Chronic heart failure beyond city limits

INTRODUCTION: Chronic heart failure (CHF) develops in frail elderly individuals who have suffered an acute or sustained insult to the structural efficiency of the heart due to the presence of underlying heart disease and/or hypertension. It is also more common in individuals with disproportionately high levels of cardiac disease or its risk factors, for example lower socioeconomic status. As such, this epidemic is particularly significant for older people, males and Aboriginal people; groups who comprise a greater proportion of the population in rural and remote Australia. The aim of this study is to determine if the rates of CHF differ between urban and rural Australia. METHOD: CHF prevalence rates derived from well validated international CHF prevalence data were applied to the Australian Bureau of Statistics Census data for 2001 and weighted to reflect the proportion of Aboriginal people in each geographical stratum. RESULTS: Australia wide, the estimated prevalence of CHF was 17.87 per 1000, ranging from 13.98/1000 in the Australian Capital Territory to 29.50/1000 in rural Northern Territory. Overall, CHF was more prevalent in rural and remote regions (19.84/1000) and large urban centres (19.01/1000) than in capital cities (16.94/1000) (p<0.001). High prevalence rates were also noted in the idyllic rural locations favoured by retirees. In Victoria, Western Australia, South Australia and the Australian Capital Territory over 70% of the estimated individual cases were located in capital cities. In New South Wales, Queensland, Tasmania and the Northern Territory the highest proportion of cases occurred outside capital cities. CONCLUSIONS: The main significance of these findings is that while a majority of heart failure may occur among people living in cities (because that is where most people live), a disproportionate number of cases occur among people living outside these cities (due to age and other socio-demographic risk factors) where services may be fewer and less accessible.R. A. Clark, S. McLennan, K. Eckert, A. Dawson, D. Wilkinson and S. Stewar

Rural-Urban Mental Health Differentials: A South Australian Perspective

Background There is a widespread perception that the health status of rural Australians is poorer than that of urban Australians, characterised by higher mortality, lower life expectancies, and an increased incidence of some diseases. At present this perception is difficult to confirm or refute, in terms of mental illness, because of limited published data on the extent of mental illness in regional Australia. Australians from rural areas are also reported to have less access to appropriate health care compared to their urban counterparts; however, there is limited evidence to support such claims using large population-based epidemiological data. It is not known whether remoteness per se is an important determinant of health. Aim To determine if rural and remote South Australians were disadvantaged in terms of their mental health status and access to health care. The aims were to: 1) determine if prevalence of mental illness and comorbidity were associated with accessibility and remoteness; 2) examine the effects of accessibility and remoteness on health service utilisation; and 3) determine if remoteness per se was an important determinant of mental illness. Methods Prospectively designed, secondary analysis of data from a large cross sectional, population–based health survey, conducted in South Australia (SA) in 2000. In all, 2,454 adults, aged 18 years or more, were randomly selected and interviewed using the Computer Assisted Telephone Interview (CATI) system. CATI is a telephone monitoring system that is an efficient means of assessing self-reported aspects of population health, particularly in rural and remote areas. Psychological distress and depression were assessed using the Kessler 10 (K10) Psychological Distress Scale, the SF-12 measure of health status and self-reported, medically-confirmed mental illness, in the previous 12 months. Additional outcome measures included socio-demographic characteristics, a range of health services measures, psychosocial and health risk factors. Geographical variation in outcome measures was assessed using the Accessibility and Remoteness Index of Australia (ARIA). The data were analysed using SPPS and Stata statistical programs and weighted by region, age, sex and probability of selection in the household, using the 1999 total estimated resident population (ERP) figures supplied by the Australian Bureau of Statistics. Direct age-sex standardisation was applied to prevalence rates of mental illness, socio-demographic and health service utilisation data. Results Overall age-sex adjusted mental illness prevalence estimates were similar using the three measures of psychological distress (10.5%), depression (12.9%) and self-reported medically-confirmed mental illness (12.9%). For each measure, there was no significant variation in prevalence across ARIA categories, except for a lower than expected prevalence of depression (7.7%) in the accessible category. There was also no significant difference in the median number of uses of four types of health services across ARIA categories. Significantly fewer residents of highly accessible areas reported never using primary health care services (14.4% vs. 22.2% in very remote areas), and significantly more reported high use (6 visits, 29.3% vs. 21.5%). Fewer residents of remote areas reported never attending hospital (65.6% vs. 73.8% in highly accessible areas). Frequency of use of mental health services was low and not significantly different across ARIA categories. Very remote residents were more likely to spend at least one night in a public hospital (15.8%) than were residents of other areas (eg 5.9% for highly accessible areas). After controlling for the joint effects of stressful life events, perceived control of life events, socio-demographic characteristics and health risk factors, odds of mental illness did not vary by ARIA category (highly accessible: reference category; accessible: OR 0.9, 95% CI 0.60-1.31; moderately accessible: OR 0.80, 95% CI 0.45-1.43; remote/ very remote: 0.70, 95% CI 0.44-1.03). The most important predictors of mental illness in the multivariate logistic model were female sex; smoking; low consumption of vegetables; low exercise; a physical condition; perceived lack of control with: life in general, personal life, job security or health; and major stressful events such as family or domestic violence and the death of someone close. Conclusions Prevalence rates of psychological distress, depression and medically-confirmed mental illness in SA were high. However, there was no evidence that the prevalence of these conditions varied substantially across ARIA categories. The frequency of use of a range of health services was also broadly similar across the state. Remoteness per se was not associated with mental illness, either directly or indirectly as an important confounder in stressful life event/mental illness associations. Psychosocial factors were more important determinants of mental illness. The data do not support existing stereotypes of a rural – urban mental health differential in SA and point to potential mechanisms that may be responsible for poorer mental health outcomes

Skin cancer surgery in Australia 2001-2005 : the changing role of the general practitioner

Objective: To describe changing patterns of skin cancer surgery by Australian general practitioners and make comparisons with specialists. Design and setting: Analysis of Medicare Australia item number reports for skin cancer excisions and for flap and graft repairs between 2001 and 2005. Main outcome measures: GPs' and specialists' rates of non-melanoma skin cancer (NMSC) excisions, melanoma excisions, flap repairs and graft repairs; excision to flap ratios. Results: NMSC excisions in Australia increased from 338712 (2001)to 451 628 (2005), a mean annual increase of 1.11/1000 population (P =0.04); GPs did 51.1% of excisions in 2001, increasing to 54.4% in 2005, representing a higher mean annual rate increase than in specialists (P = 0.003). Nationally, melanoma excisions increased from 20414 (2001) to 25 580 (2005); GPs did 34.3% of excisions in 2001, increasing to 35.8% in 2005 - a similar mean annual rate increase to that in specialists (P = 0.25). Total flap repairs increased from 58 550 (2001) to 80 742 (2005); GPs did 21.3% of flap repairs in 2001, increasing to 26.9% in 2005 - a similar mean annual rate increase to that in specialists (P = 0.83). Nationally, the excision to flap ratio for GPs fell from 14: 1 (2001) to 12: 1 (2005); in Queensland the ratio fell from 14: 1 to 9: 1 over the same period. Conclusion: GPs excise the majority of skin cancers, and the proportion excised by GPs is increasing. GPs are increasingly using skin flaps for repair, suggesting substantial changes to patterns of treatment, especially in Queensland.5 page(s

CARDIAC-ARIA: Measuring the Accessibility to Cardiovascular Services in Rural and Remote Australia Via Applied Geographical Spatial Technology (GIS)

Background/aims: Cardiovascular disease (CVD) continues to impose a heavy burden in terms of cost, disability and death in Australia. Recent evidence suggests that increasing remoteness, where cardiac services are scarce, is linked to an increased risk of dying from CVD. Fatal CVD events are reported to be between 20% and 50% higher in rural areas compared to major cities.\ud \ud Method: This project, with its extensive use of Geographic Information Systems (GIS) technology, will rank 11,338 rural and remote population centres to identify geographical ‘hotspots’ where there is likely to be a mismatch between the demand for and actual provision of cardiovascular services. It will, therefore, guide more equitable provision of services to rural and remote communities.\ud \ud Outcomes: The CARDIAC-ARIA project is designed to; map the type and location of cardiovascular services currently available in Australia, relative to the distribution of individuals who currently have symptomatic CVD; determine, by expert panel, what are the minimal requirements for comprehensive cardiovascular health support in metropolitan and rural communities and derive a rating classification based on the Accessibility and Remoteness Index of Australia (ARIA) for each of Australia's 11,338 rural and remote population centres.\ud \ud Conclusion: This unique, innovative and highly collaborative project has the potential to deliver a powerful tool to highlight and combat the burden imposed by cardiovascular disease (CVD) in Australia

Access to cardiac rehabilitation and secondary prevention services in Australia: Is geography really the issue? [Conference Abstract]

CSANZ 2011 Published abstractsR. Clark, N. Coffee, D. Turner, K. Eckert, Deborah, S. Stewart, D.Wilkinson, A. Tonki

Can the cardiac ARIA index improve cardiac care for Australia's indigenous population? [Conference Abstract]

Background: Timely access to appropriate cardiac care is critical for optimising outcomes. Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services for Australia's 20,387 population locations. Methods: An expert panel defined a single patient care pathway. Using geographic information systems (GIS) the numeric/alpha index was modelled in two phases. The acute phase index (numeric) ranged from 1 (access to tertiary centre with PCI ≤1 h) to 8 (no ambulance service, >3 h to medical facility, air transport required). The aftercare index was modelled into 5 alphabetic categories; A (Access to general practitioner, pharmacy, cardiac rehabilitation, pathology ≤1 h) to E (no services available within 1 h). Results: Approximately 70% or 13.9 million people lived within a CardiacARIAindex category 1A location. Disparity continues in access to category 1A cardiac services for 5.8 million (30%) of all Australians, 60% of Aboriginal and Torres Strait Islander people and 32% of people over 65 years of age. In a cardiac emergency only 40% of the Indigenous population reside within one hour of category 1 hospital. Approximately 30% (81,491 Indigenous persons) are more than one to three hours from basic cardiac services. Conclusion: Geographically, the majority of Australian's have timely access for survival of a cardiac event. The CardiacARIAindex objectively demonstrates that the healthcare system may not be providing for the needs of 60% of Indigenous people residing outside the 1A geographic radius. Innovative clinical practice maybe required to address these disparities

Access to cardiac rehabilitation does not equate to attendance

Background/Aims\ud \ud Timely access to appropriate cardiac care is critical for optimizing positive outcomes after a cardiac event. Attendance at cardiac rehabilitation (CR) remains less than optimal (10%–30%). Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services after a cardiac event in Australia.\ud \ud Methods\ud \ud An expert panel defined a single patient care pathway and a hierarchy of the minimum health services for CR and secondary prevention. Using geographic information systems a numeric/alpha index was modelled to describe access before and after a cardiac event. The aftercare phase was modelled into five alphabetical categories: from category A (access to medical service, pharmacy, CR, pathology within 1 h) to category E (no services available within 1 h).\ud \ud Results\ud \ud Approximately 96% or 19 million people lived within 1 h of the four basic services to support CR and secondary prevention, including 96% of older Australians and 75% of the indigenous population. Conversely, 14% (64,000) indigenous people resided in population locations that had poor access to health services that support CR after a cardiac event.\ud \ud Conclusion\ud \ud Results demonstrated that the majority of Australians had excellent ‘geographic’ access to services to support CR and secondary prevention. Therefore, it appears that it is not the distance to services that affects attendance. Our ‘geographic’ lens has identified that more research on socioeconomic, sociological or psychological aspects to attendance is needed.\u