Characteristics, Process Metrics, and Outcomes Among Patients With ST-Elevation Myocardial Infarction in Rural vs Urban Areas in the US

Abstract

ImportancePatients with ST-segment elevation myocardial infarction (STEMI) living in rural settings often have worse clinical outcomes compared with their urban counterparts. Whether this discrepancy is due to clinical characteristics or delays in timely reperfusion with primary percutaneous coronary intervention (PPCI) or fibrinolysis is unclear.ObjectiveTo assess process metrics and outcomes among patients with STEMI in rural and urban settings across the US.Design, Setting, and ParticipantsThis cross-sectional multicenter study analyzed data for 70 424 adult patients with STEMI from the National Cardiovascular Data Registry Chest Pain–MI Registry in 686 participating US hospitals between January 1, 2019, and June 30, 2020. Patients without a valid zip code were excluded, and those transferred to a different hospital during the course of the study were excluded from outcome analysis.Main Outcomes and MeasuresIn-hospital mortality and time-to-reperfusion metrics.ResultsThis study included 70 424 patients with STEMI (median [IQR] age, 63 [54-73] years; 49 850 [70.8%] male and 20 574 [29.2%] female; patient self-reported race: 6753 [9.6%] Black, 60 114 [85.4%] White, and 2096 [3.0%] of another race [including American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander]; 5281 [7.5%] individuals of Hispanic or Latino ethnicity) in 686 hospitals (50 702 [72.0%] living in urban zip codes and 19 722 [28.0%] in rural zip codes). Patients from rural settings were less likely to undergo PPCI compared with patients from urban settings (14 443 [73.2%] vs 43 142 [85.1%], respectively; P < .001) and more often received fibrinolytics (2848 [19.7%] vs 937 [2.7%]; P < .001). Compared with patients from urban settings, those in rural settings undergoing PPCI had longer median (IQR) time from first medical contact to catheterization laboratory activation (30 [12-42] minutes vs 22 [15-59] minutes; P < .001) and longer median (IQR) time from first medical contact to device (99 minutes [75-131] vs 81 [66-103] minutes; P < .001), including those who arrived directly at PPCI centers (83 [66-107] minutes vs 78 [64-97] minutes; P < .001) and those who transferred to PPCI centers from another treatment center (125 [102-163] minutes vs 103 [85-135] minutes; P < .001). Among those who transferred in, median (IQR) door-in-door-out time was longer in patients from rural settings (63 [41-100] minutes vs 50 [35-80] minutes; P < .001). Out-of-hospital cardiac arrest was more common in patients from urban vs rural settings (3099 [6.1%] vs 958 [4.9%]; P < .001), and patients from urban settings were more likely to present with heart failure (4112 [8.1%] vs 1314 [6.7%]; P < .001). After multivariable adjustment, there was no significant difference in in-hospital mortality between rural and urban groups (adjusted odds ratio, 0.97; 95% CI, 0.89-1.06).Conclusions and RelevanceIn this large cohort of patients with STEMI from US hospitals participating in the National Cardiovascular Data Registry Chest Pain–MI Registry, patients living in rural settings had longer times to reperfusion, were less likely to receive PPCI or meet guideline-recommended time to reperfusion, and more frequently received fibrinolytics than patients living in urban settings. However, there was no difference in adjusted in-hospital mortality between patients with STEMI from urban and rural settings.

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

“…29 Sixth, participation in the GWTG-HF registry is voluntary and may not be representa-tive of rural or urban hospitals. For example, rural hospitals in GWTG-HF tended to be larger than most rural US hospitals, 30 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. 31,32 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.…”

Achieving Equitable Access to Acute Myocardial Infarction Therapies for Rural Patients—Is It Possible?

“…Despite improved rural-urban differences in STEMI outcomes, access to guideline-recommended therapies remains challenging for low-income individuals in rural areas and those who identify as Black or Hispanic. This study by Hillerson et al 4 demonstrates that when processes of care are in place, equitable STEMI outcomes can be achieved. Achieving similar outcomes for vulnerable rural populations hinges on public health and policy efforts aimed at encouraging greater inclusion of smaller rural hospitals in regionalization efforts while alleviating financial and reimbursement barriers associated with telemedicine.…”

“…2 Beyond differences in hospital-level services, patients from these vulnerable rural communities face significant barriers to accessing postacute medical and rehabilitative services, resulting in increased morbidity and decrease quality of life posthospitalization for acute myocardial infarction. 1 This study from Hillerson et al 4 demonstrates that equitable STEMI outcomes can be achieved for rural patients with prompt recognition and initiation of guidelinerecommended therapies. To extend these findings to the most vulnerable rural communities, public health and policy efforts must focus on establishing statewide initiatives that encourage widespread participation in regionalization efforts among all hospitals, while providing adequate financial and reimbursement incentives.…”

Defining Rural in Rural-Urban Differences in Myocardial Infarction Management—Reply

“…In addition, it would be unrealistic for a national and clinically oriented database, such as the National Cardiovascular Data Registry, to assume that hospital clerks, nurses, or physicians will be able to collect or abstract more accurate data elements, such as patient Census tract data. In the case of this work, using the zip code seems to have broken down the STEMI population into 2 distinct groups with different characteristics and process metrics, consistent with rural-urban divide in ethnicity, prevalence of comorbidity, delays in access to care, and increased frequency of fibrinolysis as a result …”

“…We agree with the premise that zip codes are not perfectly suited to define rurality. We have acknowledged that fact in the Discussion section of our article . However, it is also important to acknowledge the usefulness of this simple tool to use in large-scale epidemiologic research.…”