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People living in rural areas in the U.S. are less likely to have health insurance, have less access to health care services for urgent conditions, and are more likely to encounter lower quality care than their urban counterparts, according to the U.S. Centers for Disease Control and Prevention.
These and other factors mean that the 46 million people, or 15 percent of the U.S. population, who live in rural locations are more likely to die of cancer, respiratory diseases, and cardiovascular diseases than those in urban areas.
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In a nationwide study of Medicare beneficiaries, researchers at Harvard Medical School and Beth Israel Deaconess Medical Center evaluated differences in procedural care and mortality for acute cardiovascular conditions between rural and urban hospitals.
The physician-scientists found significant disparities, including demonstrating that older adults initially seeking care at rural hospitals are less likely to receive important procedures and treatments for heart attack and stroke.
Mortality rates were also higher at rural hospitals for patients accessing care for heart attack, heart failure, or stroke than at urban hospitals. The findings are published in the Journal of the American College of Cardiology.  
“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,” said corresponding author Rishi Wadhera, HMS assistant professor of medicine at Beth Israel Deaconess.
“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 past 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,” said Eméfah Loccoh, first author of the study and a clinical fellow in medicine at HMS.
In this retrospective cross-sectional study, Wadhera, Loccoh, and colleagues looked at data from more than 2 million Medicare beneficiaries age 65 or older who were hospitalized with acute cardiovascular conditions at more than 4,000 urban and rural hospitals across the U.S. from 2016 to 2018.
Medicare beneficiaries accessing care for acute cardiovascular conditions at rural hospitals were older, more likely to be female, and more likely to be white than their urban counterparts.
These patients were less likely to receive procedural care such as cardiac catheterization for heart attack or thrombolysis and endovascular therapy for stroke. Moreover, mortality rates were higher among patients seeking care at rural hospitals than at urban hospitals—a pattern the researchers saw both at 30 days after initial presentation and 90 days after.
The researchers suggest several factors that may be contributing to worse outcomes in rural areas, despite significant public health and policy efforts to reduce rural-urban inequities.
Even as the rate of uninsured rural Americans declined over recent years, a spate of rural hospital closures over the past decade has resulted in longer travel times and delays in emergency medical services and treatments that adversely affected outcomes for emergent cardiac conditions.
“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 ST-elevation myocardial infarction, or STEMI, experience similar outcomes to their urban counterparts,” said Wadhera.
“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.”
In addition, rural areas have experienced a decline in primary care physicians and specialties which may make access to follow-up care after discharge more difficult. These challenges, coupled with worse access to cardiac rehab and important rehab services after stroke may contribute to worse outcomes in rural areas and may disproportionately affect minorities. 
Beyond challenges with access to care, the researchers cite a relative lack of “intensity of care,” or a lack of resources and infrastructure in the rural setting, as another factor that may contribute to these rural-urban disparities.
“These findings may reflect rural-urban gaps in telestroke services that are secondary to financial constraints, the lack of high-speed internet, and regulatory barriers,” said Loccoh.
Within rural areas, the researchers saw significant disparities in care received at critical access hospitals (CAHs) versus noncritical access hospitals. Federally designated as part of the Medicare Rural Hospital Flexibility Program, critical access hospitals are intended to improve health care and emergency services in remote rural areas.
However, Wadhera and colleagues found that Medicare beneficiaries were actually less likely to receive procedural care for heart attack or stroke when initially seeking care at CAHs than they were at noncritical access sites. The risk of mortality was higher among patients accessing care at CAHs as well.
This work was supported by the Sarnoff Cardiovascular Research Fellowship; grants from the National Institutes of Health, National Heart, Lung, and Blood Institute (grants K23HL14852500, R01HL143421, R01HL136708, R01HL157530 and K23HL14852500); the National Institute on Aging (grant R018G060935).
Co-authors include Yun Wang, Dhruv Kazi, and Karen Joynt Maddox of Brigham and Women’s Hospital.
Robert Yeh, a co-author of the paper at Beth Israel Deaconess, receives personal fees from Biosense Webster, grants and personal fees from Abbott Vascular, AstraZeneca, Boston Scientific, and Medtronic, outside the submitted work. Wadhera serves as a consultant for Abbott, outside the submitted work. All other authors have no disclosures.
Adapted from a Beth Israel Deaconess news release.
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