Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, New Hampshire, USA.
The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
J Rural Health. 2024 Mar;40(2):386-393. doi: 10.1111/jrh.12803. Epub 2023 Oct 22.
There is now a 20% disparity in all-cause, excess deaths between urban and rural areas, much of which is driven by disparities in cardiovascular death. We sought to explain the sources of these disparities for Medicare beneficiaries with heart failure with reduced ejection fraction (HFrEF).
Using a sample of Medicare Parts A, B, and D, we created a cohort of 389,528 fee-for-service beneficiaries with at least 1 heart failure hospitalization from 2008 to 2017. The primary outcome was 30-day mortality after discharge; 1-year mortality, readmissions, and return emergency room (ER) admissions were secondary outcomes. We used hierarchical, logistic regression modeling to determine the contribution of comorbidities, guideline-directed medical therapy (GDMT), and social determinants of health (SDOH) to outcomes.
Thirty-day mortality rates after hospital discharge were 6.3% in rural areas compared to 5.7% in urban regions (P < .001); after adjusting for patient health and GDMT receipt, the 30-day mortality odds ratio for rural residence was 1.201 (95% CI 1.164-1.239). Adding the SDOH measure reduced the odds ratio somewhat (1.140, 95% CI 1.103-1.178) but a gap remained. Readmission rates in rural areas were consistently lower for all model specifications, while ER admissions were consistently higher.
Among patients with HFrEF, living in a rural area is associated with an increased risk of death and return ER visits within 30 days of discharge from HF hospitalization. Differences in SDOH appear to partially explain mortality differences but the remaining gap may be the consequence of rural-urban differences in HF treatment.
城乡之间全因超额死亡率存在 20%的差异，其中大部分是由心血管疾病死亡率的差异造成的。我们试图解释导致伴有射血分数降低的心力衰竭（HFrEF）的医疗保险受益人的这些差异的原因。
使用医疗保险 A、B 和 D 部分的样本，我们创建了一个队列，其中包括 2008 年至 2017 年至少有 1 次心力衰竭住院治疗的 389528 名付费服务受益人。主要结局是出院后 30 天死亡率；次要结局为 1 年死亡率、再入院率和返回急诊室（ER）就诊率。我们使用分层逻辑回归模型来确定合并症、指南指导的药物治疗（GDMT）和健康社会决定因素（SDOH）对结局的贡献。
农村地区出院后 30 天死亡率为 6.3%，而城市地区为 5.7%（P<.001）；在调整患者健康状况和 GDMT 接受情况后，农村居民的 30 天死亡率比值比为 1.201（95%可信区间为 1.164-1.239）。加入 SDOH 测量值后，比值比略有降低（1.140，95%可信区间为 1.103-1.178），但差距仍然存在。在所有模型规格中，农村地区的再入院率始终较低，而急诊室就诊率始终较高。
在伴有 HFrEF 的患者中，居住在农村地区与 HF 住院后 30 天内死亡和返回急诊室就诊的风险增加相关。SDOH 的差异似乎部分解释了死亡率的差异，但剩余的差距可能是 HF 治疗中城乡差异的结果。
