Urban-rural inequalities in ischemic heart disease in Scotland, 1981-1999

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.