Rural and urban differentials in primary care management of chronic heart failure: new data from the CASE study

Clark, Robyn; Eckert, Kerena; Stewart, Simon; Phillips, Susan M.; Yallop, Julie Jane; Tonkin, Andrew; Krum, Henry

doi:10.5694/j.1326-5377.2007.tb00993.x

Cited by 52 publications

(53 citation statements)

References 9 publications

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“…Different pharmacotherapy patterns in rural and metropolitan Canadian patients with HF have also been reported 9. We found that receipt of coronary angiography or interventions were lower in rural patients, consistent with the previous findings,10 24 although disparity in discharge medications was not examined in our study.…”

Section: Discussionsupporting

confidence: 90%

“…Earlier research by Clark et al 24 showed a significantly higher prevalence of congestive HF in rural compared with metropolitan areas among patients aged 60 years and over. Furthermore, rates of echocardiography for diagnosis or specialist referrals and rate of prescribing ACE inhibitor drugs were consistently lower in rural compared with metropolitan areas 24.…”

Section: Discussionmentioning

confidence: 90%

“…Furthermore, rates of echocardiography for diagnosis or specialist referrals and rate of prescribing ACE inhibitor drugs were consistently lower in rural compared with metropolitan areas 24. Different pharmacotherapy patterns in rural and metropolitan Canadian patients with HF have also been reported 9.…”

Section: Discussionmentioning

confidence: 95%

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Rural–urban differentials in 30-day and 1-year mortality following first-ever heart failure hospitalisation in Western Australia: a population-based study using data linkage

et al. 2014

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ObjectivesWe examined differentials in short-term (30-day mortality) and 1-year mortality (in 30-day survivors) following index (first-ever) hospitalisation for heart failure (HF), between rural and metropolitan patients resident in Western Australia.DesignA population-based cohort study.SettingHospitalised patients in Western Australia, Australia.ParticipantsIndex patients aged 20–84 years with a first-ever hospitalisation for HF between 2000 and 2009 (with no prior admissions for HF in previous 10 years), identified using the Western Australia linked health data.Main outcome measures30-day and 1-year all-cause mortality (in 30-day survivors) following index admission for HF.ResultsOf 17 379 index patients with HF identified, 25.9% (4499) were from rural areas. Rural patients were significantly younger at first HF hospitalisation than metropolitan patients. Aboriginal patients comprised 1.9% of metropolitan and 17.2% of rural patients. Despite some statistical differences, the prevalence of antecedents including ischaemic heart disease, hypertension, diabetes and chronic kidney disease was high (>20%) in both subpopulations. After adjusting for age only, patients from rural areas had a higher risk of 30-day death (OR 1.16 (95% CI 1.01 to 1.33)) and 1-year death in 30-day survivors (HR 1.11 (95% CI 1.01 to 1.23)). These relative risk estimates increased and remained significant after further progressive adjustments for Aboriginality, socioeconomic status, insurance status, emergency presentation, individual comorbidities and revascularisation with OR 1.25 (1.06 to 1.48) for 30-day mortality and HR 1.13 (1.02 to 1.27) for 1-year mortality. The addition of the weighted Charlson index to the 30-day model improved the ‘c’ statistic (under the receiver operating characteristic curve) from 0.656 (using a variation of administrative claims model) to 0.714.ConclusionsRemoteness and variable access to healthcare can cause important disparities in health outcomes. Rural patients with HF in Western Australia have poorer risk-adjusted outcomes compared with metropolitan patients. This finding has important implications for chronic disease management and provision of health services in rural Australia.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 90%

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Rural–urban differentials in 30-day and 1-year mortality following first-ever heart failure hospitalisation in Western Australia: a population-based study using data linkage

et al. 2014

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“…Exploring rural–urban differences was the primary objective of 18 studies (35%) [2,27,28,30,31,35,36,39,43,44,49,51,54,59,68,69,71,73]. Seven studies reported medication adherence (the proportion of doses taken as prescribed over a specific time period) or persistence (the length of continuous treatment) [76], and 47 reported outcomes related to medication utilization.…”

Section: Resultsmentioning

confidence: 99%

“…Overall, 16 studies included patient self-report, 31 studies included data from medical records or registries, and 5 studies were conducted using administrative databases. Nineteen studies reported crude utilization or adherence outcome data only [8,28,35-37,39,40,50,51,53,54,63,64,67,68,71,73-75]. …”

Section: Resultsmentioning

confidence: 99%

Cardiovascular medication utilization and adherence among adults living in rural and urban areas: a systematic review and meta-analysis

et al. 2014

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BackgroundRural residents face numerous barriers to healthcare access and studies suggest poorer health outcomes for rural patients. Therefore we undertook a systematic review to determine if cardiovascular medication utilization and adherence patterns differ for rural versus urban patients.MethodsA comprehensive search of major electronic datasets was undertaken for controlled clinical trials and observational studies comparing utilization or adherence to cardiovascular medications in rural versus urban adults with cardiovascular disease or diabetes. Two reviewers independently identified citations, extracted data, and evaluated quality using the STROBE checklist. Risk estimates were abstracted and pooled where appropriate using random effects models. Methods and reporting were in accordance with MOOSE guidelines.ResultsFifty-one studies were included of fair to good quality (median STROBE score 17.5). Although pooled unadjusted analyses suggested that patients in rural areas were less likely to receive evidence-based cardiovascular medications (23 studies, OR 0.88, 95% CI 0.79, 0.98), pooled data from 21 studies adjusted for potential confounders indicated no rural–urban differences (adjusted OR 1.02, 95% CI 0.91, 1.13). The high heterogeneity observed (I2 = 97%) was partially explained by treatment setting (hospital, ambulatory care, or community-based sample), age, and disease. Adherence did not differ between urban versus rural patients (3 studies, OR 0.94, 95% CI 0.39, 2.27, I2 = 91%).ConclusionsWe found no consistent differences in rates of cardiovascular medication utilization or adherence among adults with cardiovascular disease or diabetes living in rural versus urban settings. Higher quality evidence is needed to determine if differences truly exist between urban and rural patients in the use of, and adherence to, evidence-based medications.

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Association of Rurality With Risk of Heart Failure

Turecamo

Dixon

et al. 2023

JAMA Cardiol

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ImportanceRural populations experience an increased burden of heart failure (HF) mortality compared with urban populations. Whether HF incidence is greater among rural individuals is less known. Additionally, the intersection between racial and rural health inequities is understudied.ObjectiveTo determine whether rurality is associated with increased risk of HF, independent of cardiovascular (CV) disease and socioeconomic status (SES), and whether rurality-associated HF risk varies by race and sex.Design, Setting, and ParticipantsThis prospective cohort study analyzed data for Black and White participants of the Southern Community Cohort Study (SCCS) without HF at enrollment who receive care via Centers for Medicare &amp; Medicaid Services (CMS). The SCCS is a population-based cohort of low-income, underserved participants from 12 states across the southeastern United States. Participants were enrolled between 2002 and 2009 and followed up until December 31, 2016. Data were analyzed from October 2021 to November 2022.ExposuresRurality as defined by Rural-Urban Commuting Area codes at the census-tract level.Main Outcomes and MeasuresHeart failure was defined using diagnosis codes via CMS linkage through 2016. Incidence of HF was calculated by person-years of follow-up and age-standardized. Sequentially adjusted Cox proportional hazards regression models tested the association between rurality and incident HF.ResultsAmong 27 115 participants, the median (IQR) age was 54 years (47-65), 18 647 (68.8%) were Black, and 8468 (32.3%) were White; 5556 participants (20%) resided in rural areas. Over a median 13-year follow-up, age-adjusted HF incidence was 29.6 (95% CI, 28.9-30.5) per 1000 person-years for urban participants and 36.5 (95% CI, 34.9-38.3) per 1000 person-years for rural participants (P &lt; .001). After adjustment for demographic information, CV risk factors, health behaviors, and SES, rural participants had a 19% greater risk of incident HF (hazard ratio [HR], 1.19; 95% CI, 1.13-1.26) compared with their urban counterparts. The rurality-associated risk of HF varied across race and sex and was greatest among Black men (HR, 1.34; 95% CI, 1.19-1.51), followed by White women (HR, 1.22; 95% CI, 1.07-1.39) and Black women (HR, 1.18; 95% CI, 1.08-1.28). Among White men, rurality was not associated with greater risk of incident HF (HR, 0.97; 95% CI, 0.81-1.16).Conclusions and RelevanceAmong predominantly low-income individuals in the southeastern United States, rurality was associated with an increased risk of HF among women and Black men, which persisted after adjustment for CV risk factors and SES. This inequity points to a need for additional emphasis on primary prevention of HF among rural populations.

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Rural and urban differentials in primary care management of chronic heart failure: new data from the CASE study

Cited by 52 publications

References 9 publications

Rural–urban differentials in 30-day and 1-year mortality following first-ever heart failure hospitalisation in Western Australia: a population-based study using data linkage

Rural–urban differentials in 30-day and 1-year mortality following first-ever heart failure hospitalisation in Western Australia: a population-based study using data linkage

Cardiovascular medication utilization and adherence among adults living in rural and urban areas: a systematic review and meta-analysis

Association of Rurality With Risk of Heart Failure

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