Shelley Wood

June 23, 2013

CHICAGO, Illinois — It's well-known that living in rural and remote areas can lead to worse outcomes after a cardiovascular event--now new data from Australia suggests that that risk is augmented in people with type 1 and 2 diabetes [1].

Dr Dianna J Magliano (Monash University, Melbourne, Australia) presented the study findings here today at the American Diabetes Association (ADA) 2013 Scientific Sessions.

"In Australia, prevention efforts should focus on both the prevention of diabetes as well as preventing health inequities associated with living away from a major city," she said.

Magliano and colleagues linked vital status and cause-of-death data from the national death index to patient-location data collected in the National Diabetes Services Scheme (NDSS). The NDSS delivers diabetes-related products at subsidized prices and provides education and support to over one million people, capturing 90% of all people with known diabetes in Australia. The Accessibility/Remoteness Index of Australia (ARIA) was used to group subjects into four location categories--major cities, inner regional cities, outer regional, and remote areas--according to distance from major service centers.

Investigators found that for both type 1 and type 2 diabetes, the risk of dying from cardiovascular disease over approximately five years of follow-up--as compared with the risk in non-diabetics--was significantly higher across location categories, ranging from marginal increases in the major cities to more than six times higher for type 1 diabetes and more than four times higher for people with type 2 diabetes in remote/rural areas.

Standardized Mortality Ratios (95% CI) for CVD, Compared With Nondiabetic Subjects in the Same Regions

Diabetes type Major cities Inner regional cities Outer-regional cities Rural/remote areas
Type 1 1.85 (1.80–1.90) 2.95 (2.82–3.10) 4.97 (4.63–5.34) 6.89 (5.60–8.40)
Type 2 1.03 (1.01–1.04) 1.62 (1.58–1.66) 2.94 (2.81–3.05) 4.27 (3.83–4.76)

Findings followed roughly the same pattern when men and women were viewed separately, although women appeared to have worse outcomes than men in the rural and remote areas.

Of note, the increased mortality appeared to be driven by ischemic heart disease deaths and not by strokes.

Speaking with heartwire , Magliano said this was the "surprising" finding in the data. "I think it's because if you get sick and have a stroke, you can be managed in the country, but if you have a heart attack . . . you need to be in a big city to get CABG and other interventions."

As for why CV deaths among diabetics were higher for women than for men, Magliano noted that "social gradients are always stronger in women than in men," and that's seen in rates of CVD, diabetes, and other risk factors.

This may be in part because women are more likely to respond to and answer more thoroughly on health questionnaires. It may also be that while more men get diabetes, women with diabetes are more likely than male diabetics to die of the disease. "That's because they don't get crushing chest pain, they don't get sent as quickly to emergency, and all that stuff," Magliano said.

Commenting on the study for heartwire , Dr Mercedes R Carnethon (Feinberg School of Medicine, Chicago, IL) speculated that the Australian observations would likely mirror those in the US, "in part because of who lives in rural areas. One, you'd have possibly lower socioeconomic status groups in rural/remote areas, and two, heart-disease outcomes are better the shorter the distance to the hospital, that's a well-known observation.

"In a rural area, even if you had socioeconomic parity, you'd continue to have longer times to the cath lab, longer times to identify a stroke, so I do you believe you'd see these same patterns in the United States."

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