Rural-urban differences in acute myocardial infarction mortality: Evidence from Nebraska

Analysis of the Weekend Effect on Mortality, Diagnostic Coronary Angiography, and Percutaneous Coronary Intervention in Acute Myocardial Infarction Across Rural US Hospitals

BACKGROUND

Rural hospitals face several unique challenges in delivering healthcare to an underserved population. Achieving time-sensitive goals in a resource-scarce facility is often a difficult task without the right team at hand. Resources are further depleted on the weekends, exposing understaffed hospitals to poorer outcomes. Acute myocardial infarction (AMI) mortality depends on timely diagnosis and intervention. It is unknown to what extent resource shortages impact rural hospitals during weekends and how they affect AMI mortality.

METHODS

This cross-sectional study was performed on patients admitted on weekends with AMI using the National Inpatient Sample (NIS) 2019. Patients with type II non-ST-elevation myocardial infarction (NSTEMI) and missing information were excluded. The rates and timing of in-hospital diagnostic coronary angiograms, PCIs (percutaneous coronary interventions), and in-hospital mortality were studied. Regression models were used for data analyses.

RESULTS

A total of 161,625 patients met the inclusion criteria (58,690 females (36%), 114,830 Caucasians (71%), 17,910 African American (11%), 13,920 Hispanic (8.6%); mean (SD) age, 66.5 (0.5) years), including 47,665 (29.5%) ST-elevation myocardial infarction (STEMI) and 113,960 (70.5%) NSTEMI. Patients admitted to rural hospitals were less likely to undergo diagnostic coronary angiogram (adjusted odds ratio (aOR), 0.69; CI, 0.57-0.83; p<0.001) and PCI (aOR, 0.83; CI, 0.72-0.96; p 0.012). Rural hospitals had lesser odds of early diagnostic angiograms (aOR, 0.79; CI, 0.67-0.95; p<0.05) and PCI (aOR, 0.78; CI, 0.66-0.92; p<0.05) within 24 hours. The mortality difference between rural and urban hospitals was not significant (aOR, 1.08; CI, 0.85-1.4; p 0.52).

CONCLUSIONS

Diagnostic coronary angiograms and PCI are performed at a lesser rate in rural hospitals during weekends. This trend did not affect rural AMI mortality.

Don't go breakin' my heart: cardioprotective alterations to the mechanical and structural properties of reperfused myocardium during post-infarction inflammation

Myocardial infarctions (MIs) kickstart an intense inflammatory response resulting in extracellular matrix (ECM) degradation, wall thinning, and chamber dilation that leaves the heart susceptible to rupture. Reperfusion therapy is one of the most effective strategies for limiting adverse effects of MIs, but is a challenge to administer in a timely manner. Late reperfusion therapy (LRT; 3 + hours post-MI) does not limit infarct size, but does reduce incidences of post-MI rupture and improves long-term patient outcomes. Foundational studies employing LRT in the mid-twentieth century revealed beneficial reductions in infarct expansion, aneurysm formation, and left ventricle dysfunction. The mechanism by which LRT acts, however, is undefined. Structural analyses, relying largely on one-dimensional estimates of ECM composition, have found few differences in collagen content between LRT and permanently occluded animal models when using homogeneous samples from infarct cores. Uniaxial testing, on the other hand, revealed slight reductions in stiffness early in inflammation, followed soon after by an enhanced resistance to failure for cases of LRT. The use of one-dimensional estimates of ECM organization and gross mechanical function have resulted in a poor understanding of the infarct's spatially variable mechanical and structural anisotropy. To resolve these gaps in literature, future work employing full-field mechanical, structural, and cellular analyses is needed to better define the spatiotemporal post-MI alterations occurring during the inflammatory phase of healing and how they are impacted following reperfusion therapy. In turn, these studies may reveal how LRT affects the likelihood of rupture and inspire novel approaches to guide scar formation.

Association of Rural Hospital Admissions with Access, Treatment, and Mortality for Patients with Acute Myocardial Infarction in Shanxi, China

China recently launched healthcare reforms to reduce disparities in healthcare resources between urban and rural areas. However, few studies have determined how admission to rural hospitals has affected patient care and outcomes. This study aims to determine whether admission to a rural hospital is associated with changes in treatment and outcomes. Using a province-wide, administrative database of 62,380 patients (51,355 urban patients vs. 11,025 rural patients) with acute myocardial infarction (AMI) in Shanxi from 2015 to 2017, we identified the differential distance from the patient’s residential address to the nearest hospital and the nearest percutaneous coronary intervention (PCI)-capable hospital as instrumental variables. We estimated the risk-adjusted differences in outcomes and treatments for patients admitted to rural hospitals versus urban hospitals using a two-stage least squares instrumental variable analysis method. Based on instrumental variable analysis, admission to a rural hospital was associated with a 5.3% (95% CI, 0.012 to 0.093; p = 0.011) increase in mortality. There was a 59.8% (95% CI, −0.733 to −0.463; p-values < 0.0001) decrease in receiving PCI, an 18.8% (95% CI, −0.231 to −0.146; p-values < 0.0001) decrease in receiving fibrinolysis, and a 71.8% (95% CI, 0.586 to 0.849; p-values < 0.0001) increase in receiving medication-only treatment for patients admitted to rural hospitals. Rural hospitals in China thus offer relatively poor care for myocardial infarction. Hospital facilities and reperfusion therapies must be improved.

Understanding the importance of social determinants and rurality for the long-term outcome after acute myocardial infarction: study protocol for a single-centre cohort study

INTRODUCTION

Acute myocardial infarction (AMI) is a major public health issue in Germany with considerable regional differences in morbidity and mortality. Possible reasons for regional differences include a higher prevalence of cardiovascular risk factors, infrastructural deficits, different levels of healthcare quality or social determinants. We aim to study associations of social determinants and of rural infrastructure with the quality of medical care (eg, time to reperfusion or medication adherence) and on the long-term outcome after myocardial infarction.

METHODS AND ANALYSIS

We will employ a prospective cohort study design. Patients who are admitted with AMI will be invited to participate. We aim to recruit a total of 1000 participants over the course of 5 years. Information on outpatient care prior to AMI, acute healthcare of AMI, healthcare-related environmental factors and social determinants will be collected. Baseline data will be assessed in interviews and from the electronic data system of the hospital. Follow-up will be conducted after an observation period of 1 year via patient interviews. The outcomes of interest are cardiac and all-cause mortality, changes in quality of life, changes in health status of heart failure, major adverse cardiovascular events and participation in rehabilitation programmes.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethics Committee of Brandenburg Medical School (reference: E-01-20200923). Research findings will be disseminated and shared in different ways and include presenting at international and national conferences, publishing in peer-reviewed journals and facilitating dissemination workshops within local communities with patients and healthcare professionals.

TRIALS REGISTRATION NUMBER

DRKS00024463.

Mortality from Acute Coronary Syndrome: Does Place of Residence Matter?

Background : Current evidence shows inequality in the outcomes of rural and urban patients treated at their place of residence. This study compared in-hospital mortality between rural and urban patients with acute coronary syndrome (ACS) to find whether there were differences in the outcome and received treatment. Methods : Between May 2007 and January 2018, patients admitted with ACS were included. The patients' demographic, clinical, and laboratory data, as well as their in-hospital medical courses, were recorded. The association between place of residence (rural/urban) and in-hospital mortality due to ACS was evaluated using logistic regression adjusted for potential confounders. Results: Of 9088 recruited patients (mean age =61.30±12.25 y; 5557 men [61.1%]), 838 were rural residents. A positive family history of coronary artery disease (P=0.003), smoking (P=0.002), and hyperlipidemia (P=0.026), as well as a higher body mass index (P=0.013), was seen more frequently in the urban patients, while the rural patients had lower education levels (P<0.001) and higher unemployment rates (P=0.009). In-hospital mortality occurred in 135 patients (1.5%): 10 rural (1.2%) and 125 urban (1.5%) patients (P=0.465). The Firth regression model, used to adjust the effects of possible confounders, showed no significant difference concerning in-hospital mortality between the rural and urban patients (OR, 1.57; 95% CI, 0.376 to 7.450; P=0.585). Conclusion : This study found no significant differences in receiving proper treatment and in-hospital mortality between rural and urban patients with ACS.

Examining Predictors of Myocardial Infarction

Cardiovascular diseases are the leading cause of death in the United States. This study analyzed predictors of myocardial infarction (MI) for those aged 35 and older based on demographic, socioeconomic, geographic, behavioral, and risk factors, as well as access to healthcare variables using the Center for Disease (CDC) Control Behavioral Risk Factor Surveillance System (BRFSS) survey for the year 2019. Multiple quasibinomial models were generated on an 80% training set hierarchically and then used to forecast the 20% test set. The final training model proved somewhat capable of prediction with a weighted F1-Score = 0.898. A complete model based on statistically significant variables using the entirety of the dataset was compared to the same model built on the training set. Models demonstrated coefficient stability. Similar to previous studies, age, gender, marital status, veteran status, income, home ownership, employment status, and education level were important demographic and socioeconomic predictors. The only geographic variable that remained in the model was associated with the West North Central Census Division (in-creased risk). Statistically important behavioral and risk factors as well as comorbidities included health status, smoking, alcohol consumption frequency, cholesterol, blood pressure, diabetes, stroke, chronic obstructive pulmonary disorder (COPD), kidney disease, and arthritis. Three access to healthcare variables proved statistically significant: lack of a primary care provider (Odds Ratio, OR = 0.853, p < 0.001), cost considerations prevented some care (OR = 1.232, p < 0.001), and lack of an annual checkup (OR = 0.807, p < 0.001). The directionality of these odds ratios is congruent with a marginal effects model and implies that those without MI are more likely not to have a primary provider or annual checkup, but those with MI are more likely to have missed care due to the cost of that care. Cost of healthcare for MI patients is associated with not receiving care after accounting for all other variables.

Spatial and temporal analysis of myocardial infarction incidence in Zanjan province, Iran

Background

Myocardial Infarction (MI) is a major important public health concern and has huge burden on health system across the world. This study aimed to explore the spatial and temporal analysis of the incidence of MI to identify potential clusters of the incidence of MI patterns across rural areas in Zanjan province, Iran.

Materials & methods

This was a retrospective and geospatial analysis study of the incidence of MI data from nine hospitals during 2014–2018. Three different spatial analysis methods (Spatial autocorrelation, hot spot analysis and cluster and outlier analysis) were used to identify potential clusters and high-risk areas of the incidence of MI at the study area.

Results

Three thousand eight hundred twenty patients were registered at Zanjan hospitals due to MI during 2014–2018. The overall age-adjusted incidence rate of MI was 343 cases per 100,000 person which was raised from 88 cases in 2014 to 114 cases in 2018 per 100,000 person-year (a 30% increase, P < 0.001). Golabar region had the highest age-adjusted incidence rate of MI (515 cases per 100,000 person). Five hot spots and one high-high cluster were detected using spatial analysis methods.

Conclusion

This study showed that there is a great deal of spatial variations in the pattern of the incidence of MI in Zanjan province. The high incidence rate of MI in the study area compared to the national average, is a warning to local health authorities to determine the possible causes of disease incidence and potential drivers of high-risk areas. The spatial cluster analysis provides new evidence for policy-makers to design tailored interventions to reduce the incidence of MI and allocate health resource to unmet need areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11695-8.

Associations between Hospital Quality Outcomes and Medicare Spending per Beneficiary in the USA

The cost of healthcare in the United States has increased over time. However, patient health outcomes have not trended with spending. There is a need to better comprehend the association between healthcare costs in the United States and hospital quality outcomes. Medicare spending per beneficiary (MSPB), a homogeneous metric across providers, can be used to evaluate the association between episodic Medicare spending and quality of care. Fifteen inpatient outcome measures were selected from Hospital Compare data among all (n = 4758) facilities and transformed to quintiles to ensure comparability across measures and to reduce the influence of outliers on the analysis. Both univariate and multiresponse multinomial ordered probit regression models were utilized across outcome domains to quantify associations between outcomes and spending. We found that MSPB was not associated with quality of care in most cases, adding evidence of a lack of outcome accountability among Medicare-funded facilities. Furthermore, worse outcomes were found to be associated with increased spending for some metrics. Policies are needed to align quality of care outcomes with the increasing costs of U.S. healthcare.

Comparing models of delivery for cancer genetics services among patients receiving primary care who meet criteria for genetic evaluation in two healthcare systems: BRIDGE randomized controlled trial

BACKGROUND

Advances in genetics and sequencing technologies are enabling the identification of more individuals with inherited cancer susceptibility who could benefit from tailored screening and prevention recommendations. While cancer family history information is used in primary care settings to identify unaffected patients who could benefit from a cancer genetics evaluation, this information is underutilized. System-level population health management strategies are needed to assist health care systems in identifying patients who may benefit from genetic services. In addition, because of the limited number of trained genetics specialists and increasing patient volume, the development of innovative and sustainable approaches to delivering cancer genetic services is essential.

METHODS

We are conducting a randomized controlled trial, entitled Broadening the Reach, Impact, and Delivery of Genetic Services (BRIDGE), to address these needs. The trial is comparing uptake of genetic counseling, uptake of genetic testing, and patient adherence to management recommendations for automated, patient-directed versus enhanced standard of care cancer genetics services delivery models. An algorithm-based system that utilizes structured cancer family history data available in the electronic health record (EHR) is used to identify unaffected patients who receive primary care at the study sites and meet current guidelines for cancer genetic testing. We are enrolling eligible patients at two healthcare systems (University of Utah Health and New York University Langone Health) through outreach to a randomly selected sample of 2780 eligible patients in the two sites, with 1:1 randomization to the genetic services delivery arms within sites. Study outcomes are assessed through genetics clinic records, EHR, and two follow-up questionnaires at 4 weeks and 12 months after last genetic counseling contactpre-test genetic counseling.

DISCUSSION

BRIDGE is being conducted in two healthcare systems with different clinical structures and patient populations. Innovative aspects of the trial include a randomized comparison of a chatbot-based genetic services delivery model to standard of care, as well as identification of at-risk individuals through a sustainable EHR-based system. The findings from the BRIDGE trial will advance the state of the science in identification of unaffected patients with inherited cancer susceptibility and delivery of genetic services to those patients.

TRIAL REGISTRATION

BRIDGE is registered as NCT03985852 . The trial was registered on June 6, 2019 at clinicaltrials.gov .

Fibrinolysis vs. primary percutaneous coronary intervention for ST-segment elevation myocardial infarction cardiogenic shock

AIMS

There are limited contemporary data on the use of initial fibrinolysis in ST-segment elevation myocardial infarction cardiogenic shock (STEMI-CS). This study sought to compare the outcomes of STEMI-CS receiving initial fibrinolysis vs. primary percutaneous coronary intervention (PPCI).

METHODS

Using the National (Nationwide) Inpatient Sample from 2009 to 2017, a comparative effectiveness study of adult (>18 years) STEMI-CS admissions receiving pre-hospital/in-hospital fibrinolysis were compared with those receiving PPCI. Admissions with alternate indications for fibrinolysis and STEMI-CS managed medically or with surgical revascularization (without fibrinolysis) were excluded. Outcomes of interest included in-hospital mortality, development of non-cardiac organ failure, complications, hospital length of stay, hospitalization costs, use of palliative care, and do-not-resuscitate status.

RESULTS

During 2009-2017, 5297 and 110 452 admissions received initial fibrinolysis and PPCI, respectively. Compared with those receiving PPCI, the fibrinolysis group was more often non-White, with lower co-morbidity, and admitted on weekends and to small rural hospitals (all P < 0.001). In the fibrinolysis group, 95.3%, 77.4%, and 15.7% received angiography, PCI, and coronary artery bypass grafting, respectively. The fibrinolysis group had higher rates of haemorrhagic complications (13.5% vs. 9.9%; P < 0.001). The fibrinolysis group had comparable all-cause in-hospital mortality [logistic regression analysis: 28.8% vs. 28.5%; propensity-matched analysis: 30.8% vs. 30.3%; adjusted odds ratio 0.97 (95% confidence interval 0.90-1.05); P = 0.50]. The fibrinolysis group had comparable rates of acute organ failure, hospital length of stay, rates of palliative care referrals, do-not-resuscitate status use, and lesser hospitalization costs.

CONCLUSIONS

The use of initial fibrinolysis had comparable in-hospital mortality than those receiving PPCI in STEMI-CS in the contemporary era in this large national observational study.

Rurality and atrial fibrillation: a pathway to virtual engagement and clinical trial recruitment in response to COVID-19

Study Objective

To summarize trial adaptation from in-clinic to virtual design in response to the SARS-2 coronavirus-2 (COVID-19).

Design

A clinical trial of a mobile health intervention to improve chronic disease self-management for rural individuals with atrial fibrillation (AF). The trial has a 4-month intervention - accessible regardless of health or digital literacy - to enhance AF medication adherence and patient experience with 8- and 12-month assessments of sustainability.

Setting

Rural, western Pennsylvania.

Participants

Rural individuals with AF receiving oral anticoagulation for stroke prevention.

Interventions

Enrolled participants underwent a telephone-based orientation, provided verbal consent, and were randomized using a digital platform. They received a smartphone with intervention or control applications and a curriculum on usage tailored for study arm. Participants received study assessments by mail with telephone-based administration and contact for the 12-month trial.

Main Outcome Measures

Successful adaptation to virtual engagement and recruitment.

Results

The study enrolled 18 participants during in-clinic recruitment (January-March 2020). From 5/1/2020 to 5/6/2021 the study team enrolled 130 individuals (median age 72.4 years, range 40.8-92.2; 49.2% women, 63.1% without college degree, and 45.4% with limited health literacy. Retention of participants enrolled using virtual methods during the 4-month intervention phase is 92%.

Conclusions

We report a virtual trial of a mobile health intervention for rural individuals with AF. Our successful implementation suggests promise for engaging geographically isolated rural individuals, potential to enhance digital health access, and advance rural health equity.

Comparison between urban and rural mortality in patients with acute myocardial infarction: a nationwide longitudinal cohort study in South Korea

OBJECTIVES

This study investigated the risk associated with interhospital transfer of patients with acute myocardial infarction (AMI) and clinical outcomes according to the location of the patient' residence.

DESIGN

A nationwide longitudinal cohort.

SETTING

National Health Insurance Service database of South Korea.

PARTICIPANTS

This study included 69 899 patients with AMI who visited an emergency centre from 2013 to 2015, as per the Korea National Health Insurance Service database.

PRIMARY OUTCOME MEASURE

The clinical outcome of a patient with AMI was defined as mortality within 7 days, 30 days and 1 year.

RESULTS

Clinical outcomes were analysed and compared with respect to the location of the patient's residence and occurrence of interhospital transfer. We concluded that the HR of mortality within 7 days was 1.49 times higher (95% CI 1.18 to 1.87) in rural patients than in urban patients not subjected to interhospital transfer and 1.90 times higher (95% CI 1.13 to 3.19) in transferred rural patients than in non-transferred urban patients.

CONCLUSIONS

To reduce health inequality in rural areas, a healthcare policy considering regional characteristics, rather than a central government-led, catch-all approach to healthcare policy, must be formulated. Additionally, a local medical emergency delivery system, based on allocation of roles between different medical facilities in the region, must be established.

Emergency Department Telemedicine Consults are Associated with Faster Time-to-Electrocardiogram and Time-to-Fibrinolysis for Myocardial Infarction Patients

Introduction: Acute myocardial infarction (AMI) is a time-sensitive condition. Meeting guideline-recommended time metrics for these patients can be challenging in rural emergency departments (EDs). Telemedicine has been shown to improve the quality and timeliness of emergency care in rural areas. The objective of this study was to evaluate the impact of telemedicine on the timeliness of emergency AMI care for patients presenting to rural EDs with chest pain. Methods: A prospective cohort study, conducted in six telemedicine networks, identified ED patients presenting with chest pain from November 2015 through December 2017. Primary exposure was telemedicine consultation during the ED visit. The primary outcome was time-to-electrocardiogram (ECG). For eligible AMI patients, secondary outcomes included: (1) fibrinolysis administered and (2) time-to-fibrinolysis. Analyses for multivariable models were conducted by using logistic regression, clustered at the hospital level. Results: Overall, 1,220 patients presenting with chest pain were included in the study cohort (27.1% received telemedicine). Time-to-ECG was, on average, 0.39 times (95% confidence interval [CI] -0.26 to -0.52) faster for telemedicine cases. Among eligible patients, telemedicine was associated with higher odds of fibrinolysis administration (adjusted odds ratio 7.17, 95% CI 2.48-20.49). In a sensitivity analysis excluding patients with cardiac arrest, time-to-fibrinolysis administration did not differ when telemedicine was used. Discussion: In telemedicine networks, telemedicine consultation during the ED visit was associated with improved timeliness of ECG evaluation and increased use of fibrinolytic reperfusion therapy for rural AMI patients. Future work should focus on the impact of telemedicine consultation on patient-centered outcomes.

Influence of rurality on the awareness of myocardial infarction symptoms in the US

BACKGROUND

Myocardial infarctions (MIs) are the leading cause of death in the United States (US). Differences in MI mortality rates exist between rural and urban areas in the US. Early recognition of MI symptoms can lead to receiving prompt lifesaving treatment. In this study, we identified the influence of living in a rural area, rurality, on disparities in MI symptom awareness across the US.

METHODS

We examined 2007 and 2009 Behavioral Risk Factor Surveillances System survey data using logistic regressions to model the impact of rurality on MI symptom awareness while controlling for sociodemographic and MI clinical factors. From the results of these models, we created a type of marginal probability, known as average adjusted predictions (AAPs) and the difference in AAPs, called average marginal effects (AMEs), to determine patterns of awareness for each MI symptom between rural, suburban, and urban areas.

RESULTS

We found that there were similar odds and probabilities of being aware of all five MI symptoms between rural, suburban, and urban areas, although rural residents consistently had a slightly higher odds and probability of being aware of all five MI symptoms compared with suburban and urban residents. Rural, suburban, and urban residents had the highest probability of being aware of chest pain/discomfort (95.5-96.1%) and the lowest probability of being aware of jaw/back/neck pain (68.6-72.0%). After adjustment, more than 25% of rural, suburban, and urban residents were found to be unaware that jaw/back/neck pain and feeling weak/light-headed/faint were symptoms of MI. AMEs were greatest for all areas for jaw/back/neck pain (-3.5% to -3.2%) and smallest for chest pain/discomfort (-0.6% to -0.2%).

CONCLUSIONS

The study's results highlight the need to increase awareness of the MI symptoms of jaw/back/neck pain and feeling weak/light-headed/faint to shorten hospital delay and time to treatment, especially for rural areas where cardiovascular disease mortality is high.

Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction: Understanding and addressing the global risk-treatment paradox

Clinical guidelines for the treatment of patients with non-ST-segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long-term mortality risk than patients with ST-segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the "treatment-risk paradox"). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four "P" factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long-term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.

Rural and urban patients with diffuse large B-cell and follicular lymphoma experience reduced overall survival: a National Cancer DataBase study

We examined 83,108 patients with diffuse large B-cell lymphoma (DLBCL) and 43,393 patients with follicular lymphoma (FL) to investigate disparities related to geographic population density, stratified as rural, urban, or metropolitan. We found that urban and rural patients less commonly had private insurance and high socioeconomic status. Urban and rural DLBCL patients were more likely to receive treatment within 14 days of diagnosis (OR 0.93, 95% confidence interval [CI] 0.89-0.98; and OR 0.81, 95% CI 0.72-0.91) while urban FL patients were more likely to have treatment >14 days after diagnosis (OR 1.08, 95% CI 1.01-1.16). Multivariable analyses demonstrated that rural and urban patients had worse overall survival with DLBCL (hazard ratio [HR] 1.09; 95% CI 1-1.19 and HR 1.08; 95% CI 1.04-1.11) and FL (HR 1.11; 95% CI 1.04-1.18 and HR 1.2; 95% CI 1.02-1.41), respectively, suggesting needs for focused study and interventions for these populations.

Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review

The goal of this systematic review was to examine the existing literature base regarding the factors impacting patient outcomes associated with use of emergency medical services (EMS) operating in urban versus rural areas. A specific subfocus on low and lower-middle-income countries was planned but acknowledged in advance as being potentially limited by a lack of available data. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed during the preparation of this systematic review. A comprehensive literature search of PubMed, EBSCO (Elton B. Stephens Company) host, Web of Science, ProQuest, Embase, and Scopus was conducted through May 2018. To appraise the quality of the included papers, the Critical Appraisal Skills Programme Checklists (CASP) were used. Thirty-one relevant and appropriate studies were identified; however, only one study from a low or lower-middle-income country was located. The research indicated that EMS in urban areas are more likely to have shorter prehospital times, response times, on-scene times, and transport times when compared to EMS operating in rural areas. Additionally, urban patients with out-of-hospital cardiac arrest or trauma were found to have higher survival rates than rural patients. EMS in urban areas were generally associated with improved performance measures in key areas and associated higher survival rates than those in rural areas. These findings indicate that reducing key differences between rural and urban settings is a key factor in improving trauma patient survival rates. More research in rural areas is required to better understand the factors which can predict these differences and underpin improvements. The lack of research in this area is particularly evident in low- and lower-middle-income countries.

Rural-Urban Variation in Weight Loss Recommendations Among US Older Adults with Arthritis and Obesity

Purpose: Weight loss is advantageous for individuals with obesity and arthritis. Therefore, this study was conducted to determine if there are differences by rural-urban status among older adults with these conditions who reported being advised by a health care provider to lose weight for arthritis or to ameliorate arthritis symptoms. Methods: A cross-sectional analysis of 2011 Behavioral Risk Factor Surveillance System (BRFSS) data. Respondents reported if they had been diagnosed with arthritis and if they received a provider weight loss recommendation (WLR). The analytic sample was limited to older adults aged 60⁻79 living in the five states that administered the examined BRFSS arthritis module who had body mass index ≥ 30 kg/m² and reported having arthritis (n = 2920). The respondent's county of residence was linked to the corresponding county-level population density from the US Decennial Census to determine rural-urban status. A generalized linear model examined the association between receipt of a WLR and population density, controlling for demographics. Results: The sample was 83.6% white, 57.8% female, and 63.2% received a WLR. Respondents from more urban counties were more likely to receive a WLR (p value for trend <0.001). Additionally, older respondents, men, individuals with less than a high school education, and whites had a decreased likelihood of receiving a WLR. Conclusions: The analysis identified notable rural-urban differences with respondents in more urban counties being more likely to receive a WLR. Furthermore, there were differences in those who received a WLR by age, sex, and education. Reasons for these differences should be explored.

Disparities in Cardiac Rehabilitation Among Individuals from Racial and Ethnic Groups and Rural Communities-A Systematic Review

PURPOSE

Despite the well-described benefits of cardiac rehabilitation (CR) on long-term health outcomes, CR is a resource that is underutilized by a significant proportion of patients that suffer from cardiovascular diseases. The main purpose of this study was to examine disparities in CR referral and participation rates among individuals from rural communities and racial and ethnic minority groups with coronary heart disease (CHD) when compared to the general population.

METHODS

A systematic search of standard databases including MedlLine, PubMed, and Cochrane databases was conducted using keywords that included cardiac rehabilitation, women, race and ethnicity, disparities, and rural populations. Twenty-eight clinical studies from 1990 to 2017 were selected and included 478,955 patients with CHD.

RESULTS

The majority of available clinical studies showed significantly lower CR referral and participation rates among individuals from rural communities, women, and racial and ethnic groups when compared to the general population. Similar to geographic region, socioeconomic status (SES) appears to directly impact the use of CR programs. Patients of lower SES have significantly lower CR referral and participation rates than patients of higher SES.

CONCLUSIONS

Data presented underscores the need for systematic referrals using electronic health records for patients with CHD in order to increase overall CR referral and participation rates of minority populations and other vulnerable groups. Educational programs that target healthcare provider biases towards racial and ethnic groups may help attenuate observed disparities. Alternative modalities such as home-based and internet-based CR programs may also help improve CR participation rates among vulnerable populations.

Urban-Rural Comparisons in Hospital Admission, Treatments, and Outcomes for ST-Segment-Elevation Myocardial Infarction in China From 2001 to 2011: A Retrospective Analysis From the China PEACE Study (Patient-Centered Evaluative Assessment of Cardiac Events)

BACKGROUND

In response to urban-rural disparities in healthcare resources, China recently launched a healthcare reform with a focus on improving rural care during the past decade. However, nationally representative studies comparing medical care and patient outcomes between urban and rural areas in China during this period are not available.

METHODS AND RESULTS

We created a nationally representative sample of patients in China admitted for ST-segment-elevation myocardial infarction in 2001, 2006, and 2011, using a 2-stage random sampling design in 2 urban and 3 rural strata. In China, evidence-based treatments were provided less often in 2001 in rural hospitals, which had lower volume and less availability of advanced cardiac facilities. However, these differences diminished by 2011 for reperfusion therapy (54% in urban versus 57% in rural; P=0.1) and reversed for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (66% versus 68%; P=0.04) and early β-blockers (56% versus 60%; P=0.01). The risk-adjusted rate of in-hospital death or withdrawal from treatment was not significantly different between urban and rural hospitals in any study year, with an adjusted odds ratio of 1.13 (0.77-1.65) in 2001, 0.99 (0.77-1.27) in 2006, and 0.94 (0.74-1.19) in 2011.

CONCLUSIONS

Although urban-rural disparities in evidence-based treatment for myocardial infarction in China have largely been eliminated, substantial gaps in quality of care persist in both settings. In addition, urban hospitals providing more resource-intensive care did not achieve better outcomes.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01624883.

Current Trends for ST-segment Elevation Myocardial Infarction during the Past 5 Years in Rural Areas of China's Liaoning Province: A Multicenter Study

Background:

Since 2010, two versions of National Guidelines aimed at promoting the management of ST-segment elevation myocardial infarction (STEMI) have been formulated by the Chinese Society of Cardiology. However, little is known about the changes in clinical characteristics, management, and in-hospital outcomes in rural areas.

Methods:

In the present multicenter, cross-sectional study, participants were enrolled from rural hospitals located in Liaoning province in Northeast China, during two different periods (from June 2009 to June 2010 and from January 2015 to December 2015). Data collection was conducted using a standardized questionnaire. In total, 607 and 637 STEMI patients were recruited in the 2010 and 2015 cohorts, respectively.

Results:

STEMI patients in rural hospitals were older in the second group (63 years vs. 65 years, P = 0.039). We found increases in the prevalence of hypertension, prior percutaneous coronary intervention (PCI), and prior stroke. Over the past 5 years, the cost during hospitalization almost doubled. The proportion of STEMI patients who underwent emergency reperfusion had significantly increased from 42.34% to 54.47% (P < 0.0001). Concurrently, the proportion of primary PCI increased from 3.62% to 10.52% (P < 0.0001). The past 5 years have also seen marked increases in the use of guideline-recommended drugs and clinical examinations. However, in-hospital mortality and major adverse cardiac events did not significantly change over time (13.01% vs. 10.20%, P = 0.121; 13.34% vs. 13.66%, P = 0.872).

Conclusions:

Despite the great progress that has been made in guideline-recommended therapies, in-hospital outcomes among rural STEMI patients have not significantly improved. Therefore, there is still substantial room for improvement in the quality of care.

The regional myocardial infarction registry of Saxony-Anhalt (RHESA) in Germany - rational and study protocol

BACKGROUND

In 2012 the age-standardized acute myocardial infarction (AMI) mortality rate was in the federal state Saxony-Anhalt 67 deaths per 100.000 whereas in Germany the AMI-rate was 47 deaths per 100.000. The rate in Saxony-Anhalt was therefore 43 % above the national average. Many factors may explain this above-average AMI mortality rate: First, the prevalence of cardiovascular risk factors (e.g. arterial hypertension, diabetes mellitus, smoking) in Saxony-Anhalt is the highest among all the Federal States of Germany. Second, structural health care for patients with AMI is potentially deficient (e.g. insufficient number of percutaneous coronary intervention-centers or deficits in the pre-hospital logistics of care). Third, the pre- and in-hospital process quality of health care for patients with AMI is possibly insufficient (e.g. time to reperfusion therapy). In July 2013 we established the regional myocardial infarction registry of Saxony-Anhalt (Regionales Herzinfarktregister in Sachsen-Anhalt, RHESA). RHESA is a population-based registry in the eastern part of Germany. Aims of RHESA are to calculate the AMI morbidity and mortality rates. Furthermore we study the factors that may potentially influence these rates in Saxony-Anhalt.

METHODS

RHESA is a population-based registry of patients with fatal or non-fatal AMI that was established in July 2013. The registry population comprises inhabitants aged 25 years or more of the city of Halle (Saale) (n = 179.000) and inhabitants of the rural district Altmark (n = 165.000) in the federal state Saxony-Anhalt, Germany.

DISCUSSION

The main objectives of RHESA are to provide detailed estimates of the burden of AMI in Saxony-Anhalt which is the federal state with the highest AMI mortality rate in Germany and to investigate factors that influence morbidity and mortality rates due to AMI. Data collected in RHESA enable us to assess different levels of quality of health care of patients with AMI (structural, process and outcome). RHESA provides for the first time estimates of the burden of AMI in Saxony-Anhalt, and therefore contributes considerably to an improvement of the German Health Monitoring that strives for a more valid extrapolation of the nationwide morbidity and mortality rates of AMI.