Rural patients less likely to receive critical care, more likely to die from heart problems

BOSTON, Mass. — Life might be simpler out in the country, but new research finds it’s also much harder to find high quality health care if you have health problems. Scientists from the Beth Israel Deaconess Medical Center found that older adults receiving treatment at rural hospitals are less likely to receive important procedures and treatments for a heart attack or stroke. Even worse, rural mortality rates are much higher in comparison to patients at urban hospitals for major heart events.

“Although public health and policy efforts to improve rural health have intensified over the past decade, our findings highlight that large gaps in clinical outcomes for cardiovascular conditions remain in the United States,” says corresponding author Rishi K. Wadhera, MD, MPP, MPhil, a cardiologist at BIDMC and section head of health policy and equity research at the Smith Center for Outcomes Research in Cardiology, in a university release.

“These disparities suggest that rural adults continue to face challenges accessing the care they need for urgent conditions, an issue that has likely been magnified by the rapid rise in rural hospital closures over the last decade.”

“Our findings highlight that ongoing public health, policy, and clinical efforts are needed to close the gaps in outcomes for urgent cardiovascular conditions, such as heart attacks and stroke,” adds first study author Emefah C. Loccoh, MD, an investigator in the Smith Center and a physician at Brigham and Women’s Hospital.

Heart problems in rural areas more likely to be fatal

Study authors analyzed a massive dataset featuring over two million Medicare beneficiaries over the age of 65, hospitalized between 2016 and 2018 for an acute cardiovascular condition. The analyzed data encompassed more than 4,000 urban and rural hospitals across the United States.

Medicare beneficiaries at rural hospitals for heart issues were more likely to be women or Caucasian in comparison to their urban counterparts. These rural heart patients were also less likely to receive procedural care, such as cardiac catheterization for heart attack patients or thrombolysis and endovascular therapy for stroke patients. Rural heart patients also had much higher mortality rates, with this pattern extending to both 30 days after hospital admission and 90 days after initially arriving at a hospital.

What’s the cause of this major medical disparity?

Study authors hypothesize there are several factors at play. To start, many rural hospitals have closed in recent years. This means locals have to travel longer to get the care they need.

“One bright spot is that we found that the subgroup of older adults who present to rural hospitals with a very severe type of a heart attack – known as a ST elevation myocardial infarction, or STEMI – experience similar outcomes as their urban counterparts,” explains Dr. Wadhera, who is also an assistant professor of medicine at Harvard Medical School.

“This is good news, and suggests that concerted public health initiatives over the past decade, like regional systems of care and transfer protocols, have helped eliminate the rural-urban gap in outcomes for the most emergent type of heart attack.”

Making matters worse is the fact that most rural U.S. regions have also seen a notable decline in high-quality primary care and specialty physicians. These developments, in combination with diminished access to cardiac rehab and stroke rehab services, likely contribute to worse health outcomes in rural regions. Study authors also add that these factors may disproportionately affect minorities as well.

‘Intensity of care’ lacking

Another troubling trend in rural hospitals researchers found is a lack of “intensity of care,” or a general dearth of resources and infrastructure across rural healthcare settings.

“The rural-urban disparities in stroke treatment that we observed may reflect gaps in the availability of tele-stroke services that are secondary to financial constraints and a lack of high-speed internet in rural areas,” Loccoh notes.

It’s important to mention that older rural residents experienced big disparities in care at critical access hospitals (CAHs) in comparison to non-critical care access hospitals. Designed as part of the Medicare Rural Hospital Flexibility Program, CAHs are supposed to improve healthcare in remote, rural areas.

Unfortunately, this study indicates Medicare beneficiaries were actually far less likely to be given high-quality procedural care for either heart attack or stroke at CAHs in comparison to non-critical access sites. Mortality risks were also higher at CAHs.

The findings appear in the Journal of the American College of Cardiology.

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