Similar In-Hospital and Post-Discharge Outcomes in Rural vs Urban Heart Failure

In-hospital and 30-day post-discharge outcomes are similar among patients hospitalized for heart failure (HF) at rural vs urban hospitals in the United States (US), according to study findings published in the Journal of the American Medical Association Cardiology.

Investigators sought to evaluate quality of care and clinical outcomes among patients hospitalized for HF at rural vs urban hospitals in the US. Primary endpoints included 30-day mortality and readmission outcomes, length of stay, and in-hospital mortality.

They initiated a retrospective observational cohort study from January 2014 through September 2021 that included 19,832 (2.6%) patients hospitalized for HF at rural hospitals and 754,587 (97.4%) patients hospitalized for HF at urban hospitals across 569 sites (49 [8.6%] rural hospitals; 520 [91.4%] urban hospitals) in the Get With the Guidelines-Heart Failure (GWTG-HF) registry. Among these patients, 161,996 had data linked to Medicare claims that were used to evaluate post-discharge outcomes. Patients were at least 18 years of age. Sites missing hospital characteristics data were excluded from the study. Patients discharged to hospice or palliative care, who left on medical advice, or transferred to another acute care facility were excluded, as were patients with missing data for sex, age, or patient disposition.

Rural hospitals were defined as those not located within a metropolitan area designated by the US Office of Management and Budget and the Census Bureau. Investigators reclassified 2.8% of hospitals as either rural or urban based on Rural-Urban Commuting Area code definitions.

Overall, patients were median 73 years of age (IQR, 62-83) and 47.3% women. Patients at rural hospitals vs urban hospitals were more likely to be non-Hispanic White patients (73.5% vs 66.1%; standardized difference, 34.47%) and older (median 74 years [IQR, 64-84] vs median 73 years [IQR, 61-83]; standardized difference, 10.63%). Patients at rural hospitals vs urban hospitals were more likely to have Medicare insurance (58.4% vs 51.1%), higher median ejection fraction (EF) and systolic blood pressure, and lower N-terminal pro-brain natriuretic peptide levels.

At discharge, the investigators found patients at rural hospitals were less likely to be prescribed an angiotensin receptor-neprilysin inhibitor (ARNI; adjusted risk difference [aRD], -5.0%; adjusted odds ratio [aOR], 0.68; 95% CI, 0.47-0.98), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB; aRD, -3.7%; aOR, 0.71; 95% CI, 0.53-0.96), and cardiac resynchronization therapy (CRT; aRD, -13.5%; aOR, 0.44; 95% CI, 0.22-0.92).

Length of stay of 4 days or longer was less likely for patients at rural hospitals (aOR, 0.75; 95% CI, 0.67-0.85). In-hospital mortality between rural vs urban hospitals was similar (2.3% vs 2.7%; aOR, 0.86; 95% CI, 0.70-1.07) and no significant differences were noted between rural vs urban hospitals in 30-day HF readmission among Medicare beneficiaries (adjusted hazard ratio [aHR], 1.03; 95% CI, 0.90-1.19), all-cause mortality (aHR, 1.05; 95% CI, 0.91-1.21), and all-cause readmission (aHR, 0.97; 95% CI, 0.91-1.04). There was no significant interaction between rural hospitals and HF or all-cause readmission. There was a significant interaction between rural status and EF subgroup for all-cause mortality consistent in unadjusted, partially adjusted, and fully adjusted models.

Study limitations include a lack of consensus definition of rural vs urban hospitals. Additionally, potential differences in outpatient HF diagnosis and treatment are not examined, and voluntary participation in GWTG-HF registry may not be representative of rural or urban hospitals.

“In this study of US patients admitted to rural vs urban hospitals for HF, although most quality metrics were similar, patients at rural hospitals were less likely to receive multiple elements of guideline-directed HF care, such as CRT, ACEI/ARB, and ARNI therapies,” the study authors wrote. “Despite these differences in HF care, there were no significant differences between rural and urban hospitals regarding in-hospital mortality or 30-day post-discharge outcomes.”

Disclosure: This research was supported by Novartis, Boehringer Ingelheim and Eli Lilly Diabetes Alliance, Novo Nordisk, Sanofi, AstraZeneca, and Bayer. Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.