The report by Sexton and Sexton1 in this issue of the Journal updates our knowledge about geographic
differences in death rates from cardiovascular disease (CVD) in
Australia. Their major finding is that deaths from coronary heart
disease (CHD) in 1996 were 30% higher for men and 21% higher for women
who live outside our capital cities than for those who live in capital
cities. The gap widened over the period of study -- in 1986 the CHD
mortality difference (in both men and women) was 13%. The gratifying
decline in deaths from CVD over the last number of years has been
greater for those who live in capital cities, and this has led to a
widening of the geographic gradient in CVD deaths. Of particular
concern in the report is that the excess mortality outside capital
cities is greater among younger age groups.
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
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
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
for Clinical Epidemiology and Biostatistics
Faculty of Medicine and
The University of Newcastle, Newcastle, NSW
- 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.
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:
Marmot M, Ryff CD, Bumpass LL, et al. Social inequalities in health:
next questions and converging evidence. Soc Sci Med 1997; 44:
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.
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
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:
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.
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.
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.
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.
Kitchiner DJ, Bundred PE. Clinical pathways [editorial]. Med
J Aust 1999; 170: 54-55.
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.
Regional Australia Summit communiqu. Presentation of the
(Accessed 23 March 2000).