Mortality risk greater for patients with CVD presenting at rural vs. urban hospitals
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For Medicare beneficiaries presenting with acute MI, HF or ischemic stroke, admission to a rural hospital was associated with lower procedure rates and greater risk for 30- and 90-day mortality compared with admission to an urban hospital.
According to research published in the Journal of the American College of Cardiology, adjustment for hospital resource variables and procedure rates failed to attenuate the observed association with rural hospital admission and mortality compared with urban.
“In this national study, we found that older adults initially presenting to rural hospitals for acute CV conditions were less likely to receive procedural care, such as cardiac catherization for MI or thrombolysis and endovascular therapy for ischemic stroke. Mortality rates for MI, HF and ischemic stroke were also higher among patients presenting to rural hospitals than those at urban hospitals,” Eméfah C. Loccoh, MD, clinical fellow in medicine at Brigham and Women’s Hospital and research fellow at the Richard A. and Susan F. Smith Center for Outcomes Research at Beth Israel Deaconess Medical and Harvard Medical School, told Healio. “Within rural areas, we also found substantial disparities in care for older adults who initially presenting to critical access hospitals compared with those at noncritical access hospitals. As part of the Medicare Rural Hospital Flexibility Program, critical access hospitals are designed to improve access to health care and emergency services within remote, rural areas. However, we found that beneficiaries initially presenting to critical access hospitals were much less likely to receive procedural care for MI or stroke than beneficiaries who initially presented to noncritical access hospitals within rural areas, and also experienced markedly higher death rates.”
To evaluate variations in rural and urban procedural care and mortality for acute MI, HF and ischemic stroke, researchers conducted a retrospective cross-sectional study that included more than 2.1 million Medicare beneficiaries hospitalized from 2016 to 2018 to examine the association between presenting to a rural compared with an urban hospital and 30- and 90-day mortality.
Outcomes at rural vs. urban hospitals
Among patients who presented with acute MI, those admitted to rural hospitals were less likely to undergo cardiac catheterization (49.7% vs. 63.6%; P < .001), PCI (42.1% vs. 45.7%; P < .001) and CABG (9% vs. 10.2%; P < .001) compared with urban hospitals within 30 days of presentation.
Patients with ischemic stroke admitted to rural hospitals, compared with those admitted to urban hospitals, were less likely to undergo thrombolysis (3.1% vs. 10.1%; P < .001) and endovascular therapy (1.8% vs. 3.6%; P < .001).
The rate of 30-day mortality was greater for all three presentations for Medicare beneficiaries admitted to rural compared with urban hospitals:
- acute MI (12.9% vs. 11.6%; P < .001);
- HF (11.1% vs. 9.8%; P < .001); and
- ischemic stroke (14.9% vs. 13.1%; P < .001).
According to the study, these patterns were similar for 90-day mortality (P for all < .001).
Risk for 30-day mortality was greater at rural compared with urban hospitals for patients presenting with any MI (HR = 1.1; 95% CI, 1.08-1.12) and with non-STEMI (HR = 1.09; 95% CI, 1.07-1.11); however, there was no difference for patients presenting with STEMI (HR = 1.03; 95% CI, 0.96-1.1).
“Encouragingly, we found that the subgroup of older adults who present to rural hospitals with ... STEMI, experience very similar outcomes as their urban counterparts,” Rishi K. Wadhera, MD, MPP, MPhil, cardiologist at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, told Healio. “This highlights the critically important and positive impact that concerted public health initiatives, such as regional system of care and transfer protocols, have had in eliminating rural-urban gaps in outcomes for the most emergent type of heart attack.”
Although 30-day mortality risk was greater for patients presenting with HF at rural compared with urban hospitals (HR = 1.15; 95% CI, 1.13-1.16), researchers reported that 30-day readmission rates did not differ between urban and rural centers (HR = 0.99; 95% CI, 0.98-1).
Among patients who presented with ischemic stroke, risk for 30-day mortality was higher at rural compared with urban centers (HR = 1.2; 95% CI, 1.18-1.22).
Risk for 90-day mortality was greater for each of the three presentations for Medicare beneficiaries admitted to rural compared with urban hospitals:
- acute MI (HR = 1.1; 95% CI, 1.08-1.12);
- HF (HR = 1.11; 95% CI, 1.1-1.13); and
- ischemic stroke (HR = 1.18; 95% CI, 1.16-1.19).
According to the study, the addition of hospital resource variables and procedure rates failed to attenuate the observed associations between presentation site and 30- and 90-day mortality for acute MI or ischemic stroke.
In a subanalysis, researchers also compared the care of and outcomes for acute MI, HF and stroke at critical access and noncritical access hospitals.
Researchers reported that Medicare beneficiaries who presented with acute MI or ischemic stroke at critical access hospitals, were less likely to undergo PCI/CABG (3.7% vs 53.6%; P < .001) or receive thrombolysis/EVT (0.36% vs 5.4%; P < .001) within 30 days compared with noncritical access hospitals.
Moreover, compared with patients admitted to noncritical access hospitals, the risk for 30-day mortality was greater among patients admitted to critical access sites with acute MI (adjusted HR = 1.31; 95% CI, 1.23-1.4), HF (aHR = 1.12; 95% CI, 1.08-1.17), and ischemic stroke (aHR = 1.17; 95% CI, 1.11-1.24).
According to the study, these patterns in mortality were similar at 90 days.
“As rural areas continue to experience a rapid rise in hospital closures and significant declines in primary care physicians and specialty services, it is imperative that ongoing clinical, public health, and policy efforts focus on ensuring timely access to medical services and cardiovascular care, whether it be through innovative measures such as telemedicine and telestroke services, or by ensuring that hospitals stay open in rural parts of the country,” Wadhera told Healio.
‘Profound policy implications’
In a related editorial, Alexander C. Fanaroff, MD, assistant professor of medicine at the Hospital of the University of Pennsylvania, and colleagues discussed the policy-level implications of the data.
“This study by Loccoh et al further highlights the persistent disparities in processes of care and outcomes between patients receiving care at rural and nonrural hospitals,” the editorial authors wrote. “There are profound policy implications to understanding the extent to which worse outcomes of rural patients with acute cardiovascular diseases is related to quality issues or constraints in care at rural hospitals rather than patient factors. Although the current study is an important start, future research using more granular clinical data is necessary to more completely assess the root causes and to identify appropriate policy solutions that can alleviate these disparities.”
For more information:
Eméfah C. Loccoh, MD, can be reached at emefah.loccoh@gmail.com.
Rishi K. Wadhera, MD, MPP, MPhil, can be reached at rwadhera@bidmc.harvard.edu.
Reference:
Perspective
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Ashwin Nathan, MD, MS
There exists significant and disheartening inequity in the quality of care received by patients who present to rural hospitals, translating ultimately to differences CV outcomes. These differences are most pronounced among patients who receive care at critical access hospitals.
It is imperative to understand that rural hospitals, and critical access hospitals in particular, serve an incredibly important role in providing care to a well-recognized undertreated group of our population. To improve the quality of care delivered by these hospitals to the patients they serve, the health care community and the nation at large needs to make it a priority to invest in systems that can improve the care delivered by these hospitals, which need to remain in place to provide access to care. This could be through ensuring the availability of novel technologies and therapies, improved communication with tertiary care centers and specialist/subspecialist care, and solidified relationships between rural/critical access hospitals and larger referral centers to ensure timely transfers and therapeutic interventions. Until policies supporting rural and critical access hospitals are developed, we may continue to see these inequities in care as more and more rural hospitals close.
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