农村地区与心力衰竭风险的关联。

Association of Rurality With Risk of Heart Failure.

机构信息

Division of Intramural Research, Epidemiology and Community Health Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.

Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, Tennessee.

出版信息

JAMA Cardiol. 2023 Mar 1;8(3):231-239. doi: 10.1001/jamacardio.2022.5211.

DOI:10.1001/jamacardio.2022.5211

PMID:36696094

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC9878434/

Abstract

IMPORTANCE

Rural 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.

OBJECTIVE

To 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 PARTICIPANTS: This 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.

EXPOSURES

Rurality as defined by Rural-Urban Commuting Area codes at the census-tract level.

MAIN OUTCOMES AND MEASURES

Heart 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.

RESULTS

Among 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 RELEVANCE

Among 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.

摘要

重要性

与城市人口相比，农村人口的心力衰竭（HF）死亡率更高。农村个体的 HF 发病率是否更高则知之甚少。此外，种族和农村健康不平等之间的交集研究不足。

目的

确定农村与 HF 风险增加之间是否存在关联，而不考虑心血管（CV）疾病和社会经济地位（SES），以及农村相关 HF 风险是否因种族和性别而异。

设计、地点和参与者：这项前瞻性队列研究分析了南方社区队列研究（SCCS）中没有 HF 的黑人和白人参与者的数据，这些参与者在入组时通过医疗补助和医疗保险服务中心（CMS）接受治疗。SCCS 是美国东南部 12 个州的低收入、服务不足的参与者的人群队列。参与者于 2002 年至 2009 年期间入组，并随访至 2016 年 12 月 31 日。数据于 2021 年 10 月至 2022 年 11 月进行分析。

暴露情况

以人口普查区为单位的农村-城市通勤区代码定义的农村性。

主要结果和测量

通过 CMS 链接通过 2016 年使用诊断代码定义 HF。HF 的发生率通过随访的人年和年龄标准化计算。顺序调整 Cox 比例风险回归模型检验了农村性与 HF 发生率之间的关联。

结果

在 27115 名参与者中，中位（IQR）年龄为 54 岁（47-65），18647 名（68.8%）为黑人，8468 名（32.3%）为白人；5556 名参与者（20%）居住在农村地区。在中位 13 年随访期间，城市参与者的年龄调整 HF 发病率为每 1000 人年 29.6（95%CI，28.9-30.5），农村参与者为每 1000 人年 36.5（95%CI，34.9-38.3）（P<0.001）。在调整人口统计学信息、CV 危险因素、健康行为和 SES 后，农村参与者发生 HF 的风险比（HR）为 1.19（95%CI，1.13-1.26），高于城市参与者。HF 的农村相关风险因种族和性别而异，黑人男性最高（HR，1.34；95%CI，1.19-1.51），其次是白人女性（HR，1.22；95%CI，1.07-1.39）和黑人女性（HR，1.18；95%CI，1.08-1.28）。在白人男性中，农村性与 HF 发生率增加无关（HR，0.97；95%CI，0.81-1.16）。