A report by the Australian Institute of Health and Welfare (AIHW) shows that drugs and some interventions for cardiovascular disease are underused in rural areas.1It found that rural patients are getting far fewer prescriptions for beta blockers, ACE inhibitors, statins and warfarin than other Australians. For example, the report found that for males the rate of new prescriptions per 100 000 people for lipid-lowering drugs was 286 in metropolitan areas, 147 in rural areas and 10 in remote areas.1
Mortality rates for coronary heart disease are higher outside capital cities. The difference between rural and urban areas accounts for approximately 5000 excess deaths per year.2If some of the increased mortality in rural people13 is the result of under prescribing for cardiovascular disease, then doctors can make a difference by addressing the issue of appropriate prescribing and 'compliance'.
Access problems probably account for much of the rural-urban gap. We know that rural patients see their general practitioners, on average, 1-2 fewer times per year than city dwellers.14 Additionally, rural patients have less access to cardiologists, who are more likely to be aggressive with cardiac therapies and do not have to pay attention to the patient's many other needs. Timely access to technical intervention in acute coronary syndromes is a problem, for example if patients have to travel for hours before even being considered for thrombolytics, pacemakers or percutaneous coronary intervention.
The evidence about prevention and treatment of ischaemic heart disease has matured to the point that guidelines are relatively simple and straightforward for most patients.1While specialists may be more familiar with guidelines, the studies about whether or not patients with cardiovascular disease are best cared for by cardiologists, general physicians or general practitioners are conflicting. Some studies show more intervention by specialists, but no difference in mortality. Others show that patients do better if cared for by cardiologists, or doctors who graduated from medical school more recently, possibly because they have been trained to use guidelines.5
Even if doctors know the recommended drugs, they may be reluctant to prescribe them. For example, doctors often hesitate to prescribe beta blockers because of myths about suppression of hypoglycaemic reactions in diabetes.6However, patients with diabetes and cardiovascular disease benefit (reduced mortality) more than others from beta blockers so the drugs are strongly recommended.16 Chronic obstructive pulmonary disease often raises concerns among doctors when beta blockers are indicated, but systematic reviews show that this concern should not prevent doctors from prescribing this life-saving therapy.7
Rural areas have a disproportionately high and increasing percentage of elderly patients3who are more likely to have cardiovascular disease, and are also likely to have other medical problems. Legitimate concerns about drug interactions and adverse effects in this vulnerable group may increase the reluctance to prescribe. However, studies looking at hypertension treatment and anticoagulation show that, generally, older patients should have the same goals (for example blood pressure < 130/80) as younger patients.
Indigenous Australians have high rates of heart disease. Living in a remote area, as well as having comorbidities, may make them less likely to receive coronary interventions.8
Some patients do not fill their prescriptions and the major problem here seems to be cost.9The AIHW report does not address this directly, but, for example, general patients prescribed an ACE inhibitor, a beta blocker and a lipid-lowering drug would pay about $90 per month. Rural patients also face higher costs accessing medical care, although their incomes tend to be lower than those of urban residents.
Assuming cost issues can be overcome, what about compliance? The report reveals that rural patients are actually slightly more compliant than their city peers, but many stop taking the drugs because of adverse effects or a lack of understanding about their treatment.1Better doctor-patient communication and more time spent reviewing medication compliance might help. However, I know from experience as a rural doctor that the pressure on general practitioners to see more patients may subvert preventive therapies or counselling when doctor availability and waiting lists are problems and diverting 'crises' are common.
I think we can do better in the country. We should firstly think about cardiovascular disease and know the major recommendations. Secondly, we need to schedule time to review treatment or consider ordering a medication review. Adherence to lipid-lowering therapy improves if patients get their cholesterol checked and have their medications reviewed by their own doctor.10Improved adherence then improves mortality.911
Other health professionals could be involved in a structured campaign that goes straight to rural people. For example, if the main problem is access, we could look at mechanisms in pharmacies that appropriately identify people who would benefit from cardiovascular drugs. Rural pharmacies and general practices could be given support to improve patient knowledge and adherence to treatment. Staff could ask a few direct questions about heart disease or risk factors. A 'yes' then prompts a pharmacy or practice nurse review of whether the patient's blood pressure is controlled and whether they are taking the recommended list of medications.
The Commonwealth government has increased the number of medical school places across Australia. The new rural clinical schools are training 25% of the nation's medical students, so that in about 10 years we may have enough doctors for regional and rural Australians. In the meantime, knowing the guidelines and being mindful of the gap in mortality, rural doctors should work with other health professionals to identify patients for whom cardiovascular medications could prove life-saving, and work together to close the gap.
- Australian Institute of Health and Welfare. Senes S, Penm E. Medicines for cardiovascular health: are they used appropriately? Cardiovascular disease series no. 27. Cat. no. 36. Canberra: AIHW; 2007. http://www.aihw.gov.au/publications/index.cfm/title/10300 [cited 2008 Jul 10]
- Sexton PT, Sexton TLH. Excess coronary mortality among Australian men and women living outside the capital city statistical divisions. Med J Aust 2000;172:370-4.
- Australian Health Ministers' Advisory Council's National Rural Health Policy Sub-Committee and the National Rural Health Alliance. Healthy horizons: a framework for improving the health of rural, regional and remote Australians. Outlook 2003-2007. Canberra: National Rural Health Alliance; 2003.
- Rural Workforce Agency Victoria. White paper: The viability of rural and regional communities. Resolving Victoria's rural medical workforce crisis. Melbourne: RWAV; 2006.
- Norcini JJ, Kimball HR, Lipner RS. Certification and specialization: do they matter in the outcome of acute myocardial infarction? Acad Med 2000;75:1193-8.
- Lama PJ. Systemic adverse effects of beta-adrenergic blockers: an evidence-based assessment. Am J Ophthalmol 2002;134:749-60.
- Salpeter S, Ormiston T, Salpeter E. Cardio selective beta-blockers for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD003566. DOI: 10.1002/14651858.CD003566.pub2 [cited 2008 Jul 10]
- Coory MD, Walsh WF. Rates of percutaneous coronary interventions and bypass surgery after acute myocardial infarction in Indigenous patients. Med J Aust 2005;182:507-12.
- Schneeweiss S, Patrick AR, Maclure M, Dormuth CR, Glynn RJ. Adherence to statin therapy under drug cost sharing in patients with and without acute myocardial infarction: a population-based natural experiment. Circulation 2007;115:2128-35.
- Brookhart MA, Patrick AR, Schneeweiss S, Avorn J, Dormuth C, Shrank W, et al. Physician follow-up and provider continuity are associated with long-term medication adherence: a study of the dynamics of statin use. Arch Intern Med 2007;167:847-52.
- Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA 2007;297:177-86.