Lower use of guideline-recommended HF therapies at rural vs. urban hospitals
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NEW ORLEANS — Patients with HF at rural hospitals were significantly less likely to receive guideline-directed medical therapy at discharge compared with urban hospitals, but other quality metrics were similar, researchers reported.
The findings were presented at the American College of Cardiology Scientific Session and simultaneously published in JAMA Cardiology.
“While most quality-of-care metrics were similar among eligible patients hospitalized for heart failure at rural and urban U.S. hospitals, we found that patients at rural hospitals were independently less likely to be prescribed multiple important therapies at discharge,” Stephen J. Greene, MD, FACC, FHFSA, assistant professor of medicine at Duke Clinical Research Institute and Duke University School of Medicine, told Healio. ealio. “We know the in-hospital period and time of hospital discharge are critical opportunities for optimizing therapy for patients with heart failure. Medications prescribed at discharge not only set the course for the therapies the patient will receive early post-discharge, but also over the long term.” In a retrospective study, Greene and colleagues analyzed data from 774,419 patients hospitalized for HF across 569 sites participating in the Get With The Guidelines–Heart Failure registry between January 2014 and September 2021. Researchers assessed post-discharge outcomes for a subset of 161,996 patients linked to Medicare claims. Quality measures included in-hospital mortality, length of stay and 30-day mortality and readmission outcomes.
Within the cohort, 2.6% of patients were hospitalized at 49 rural hospitals and 97.4% of patients were hospitalized at 520 urban hospitals. The median age of all patients was 73 years and 47.3% were women. Compared with patients at urban hospitals, patients at rural hospitals were older and more likely to be white.
In adjusted models, patients at rural hospitals were less likely to be prescribed cardiac resynchronization therapy (adjusted risk difference, –13.5%; adjusted OR = 0.44; 95% CI, 0.22-0.92), ACE inhibitor or angiotensin receptor blocker therapy (adjusted risk difference, –3.7%; aOR = 0.71; 95% CI, 0.53-0.96), and an angiotensin receptor-neprilysin inhibitor (adjusted risk difference, –5%; aOR = 0.68; 95% CI, 0.47-0.98) at discharge.
In-hospital mortality was similar between rural and urban hospitals, with rates of 2.3% vs. 2.7%, respectively (aOR = 0.86; 95% CI, 0.7-1.07). Patients at rural hospitals were less likely to have a length of stay of 4 or more days (aOR = 0.75; 95% CI, 0.67-0.85).
Among Medicare beneficiaries, there were no significant differences between rural and urban hospitals for 30-day HF readmission rates (aHR = 1.03; 95% CI, 0.9-1.19), all-cause readmission (aHR = 0.97; 95% CI, 0.91-1.04), and all-cause mortality (aHR = 1.05; 95% CI, 0.91-1.21).
“Lower use of evidence-based therapies at discharge from rural hospitals unfortunately sets the stage for longer-term gaps in use of these therapies, which may contribute to the higher longer-term heart failure mortality rates that have been observed in rural communities,” Greene told Healio. “We need to better understand the mechanisms of the quality-of-care differences between rural and urban hospitals, and what may be the exact targets for intervention. Likewise, randomized trials of health policy and implementation strategies specifically targeted at rural hospitals should be considered. We also should acknowledge the tremendous efforts of the American Heart Association, who have declared improvement in rural health a key priority for quality improvement.”
Reference:
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Pierce J, et al. Abstract 1078-07. Presented at: American College of Cardiology Scientific Session; March 4-6, 2023; New Orleans (hybrid meeting).
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