ATLANTA, GA — In a national sample of US patients with atrial fibrillation, those treated in rural hospitals had a higher risk of dying before discharge than those cared for in urban hospitals[1].
The rate of in-hospital mortality was 1.3% in rural hospitals and 1.0% in urban hospitals (P<0.001).
AF patients treated in a rural hospital had a 17% increased risk of dying before discharge (odds ratio [OR] 1.17, 95% CI 1.04–1.32) after adjustment for age, sex, race, insurance, hospital region, obesity, hypertension, diabetes, heart failure, chronic lung disease, peripheral vascular disease, renal failure, liver disease, hypothyroidism, depression, alcohol abuse, and anemia.
Although the data were adjusted for patient demographics and comorbidities, such information as cause of death and type of AF was lacking, which might have helped explain the survival disparity, the researchers note in the study, published December 11, 2017 in Heart Rhythm.
“We did see a 17% increased risk in mortality in rural vs urban centers,” but ultimately the research is “hypothesis-generating,” lead author Dr Wesley T O’Neal (Emory University School of Medicine, Atlanta, GA) told theheart.org | Medscape Cardiology.
“I think that we should . . . look at it more closely to see why this difference exists and confirm this finding in other studies” and even in other countries.
“Claims-based analyses such as these should be viewed as hypothesis-generating instead of categorical in nature,” Drs Thomas F Deering and Ashish A Bhimani (Piedmont Heart Institute, Atlanta, GA) similarly state in an accompanying editorial[2].
Nevertheless, they praise the researchers for increasing awareness in the medical community about a potentially important arrhythmic healthcare issue.
“The electrophysiology and medical communities should look at the findings presented in this study as a motivational call to initiate prospective studies with the goal of identifying gaps in AF care, which can then be used to create effective healthcare policies designed to reduce AF-related mortality.”
AF Hospitalization Outcomes, City vs Country Hospitals
O’Neal and colleagues note that prior research has reported less-than-optimal care of patients with AF in rural compared with urban areas.
To investigate this, they examined data from the National Inpatient Sample on 248,731 patients aged 18 and older hospitalized with a primary diagnosis of AF from 2012 to 2014. Of these, 88% of patients were treated in an urban hospital (defined as a hospital in areas with >50,000 people) and 22% in a rural setting (areas with <50,000 people).
Patients treated in a rural hospital were older (mean age 70 vs 69) and more likely to receive Medicare (70% vs 64%), be female (52% vs 48%), and live in the Midwest or South. They were less likely to be black (4% vs 8%) or obese (16% vs 18%).
The most common secondary diagnoses in patients treated in rural vs urban hospitals were heart failure (16% in both), hypertension (8% vs 7%), hyperlipidemia (3% vs 5%), diabetes (4% in both), and acute kidney injury (2% vs 3%).
Patients treated in urban hospitals were more likely to receive external electrical cardioversion (8% vs 4%) or catheter ablation (9% vs 1%).
However, after researchers excluded patients who received these treatments, the risk of in-hospital death was still higher for patients treated in rural hospitals (OR 1.14, 95% CI 1.01–1.28).
“This likely just reflects that patients in urban centers are more likely to see a cardiologist or electrophysiologist or specialist who takes care of patients with AF,” O’Neal said. “Again, this is very speculative, given that with the data we have we are unable to look at individual provider characteristics, but this was a way for us to kind of gauge what sort of care was being pursued in these hospitals.”
Deering and Bhimani write that the study lacked “clinical information [that] could have played a critical role in determining the observed mortality rates.”
Information was missing about the duration and severity of comorbidities, type of AF, anatomic features (left atrial size, left ventricular function), and cause of death; as well as access to care, patient lifestyle decisions, patient compliance, and physician adherence to diagnostic and therapeutic guideline recommendations.
They note, however, “There are data suggesting that rural health outcomes are not inferior.” For example, a Canadian study[3] reported higher warfarin compliance among rural than urban patients, while a large meta-analysis[4] found no significant difference in CV medication utilization between rural and urban patients.
“More detailed information, analyzed from a number of perspectives, will be needed to shed more light on this topic,” the editorialists conclude.
O’Neal and colleagues sound a similar final note, writing that further research is needed to understand the reasons for the disparity identified in the study and to be able to develop strategies to improve survival in AF patients admitted in rural hospitals.
The study was funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health. The authors and editorialists have no relevant financial relationships.
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