摘要：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. 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 Norris 15 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 fatalities 16 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.
