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Vyas N, Zaheer A, Wijeysundera HC. Untangling the Complex Multidimensionality of the Social Determinants of Cardiovascular Health: A Systematic Review. Can J Cardiol 2024; 40:1000-1006. [PMID: 38513932 DOI: 10.1016/j.cjca.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/21/2024] [Accepted: 03/09/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The cardiovascular literature is limited by the lack of consensus on what are the best metrics for reporting social determinants of health (SDH) or social deprivation, and if they should be reported as a single metric or separately by their domains. METHODS A systematic review of the literature on cardiovascular surgeries and procedures was conducted, identifying articles from January 1, 2010, to December 31, 2023, that studied the relationship between health outcomes after cardiovascular procedures or surgeries and SDH/social deprivation. The cardiovascular procedures/surgeries of interest were coronary and valve surgeries and procedures including coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), valve replacement or repair, and transcatheter aortic valve intervention. RESULTS After screening 638 articles, we identified 47 papers that met our inclusion and exclusion criteria. The most common procedure evaluated was CABG and PCI; 46 of the studies focused on these 2 procedures. Almost all of the articles reported a different metric for SDH/social deprivation (41 different metrics); despite this, all of the metrics showed a consistent relationship with worse outcomes associated with greater degrees of SDH/deprivation. Only 9 reported on the individual domains of SDH/social deprivation; 3 studies showed a discordant relationship. CONCLUSIONS Although our systematic review identified numerous articles evaluating the relationship between SDH/social deprivation in cardiovascular disease, there was substantial heterogeneity in which metric was used and how it was reported. This reinforces the need for standards as to the best metrics for SDH/social deprivation as well as best practices for reporting.
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Affiliation(s)
- Navya Vyas
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aida Zaheer
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Howie-Esquivel J, Metzger M, Malin SK, Mazimba S, Platz K, Toledo G, Park L. Getting Into Light Exercise (GENTLE-HF) for Patients With Heart Failure: the Design and Methodology of a Live-Video Group Exercise Study. J Card Fail 2023; 29:1175-1183. [PMID: 36948269 DOI: 10.1016/j.cardfail.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 02/06/2023] [Accepted: 03/04/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVE Newer therapies have increased heart failure (HF) survival rates, but these therapies are rarely curative. The consequence of increased longevity is the likelihood that patients with HF will experience higher symptom burdens over time. Exercise such as cardiac rehabilitation programs can palliate symptom burdens, but numerous barriers prevent exercise participation and adherence. Small pilot studies indicate short-term beneficial effects of gentle forms of exercise such as yoga to address symptom burdens and accommodate comorbidities. Long-term symptom benefit and adherence to yoga are currently unknown. Therefore, a novel a home-based, gentle-stretching intervention that addresses issues of exercise access and adherence is described in this article. PURPOSE The purpose of this article is to describe the background, design and study methodology of the Getting Into Light Exercise for HF (GENTLE-HF) randomized controlled trial. Gentle-HF will test a gentle stretching and education intervention compared to an education control group concerning symptom burden (dyspnea, exercise, activity adherence, depression, and anxiety) and quality of life. As an exploratory aim, we also will determine whether rurality moderates the relationships between exercise participation and symptom burden as a measure of health equity. METHODS We designed a randomized controlled trial study (n = 234) with 2 arms: a gentle stretching intervention arm with HF education and an HF education-only control. Participants will be recruited from U.S. cardiology clinics in the mid-Atlantic and the San Francisco Bay areas. This recruitment strategy will include individuals from urban, suburban and rural areas and individuals that have diverse racial and ethnic backgrounds. All participants will be provided with an iPad set up to access HF educational topics, and the intervention arm will have both educational and gentle-stretching class links. Both arms will access the HF health education icons on their iPads weekly; they correspond to the 6 months (26 weeks) of study participation. Symptom burden (dyspnea, fatigue, exercise intolerance, depression, anxiety) and quality of life will be measured at the study's start and completion. Study adherence will be measured by using attendance rates and number of class minutes attended. RESULTS The GENTLE-HF study is a randomized study that will test the effect of a home-based, video-conference-delivered gentle stretching and HF education intervention designed for patients with HF. The findings will inform whether gentle stretching can decrease symptom burden and potentially provide access to symptom palliation for a diverse population of patients with HF.
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Affiliation(s)
| | - Maureen Metzger
- University of Virginia School of Nursing, Charlottesville, VA
| | | | - Sula Mazimba
- University of Virginia School of Medicine, Charlottesville, VA
| | - Katherine Platz
- University of Virginia School of Nursing, Charlottesville, VA
| | - Gabriela Toledo
- University of Virginia School of Nursing, Charlottesville, VA
| | - Linda Park
- University of California, San Francisco, San Francisco, CA
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Bashar H, Matetić A, Curzen N, Mamas MA. Invasive Management and In-Hospital Outcomes of Myocardial Infarction Patients in Rural Versus Urban Hospitals in the United States. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 46:3-9. [PMID: 36038495 DOI: 10.1016/j.carrev.2022.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The variation in the management and outcome of acute myocardial infarction (AMI) between rural and urban settings has been previously recognized, but there has previously been no nationwide data reported that is inclusive of the whole adult population. METHODS All discharge records between 2004 and 2018 with AMI diagnosis were extracted from the National Inpatient Sample (NIS) database and stratified by hospital location. The primary outcome was in-hospital mortality, and secondary outcomes included (a) major adverse cardiovascular and cerebrovascular events (MACCE), (b) major bleeding, (c) acute ischemic stroke, the utilization of invasive management in the form of (d) coronary angiography (CA), and (e) percutaneous coronary intervention (PCI). The adjusted odds ratios (aOR) and 95 % confidence interval (95 % CI) were determined using multivariable logistic regression. RESULTS 9,728,878 records with AMI were identified, of which 1,011,637 (10.4 %) discharges were from rural hospitals. Rural patients were older (median of 71 years vs. 67 years, p < 0.001) and had lower prevalence of the highest risk presentations of AMI than their urban counterparts. After multivariable adjustment, patients from rural hospitals had increased aOR of all-cause mortality (aOR 1.15 95 % CI 1.13-1.16) and MACCE (aOR 1.04 95 % CI 1.04-1.05), as well as the decreased aOR of coronary angiography (aOR 0.29, 95 % CI 0.29-0.29, p < 0.001) and PCI (aOR 0.40, 95 % CI 0.39-0.40, p < 0.001), compared to their urban counterparts. CONCLUSION Between 2004 and 2018, the risk of in-hospital mortality and MACCE in AMI patients was significantly higher in rural hospitals, with considerably lower utilization of invasive angiography and revascularization.
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Affiliation(s)
- Hussein Bashar
- Faculty of Medicine, University of Southampton, United Kingdom; Coronary Research Group, University Hospital Southampton NHS Foundation Trust, United Kingdom; Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, United Kingdom
| | - Andrija Matetić
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, United Kingdom; Department of Cardiology, University Hospital of Split, Split, Croatia
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, United Kingdom; Coronary Research Group, University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, United Kingdom.
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4
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Rural-urban disparities in baseline health factors and procedure outcomes. J Natl Med Assoc 2022; 114:227-231. [DOI: 10.1016/j.jnma.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 12/24/2021] [Accepted: 01/10/2022] [Indexed: 11/23/2022]
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Jánosi A, Pach FP, Erdős G, Csató G, Pápai G, Andréka P. Incidence, pre-hospital delay and prognosis of acute myocardial infarction in big regions of Hungary: Population data from the Hungarian myocardial infarction registry. Int J Clin Pract 2021; 75:e14831. [PMID: 34510670 DOI: 10.1111/ijcp.14831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/04/2021] [Accepted: 09/09/2021] [Indexed: 11/30/2022] Open
Abstract
AIM To examine the incidence and treatment of acute myocardial infarction (AMI) as well as 30-day and 1-year prognoses of patients in different regions of Hungary. According to the statistical system of the European Union, Hungary can be divided into three major socio-economic regions-west Hungary, central Hungary and east Hungary. METHODS AND RESULTS The Hungarian Myocardial Infarction Registry (HUMIR) is a prospective comprehensive and mandatory disease registry for patients with AMI. The total population of Hungary is currently 9.8 million: 39% live in the eastern region (ER), 31% in the central region (CR) and 30% in the western region (WR). Population over 30 years, the age-standardised incidence of AMI was 177.5 (175.7-179.3) per 100 000 person-year. During hospital treatment, 82.5%-84.6% of patients with ST-elevation (STEMI) and 54.8%-58.8% without ST-elevation (NSTEMI) myocardial infarction underwent PCI. The total ischaemic time of patients with STEMI was shortest in WR (221 minutes) compared with two other regions (CR: 225 minutes and ER: 262 minutes). In the STEMI group, the 30-day mortality rates of male patients were lowest in the WR (P = .03). If PCI was performed, mortality rates for both sexes were lowest in the WR (P < .01; P = .04). The 1-year mortality rate in the male population who received PCI was lowest in the WR. In the NSTEMI group, the 30-day mortality rate exhibited no differences. Regarding 1-year mortality, those who underwent PCI in the WR showed the lowest mortality. CONCLUSION The major regions of Hungary revealed significant differences regarding the incidence, prehospital delay, treatment and mortality of AMI. Logistic regression analysis confirmed the independent prognostic significance of the region on the 30-day mortality of patients with STEMI (hazard ratio = 0.88, P = .0114; CI: 0.80-0.97).
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Affiliation(s)
- András Jánosi
- Gottsegen National Cardiovascular Centre, Budapest, Hungary
| | | | | | - Gábor Csató
- National Ambulance Service, Budapest, Hungary
| | | | - Péter Andréka
- Gottsegen National Cardiovascular Centre, Budapest, Hungary
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Harvey NC, Lorentzon M, Kanis JA, McCloskey E, Johansson H. Incidence of myocardial infarction and associated mortality varies by latitude and season: findings from a Swedish Registry Study. J Public Health (Oxf) 2021; 42:e440-e448. [PMID: 31774530 DOI: 10.1093/pubmed/fdz131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We investigated whether the incidence of death following myocardial infarction (MI) varied by season and latitude in the Swedish population. METHODS We studied deaths following MI from January 1987 to December 2009, using the Swedish National Cause of Death Register. County of residence was used to determine latitude and population density. An extension of Poisson regression was used to study the relationship between risk of death following MI with age, latitude, time (from 1987), population density and calendar days. RESULTS Over the study period, there was a secular decrease in the incidence of MI-related death. In men, MI-related death incidence increased by 1.3% [95% confidence interval (CI) = 1.1-1.5] per degree of latitude (northwards). In women, MI-related death incidence increased by 0.6% (95% CI = 0.4-0.9) per degree of latitude. There was seasonal variation in the risk of MI-related death with peak values in the late winter and a nadir in the summer months in both the north and the south of Sweden. Findings were similar with incident MI as the outcome. CONCLUSIONS The incidence of MI-related death varied markedly by season and latitude in Sweden, with summer months and more southerly latitude associated with lower rates than winter months and more northerly latitude.
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Affiliation(s)
- Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK.,NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - Mattias Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Sweden.,Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.,Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - Eugene McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.,Centre for Integrated Research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.,Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
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Loccoh E, Joynt Maddox KE, Xu J, Shen C, Figueroa JF, Kazi DS, Yeh RW, Wadhera RK. Rural-Urban Disparities In All-Cause Mortality Among Low-Income Medicare Beneficiaries, 2004-17. Health Aff (Millwood) 2021; 40:289-296. [PMID: 33523738 DOI: 10.1377/hlthaff.2020.00420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is growing concern about the health of older US adults who live in rural areas, but little is known about how mortality has changed over time for low-income Medicare beneficiaries residing in rural areas compared with their urban counterparts. We evaluated whether all-cause mortality rates changed for rural and urban low-income Medicare beneficiaries dually enrolled in Medicaid, and we studied disparities between these groups. The study cohort included 11,737,006 unique dually enrolled Medicare beneficiaries. Between 2004 and 2017 all-cause mortality declined from 96.6 to 92.7 per 1,000 rural beneficiaries (relative percentage change: -4.0 percent). Among urban beneficiaries, declines in mortality were more pronounced (from 86.9 to 72.8 per 1,000 beneficiaries, a relative percentage change of -16.2 percent). The gap in mortality between rural and urban beneficiaries increased over time. Rural mortality rates were highest in East North Central states and increased modestly in West North Central states during the study period. Public health and policy efforts are urgently needed to improve the health of low-income older adults living in rural areas.
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Affiliation(s)
- Emefah Loccoh
- Emefah Loccoh is a research associate and Sarnoff Fellow in the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, in Boston, Massachusetts
| | - Karen E Joynt Maddox
- Karen E. Joynt Maddox is an assistant professor of medicine at the Washington University School of Medicine and codirector of the Center for Health Economics and Policy at the Institute for Public Health at Washington University in St. Louis, in St. Louis, Missouri
| | - Jiaman Xu
- Jiaman Xu is a data analyst in the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center
| | - Changyu Shen
- Changyu Shen is an associate professor and statistical director at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center
| | - José F Figueroa
- José F. Figueroa is an assistant professor of health policy and management in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, in Boston, Massachusetts
| | - Dhruv S Kazi
- Dhruv S. Kazi is an associate director in the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center
| | - Robert W Yeh
- Robert W. Yeh is the director of the Richard A. and Susan F. Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center and the Katz Silver Family Endowed Chair and associate professor of medicine in the field of outcomes research in cardiology at Harvard Medical School, in Boston, Massachusetts
| | - Rishi K Wadhera
- Rishi K. Wadhera is an assistant professor of medicine at Harvard Medical School and an investigator at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center
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Spatial distribution of in- and out-of-hospital mortality one year after acute myocardial infarction in France. Am J Prev Cardiol 2020; 2:100037. [PMID: 34327460 PMCID: PMC8315588 DOI: 10.1016/j.ajpc.2020.100037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/18/2020] [Accepted: 06/19/2020] [Indexed: 11/21/2022] Open
Abstract
Objective To describe the spatial distribution of acute myocardial infarction (AMI) mortality in France in association with the socio-economic characteristics of the patient's place of residence. Methods In this population-based study, we included patients hospitalized for AMI identified according to ICD-10 codes, using data from the national health insurance database from January 1, 2013 to December 31, 2014. In- and out-of-hospital deaths were identified over a period of 1 year following the first hospital stay for AMI.An exploratory analysis was performed to classify area profiles. The spatial analysis of AMI mortality was performed using a principal component analysis followed by an ascending hierarchical classification taking into account socio-economic data, access-time by road to coronary angiography, standardized in-hospital prevalence, and 1 year mortality. Results Over the 2 years, 115,418 patients were hospitalized with a diagnosis of AMI. Patients were a mean of 68 ± 15 years and most were men (68.5%). The overall mortality rate was 12.2% after 1 year. More than half of patients (65.5%) underwent an early revascularization procedure. The map of standardized 1 year mortality showed a geographic area of high mortality extending diagonally from north-east to south-west France. We identified 6 different area profiles with standardized mortality varying from 15.9 to 54.4 per 100,000 inhabitants. The spatial distribution of higher mortality was associated with lower socioeconomic levels. These findings were not associated with a lower access to coronary angiography. Conclusion There are considerable geographical differences in the prevalence of AMI and 1 year mortality. The spatial distribution of lower healthcare indicators follows the distribution of social inequalities. This study highlights the importance of focusing national policies on universally accessible prevention programs such as the promotion cardiac rehabilitation and healthy lifestyles.
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Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, Hipp J, Konig M, Sanchez E, Joynt Maddox KE. Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association. Circulation 2020; 141:e615-e644. [PMID: 32078375 DOI: 10.1161/cir.0000000000000753] [Citation(s) in RCA: 147] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association's pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association's commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.
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Alghanem F, Clements JM. Narrowing performance gap between rural and urban hospitals for acute myocardial infarction care. Am J Emerg Med 2020; 38:89-94. [DOI: 10.1016/j.ajem.2019.04.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 04/10/2019] [Accepted: 04/12/2019] [Indexed: 01/13/2023] Open
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Pross C, Strumann C, Geissler A, Herwartz H, Klein N. Quality and resource efficiency in hospital service provision: A geoadditive stochastic frontier analysis of stroke quality of care in Germany. PLoS One 2018; 13:e0203017. [PMID: 30188906 PMCID: PMC6126832 DOI: 10.1371/journal.pone.0203017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 08/14/2018] [Indexed: 02/07/2023] Open
Abstract
We specify a Bayesian, geoadditive Stochastic Frontier Analysis (SFA) model to assess hospital performance along the dimensions of resources and quality of stroke care in German hospitals. With 1,100 annual observations and data from 2006 to 2013 and risk-adjusted patient volume as output, we introduce a production function that captures quality, resource inputs, hospital inefficiency determinants and spatial patterns of inefficiencies. With high relevance for hospital management and health system regulators, we identify performance improvement mechanisms by considering marginal effects for the average hospital. Specialization and certification can substantially reduce mortality. Regional and hospital-level concentration can improve quality and resource efficiency. Finally, our results demonstrate a trade-off between quality improvement and resource reduction and substantial regional variation in efficiency.
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Affiliation(s)
- Christoph Pross
- Department of Healthcare Management, Berlin University of Technology, Straße des 17. Juni 135, 10623 Berlin, Germany
| | - Christoph Strumann
- Institute for Entrepreneurship and Business Development, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Alexander Geissler
- Department of Healthcare Management, Berlin University of Technology, Straße des 17. Juni 135, 10623 Berlin, Germany
| | - Helmut Herwartz
- Chair of Econometrics, Georg-August-University Göttingen, Humboldtallee 3, 37073 Göttingen, Germany
| | - Nadja Klein
- Melbourne Business School, University of Melbourne, 200 Leicester Street, Carlton VIC 3053, Australia
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Rural Patients With Severe Sepsis or Septic Shock Who Bypass Rural Hospitals Have Increased Mortality: An Instrumental Variables Approach. Crit Care Med 2017; 45:85-93. [PMID: 27611977 DOI: 10.1097/ccm.0000000000002026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To identify factors associated with rural sepsis patients' bypassing rural emergency departments to seek emergency care in larger hospitals, and to measure the association between rural hospital bypass and sepsis survival. DESIGN Observational cohort study. SETTING Emergency departments of a rural Midwestern state. PATIENTS All adults treated with severe sepsis or septic shock between 2005 and 2014, using administrative claims data. INTERVENTIONS Patients bypassing local rural hospitals to seek care in larger hospitals. MEASUREMENTS AND MAIN RESULTS A total of 13,461 patients were included, and only 5.4% (n = 731) bypassed a rural hospital for their emergency department care. Patients who initially chose a top-decile sepsis volume hospital were younger (64.7 vs 72.7 yr; p < 0.001) and were more likely to have commercial insurance (19.6% vs 10.6%; p < 0.001) than those who were seen initially at a local rural hospital. They were also more likely to have significant medical comorbidities, such as liver failure (9.9% vs 4.2%; p < 0.001), metastatic cancer (5.9% vs 3.2%; p < 0.001), and diabetes with complications (25.2% vs 21.6%; p = 0.024). Using an instrumental variables approach, rural hospital bypass was associated with a 5.6% increase (95% CI, 2.2-8.9%) in mortality. CONCLUSIONS Most rural patients with sepsis seek care in local emergency departments, but demographic and disease-oriented factors are associated with rural hospital bypass. Rural hospital bypass is independently associated with increased mortality.
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