATIONS

Capital city areas that are more disadvantaged have a higher incidence of ESRD. Socioeconomic factors may be important determinants of the risk of developing ESRD.

Regional variation in the incidence of end-stage renal disease in Indigenous Australians

OBJECTIVE

To evaluate regional variation in the incidence of end-stage renal disease (ESRD) in Indigenous Australians, and to examine the proximity to ESRD treatment facilities of Indigenous patients.

DESIGN

Secondary data review, with collection of primary data regarding patients' place of residence before beginning ESRD treatment.

PARTICIPANTS

Indigenous ESRD patients who commenced treatment in Australia during 1993-1998.

METHODS

We obtained data from the Australian and New Zealand Dialysis and Transplant Registry regarding 719 Indigenous patients who started ESRD treatment between 1 January 1993 and 31 December 1998. We obtained primary data from the treating renal units to determine the place of residence before beginning renal replacement therapy. We calculated the average annual incidence of ESRD for each of the 36 Aboriginal and Torres Strait Islander Commission regions using population estimates based on the 1996 Census, and calculated standardised incidence ratios with 95% confidence intervals for each region. We compared the number of cases with the treatment facilities available in each region.

MAIN OUTCOME MEASURE

Regional standardised ESRD incidence for Indigenous Australians referenced to the total resident population of Australia.

RESULTS

Standardised ESRD incidence among Indigenous Australians is highest in remote regions, where it is up to 30 times the national incidence for all Australians. In urban regions the standardised incidence is much lower, but remains significantly higher than the national incidence. Forty-eight per cent of Indigenous ESRD patients come from regions without dialysis or transplant facilities and 16.3% from regions with only satellite dialysis facilities.

CONCLUSIONS

There is marked regional variation in the incidence of ESRD among Indigenous Australians. Because of the location of treatment centres, there is inequitable access to ESRD treatment services for a significant proportion of Indigenous patients.