Rural-Urban Disparities in Outcomes of MI, Heart Failure, and Stroke

Quick Takes

  • Rural patients in the US have more difficulty accessing acute hospital care and appropriate post-hospital care compared to their urban counterparts.
  • This large observational study found that older patients with acute MI, heart failure, and ischemic stroke presenting to rural rather than urban hospitals in the US receive fewer interventions and have higher 30- and 90-day mortality rates.
  • Future policy changes should expand availability of telemedicine for not only acute presentations (e.g., telestroke consultation) but also for other phases of care (in-hospital consultation and post-discharge follow-up).

Study Questions:

Do older adults presenting to rural hospitals with acute myocardial infarction (AMI), heart failure (HF), or ischemic stroke have lower treatment rates and higher mortality rates than their urban counterparts?

Methods:

This is a retrospective study of a database of individuals aged ≥65 years enrolled in Medicare fee-for-service. Subjects were hospitalized between 2016–2018 with a primary discharge diagnosis of AMI, HF, or ischemic stroke. If a patient first presented to a rural hospital and was then transferred to an urban hospital, the treatment and outcomes were attributed to the rural hospital. The primary outcomes were the 30-day all-cause mortality rates and the 90-day all-cause mortality rates. Adjustments were made for patient demographics and clinical comorbidities. Treatments evaluated were cardiac catheterization and revascularization for AMI within 30 days of presentation and thrombolysis and endovascular therapy for ischemic stroke.

Results:

There were 578,437 Medicare beneficiaries who were hospitalized for AMI; 1,031,522 for HF; and 572,944 for ischemic stroke. Of these patients, the proportion who presented to a rural hospital was 17.1% for AMI, 17.8% for HF, and 15.7% for ischemic stroke. For patients with AMI, HF, or ischemic stroke, 30-day and 90-day mortality rates were higher for patients presenting to rural rather than urban hospitals. The greatest increased risk was observed for patients presenting with stroke (90-day mortality adjusted hazard ratio, 1.18; 95% confidence interval, 1.16-1.19). Patients with AMI presenting to urban rather than rural hospitals were more likely to receive cardiac catheterization (63.6 vs. 49.7%), percutaneous coronary intervention (45.7 vs. 42.1%), and coronary artery bypass grafting (10.2 vs. 9.0%) within 30 days. Patients with ischemic stroke presenting to urban rather than rural hospitals were more likely to receive intravenous tissue plasminogen activator (10.1% vs. 3.1%) and endovascular therapy (3.6% vs. 1.8%).

Conclusions:

Older patients with AMI, HF, and ischemic stroke presenting to rural rather than urban hospitals in the United States receive fewer interventions and have higher 30- and 90-day mortality rates.

Perspective:

The results of this large observational study suggest that differences persist in clinical outcomes for older patients with AMI, HF, and ischemic stroke treated at rural compared to urban hospitals in the United States. Rural patients have greater difficulty accessing acute hospital care and appropriate post-hospital care, factors that can increase mortality. Many of the smallest and most rural hospitals do not have access to telemedicine, which can improve acute treatment rates. Future policy changes should expand availability of telemedicine for not only acute presentations (e.g., telestroke consultation) but also for other phases of care (in-hospital consultation and post-discharge follow-up).

Keywords: Acute Coronary Syndrome, Brain Ischemia, Cardiac Catheterization, Coronary Artery Bypass, Endovascular Procedures, Geriatrics, Heart Failure, Hospitals, Rural, Hospitals, Urban, Ischemic Stroke, Myocardial Infarction, Myocardial Revascularization, Patient Discharge, Percutaneous Coronary Intervention, Rural Health Services, Stroke, Telemedicine, Thrombolytic Therapy, Tissue Plasminogen Activator, Treatment Outcome, Vascular Diseases


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