Association of Rurality With Risk of Heart Failure

Abstract

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 & 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 < .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.

Closing the Last Mile Gap in Access to Multimodality Imaging in Rural Settings: Design of the Imaging Core of the Risk Underlying Rural Areas Longitudinal Study

“…Compared with their urban counterparts, southern rural residents had a 19% greater risk of incident HF. 28 This study also reported important race- and sex-related differences in HF risk; the greatest rurality-associated risk of incident HF was in Black men (34%), White women (22%), and Black women (18%), while White men had a 3% lower risk than the overall group. The approach of RURAL to incorporating echocardiography into the baseline examination provides a paradigm-shifting approach to assess the burden of subclinical and clinical cardiac dysfunctions in selected rural communities that have hitherto had limited access to advanced cardiac imaging technology that is vital for CVD prevention.…”

“…The approach of RURAL to incorporating echocardiography into the baseline examination provides a paradigm-shifting approach to assess the burden of subclinical and clinical cardiac dysfunctions in selected rural communities that have hitherto had limited access to advanced cardiac imaging technology that is vital for CVD prevention. 3,28,29 The advanced multimodality imaging approach of RURAL goes beyond traditional risk factor screening, providing a nuanced understanding of the multifaceted factors contributing to health inequalities. By leveraging cutting-edge technology and a range of scans, the RURAL study can effectively discern and address the complex interactions shaping health outcomes in rural communities, surpassing the limitations of conventional public health approaches.…”

“…The approach of RURAL to incorporating echocardiography into the baseline examination provides a paradigm-shifting approach to assess the burden of subclinical and clinical cardiac dysfunctions in selected rural communities that have hitherto had limited access to advanced cardiac imaging technology that is vital for CVD prevention. 3,28,29…”

Quality of Care and Outcomes Among Patients Hospitalized for Heart Failure in Rural vs Urban US Hospitals

“…Sixth, participation in the GWTG-HF registry is voluntary and may not be representative of rural or urban hospitals. For example, rural hospitals in GWTG-HF tended to be larger than most rural US hospitals, and comorbidity burden among patients at rural GWTG-HF hospitals was similar to those at urban hospitals, which is different from some prior analyses of rural-urban disparities . Although prior studies have supported generalizability to US practice, quality of care and outcomes in hospitals participating in GWTG-HF may not reflect care delivered at all rural or urban hospitals .…”

Characteristics of United States Counties in Which Heart Failure Clinical Trials of Pharmacotherapy Were Conducted

“…Individuals living in rural areas of the US are at 19% higher risk of developing HF and experience higher rates of HF morbidity than their urban counterparts. 4 Our findings in combination with the disproportionate burden of HF in rural communities suggest rurality is an important factor to consider in clinical trial design.…”