One out of seven UK citizens live in an area defined as rural. In UK, rurality is commonly viewed as places with healthy lifestyle and stressless environment. Results show that life expectancy is higher in those areas. Yet health inequalities persist across rural areas which presents a high heterogeneity in term of sociodemographic population but also imbalance medical service access. Studies suggest that rurality may exacerbate the effects of socio‐economic disadvantage, ethnicity, poorer service availability, higher levels of personal risk and more hazardous environmental, occupational and transportation conditions. Moreover, rural areas are challenged by an increasing ageing population which requires bespoke health services related to chronic care, mental health, as well as, preventable communicable disease.
The aim of this study is to explore how rurality shapes an individual’s care pathway and their health outcomes for five major health conditions related to chronic diseases, mental health and communicable diseases. The overall objective is to determine the relationship between an individual’s care pathway (e.g. diagnosis or treatment access) and health outcomes with the residential context (i.e. rural-urban area), for five specific health conditions (Ischaemic heart disease–caused by a reduce blood supply to the heart, diabetes, depressive disorders, influenza and pneumococcal infection–caused by a bacteria spread in the same way as the flu), and to investigate the sociodemographic and economic relationships with urban-rural variations.
The results of this study will identify gaps in healthcare access and treatment effects for these five major health conditions and determine the influence of rurality on perceived gaps.
Technical summary
The main objective of this study is to ascertain how residential context (rural-urban) shapes the care pathway and health outcomes for five conditions (Ischaemic heart disease, diabetes, depressive disorders, influenza and pneumococcal infections). A retrospective cohort study will be conducted among patients exposed to these health conditions and seen in consultation since 1 January 2010. The primary exposure will be the rural/urban category as defined by the Office of National Statistics. The study will consider two type of outcomes: (i) the outcomes related to care step access for the five health conditions considered (i.e. access to diagnosis, access to treatment and –for preventable disease– access to immunization), (ii) the differential effect on treatment which will be measured using the occurrence of adverse events (e.g. death for ischaemic heart disease, suicide attempt for depressive disorders).
Outcomes related to patient care pathways and treatment outcomes will be collected through the following datasets: Hospital Episode Statistics (HES) Admitted Patient Care and HES Diagnostic Imaging Dataset (e.g. for the diagnosis of Ischaemic heart disease). For the case of depressive disorders, we use the Mental Health Data Set and HES Accident and Emergency (for measure suicide attempt). Pregnancy Register for pregnant women will be used to measure access to pneumococcal infection and influenza immunization for pregnant women.
Analysis will be adjusted on individuals’ characteristics and their sociodemographic environment, using Patient Level Index of Multiple Deprivation. Access to each care pathway step and treatment outcome will be investigated using Cox proportional hazards regression.
Primary outcomes:
Related to Ischaemic heart disease: Atherosclerotic cardiovascular disease; ischaemic heart disease (suspected or diagnosed); time to ischaemic heart disease diagnosis; time to ischaemic heart disease treatment; number of cardiovascular disease-related emergency hospitalizations; number of severe adverse health events (diabetic coma, stroke, heart attack [myocardial infarction] – each event type evaluated separately); all-cause mortality
Related to diabetes: type 2 diabetes diagnosis ; time to type 2 diabetes diagnosis; time to type 2 diabetes treatment; number of all-cause emergency hospitalizations; number of diabetes-related and cardiovascular disease-related emergency hospitalizations; number of severe adverse health events (e.g. diabetic coma, stroke, heart attack [myocardial infarction] – each event type evaluated separately); all-cause mortality.
Related to depressive disorder: type of depressive disorder (e.g. seasonal, recurrent, single episode); time to depressive disorder diagnosis; time to depressive disorder treatment; number of episodes of depressive disorder; number of attendances to a day care facility where the function classification is 'mental illness', score of perception of behaviour and emotional disability impact, number of severe adverse health events (e.g. suicide attempt), number of mental-health-related hospitalizations (emergency or not) ; all-cause mortality.
Related to influenza and pneumococcal infection: number of influenza episodes; number of Invasive Pneumococcal Disease episodes; time from diagnosis to treatment; immunization; number of severe adverse health events (e.g. pneumonia, meningitis, bacteraemia, chronic pulmonary disease or congestive heart failure – each event type evaluated separately); all-cause mortality
Secondary outcomes:
All health conditions considered: Probability of at least one all-cause emergency hospitalization; probability of at least one diabetes-related and cardiovascular disease-related emergency hospitalization; number of all-cause hospitalizations; probability of at least one all-cause hospitalization; number of diabetes-related and cardiovascular disease-related hospitalizations; number of mental health related hospitalizations; number of influenza and pneumococcal infection-related hospitalizations; probability of at least one all-cause hospitalization; probability of at least one diabetes-related and cardiovascular disease-related hospitalizations; probability of at least one mental health-related hospitalizations; probability of at least one influenza and pneumococcal infection-related hospitalizations; probability of at least one severe adverse health event; Ischaemic heart disease complications (e.g. chest pain or angina, heart attack, heart failure, arrhythmia); diabetic complications (e.g. ophthalmic, neurological and renal complications of diabetes); depressive disorder complications (e.g. major depression, substance abuse, suicidal behavior); influenza and pneumococcal infection complications (e.g. myocarditis, respiratory and kidney failure, meningitis, bacteremia, pneumonia); hypertension; BMI; smoking; alcohol consumption; HbA1c; fasting plasma glucose; cholesterol, HDL cholesterol, LDL cholesterol and non – HDL cholesterol, triglycerides.
Till Bärnighausen - Chief Investigator - University of Heidelberg
Maxime Inghels - Corresponding Applicant - University of Lincoln
David Nelson - Collaborator - University of Lincoln
Engelbert Bain Luchuo - Collaborator - University of Lincoln
Frank Tanser - Collaborator - University of Lincoln
Julia Lemp - Collaborator - University of Heidelberg
Pascal Geldsetzer - Collaborator - University of Heidelberg
Zahid Asghar - Collaborator - University of Lincoln
2011 Rural-Urban Classification at LSOA level;HES Accident and Emergency;HES Admitted Patient Care;HES Diagnostic Imaging Dataset;Mental Health Services Data Set (MHSDS);ONS Death Registration Data;Patient Level Index of Multiple Deprivation;Pregnancy Register