Inequitable provision of optimal health services for patients with chronic heart failure: a national geo-mapping study

To the Editor: Clark et al have claimed to map the distribution of services for people with chronic heart failure (CHF) against the distribution of these people.1 An examination will show that they have mapped the distribution of people likely to have CHF, using age and Aboriginality as surrogate markers. The stated mapping of the services shows the services probably available to these people.

A map is drawn to show us what the cartographer wants us to see.2 The authors note that high prevalence in remote regions has been shown on the maps, but they have not considered different mapping methods to provide a better representation of their results.3 This has led to an anomaly so that, when calculating numbers of people with CHF, the maps show remote areas with giant households containing between 24 and 300 people.

CHF programs were located by a snowball sampling technique, which by its nature will miss isolated examples. Isolation is a feature of rural and remote practice, so this method is biased to finding metropolitan examples. In my own rural practice in Griffith, I found a local program that had been operating in 2004 and a distance program run by a health fund, neither of which had been identified by Clark et al.

On the medical front, the authors asserted that access to a CHF management program is a mark of equity in health services. This is based on a metro-centric model looking at admission with CHF to a major teaching hospital, and showing that rates of readmission and death were reduced where a nurse and a pharmacist made a single visit to someone with CHF in their home after hospital discharge. The relevance of this activity to a rural person with a single community pharmacist who may make a home visit, a single point of contact with medical services in their general practitioner, and the possible availability of a community nurse to visit them regularly is unproven. Perhaps the city folk were copying the principles of the services we already had?