Rurality, Death, and Healthcare Utilization in Heart Failure in the Community

Regional differences in heart failure risk in the United Kingdom are partially explained by biological aging

Background

Heart failure (HF) risk is greater in rural versus urban regions in the United States (US), potentially due to differences in healthcare coverage and access. Whether this excess risk applies to countries with universal healthcare is unclear and the underlying biological mechanisms are unknown. In the prospective United Kingdom (UK) Biobank, we investigated urban-rural regional differences in HF risk and the mechanistic role of biological aging.

Methods

Multivariable Cox regression was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of incident HF in relation to residential urban-rural region and a Biological Health Score (BHS) that reflects biological aging from environmental, social, or dietary stressors. We estimated the proportion of the total effect of urban-rural region on HF mediated through BHS.

Results

Among 417,441 European participants, 10,332 incident HF cases were diagnosed during the follow-up. Compared to participants in large urban regions of Scotland, those in England/Wales had significantly increased HF risk (smaller urban: HR = 1.83, 95%CI: 1.64-2.03; suburban: HR = 1.77, 95%CI: 1.56-2.01; very rural: HR = 1.61, 95%CI: 1.39-1.85). Additionally, we found a dose-response relationship between increased biological aging and HF risk (HRper 1 SD increase = 1.14 (95%CI: 1.12-1.17). Increased biological aging mediated a notable 6.6% (p < 0.001) of the total effect of urban-rural region on HF.

Conclusion

Despite universal healthcare in the UK, disparities in HF risk by region were observed and may be partly explained by environmental, social, or dietary factors related to biological aging. Our study contributes to precision public health by informing potential biological targets for intervention.

Heart failure among Indigenous and non-Indigenous Australians in remote Central Australia

BACKGROUND

There is a paucity of data on the burden of heart failure (HF) in Central Australia, the most populous Indigenous region in the country.

AIMS

To characterize Indigenous and non-Indigenous Australians with HF in Central Australia.

METHODS

Consecutive patients with HF and reduced ejection fraction <50% were included for the period 2019 to 2021. Clinical, echocardiographic and major adverse cardiovascular events (MACE) data were collected.

RESULTS

Four hundred twenty-four patients with HF were included (70% Indigenous, 59% male; follow-up 2.2 ± 0.5 years). Indigenous Australians were younger (53 ± 15 vs 68 ± 13 years, P < 0.001) with higher rates of rheumatic heart disease (18% vs 1%, P < 0.001), diabetes (63% vs 33%, P < 0.001) and severe chronic kidney disease (CKD; 32% vs 7%, P < 0.001). HF was more prevalent among Indigenous (138 [95% confidence interval (CI), 123-155] per 10 000) compared with non-Indigenous Australians (53 [95% CI, 44-63] per 10 000), particularly among younger individuals and females. There were similar HF aetiologies between groups. Guideline-directed medical therapy (GDMT) was suboptimal and similar between the groups: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (64% vs 67%, P = 0.47) and β-blockers (68% vs 71%, P = 0.47). Indigenous Australians had a significantly higher rate of MACE (54% vs 28%, P < 0.001) and death from any cause (24% vs 13%, P = 0.013).

CONCLUSIONS

HF is more than two times as prevalent among Indigenous Central Australians, particularly among younger individuals and females. Despite similar HF aetiologies and GDMT, MACE and mortality outcomes are higher in Indigenous individuals with HF. These data have implications for efforts to close the Indigenous gap in morbidity and mortality.

Rurality, Cardiovascular Risk Factors, and Early Cardiovascular Disease among Childhood, Adolescent, and Young Adult Cancer Survivors

Background and Aims

Cardiovascular risk factors (CVRFs) later in life potentiate risk for late cardiovascular disease (CVD) from cardiotoxic treatment among survivors. This study evaluated the association of baseline CVRFs and CVD in the early survivorship period.

Methods

This analysis included patients ages 0-29 at initial diagnosis and reported in the institutional cancer registry between 2010 and 2017 (n = 1228). Patients who died within five years (n = 168), those not seen in the oncology clinic (n = 312), and those with CVD within one year of diagnosis (n = 17) were excluded. CVRFs (hypertension, diabetes, dyslipidemia, and obesity) within one year of initial diagnosis, were constructed and extracted from the electronic health record based on discrete observations, ICD9/10 codes, and RxNorm codes for antihypertensives.

Results

Among survivors (n = 731), 10 incident cases (1.4%) of CVD were observed between one year and five years after the initial diagnosis. Public health insurance (p = 0.04) and late effects risk strata (p = 0.01) were positively associated with CVD. Among survivors with public insurance(n = 495), two additional cases of CVD were identified from claims data with an incidence of 2.4%. Survivors from rural areas had a 4.1 times greater risk of CVD compared with survivors from urban areas (95% CI: 1.1-15.3), despite adjustment for late effects risk strata.

Conclusions

Clinically computable phenotypes for CVRFs among survivors through informatics methods were feasible. Although CVRFs were not associated with CVD in the early survivorship period, survivors from rural areas were more likely to develop CVD.

Implications for Survivors

Survivors from non-urban areas and those with public insurance may be particularly vulnerable to CVD.

The role of comorbidities, medications, and social determinants of health in understanding urban-rural outcome differences among patients with heart failure

PURPOSE

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).

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

The Impact of Social Determinants of Health on Outcomes Among Individuals With HIV and Heart Failure: A Literature Review

This narrative review examines the complex interplay between social determinants of health (SDoH) and the outcomes for individuals living with human immunodeficiency virus (HIV) and heart failure (HF), two conditions that pose significant socioeconomic burdens globally. With millions affected by these conditions, the review delves into how socioeconomic status, education, geography, and immigration status influence health outcomes. It further explores the exacerbating roles of stigma and mental health issues, underscoring the need for comprehensive interventions and the importance of enhancing health literacy and community support. Key findings suggest that lower socioeconomic status, limited education, rural residency, and immigrant status are associated with poorer health outcomes in individuals with HIV and HF. These factors contribute to increased morbidity and mortality and decreased quality of life, highlighting the necessity of addressing SDoH to improve patient care and outcomes. There is a critical need for integrated care models that consider the medical, social, and psychological factors affecting those with HIV and HF. Strategies proposed include improving access to care, addressing socioeconomic disparities, enhancing educational efforts, and fostering community engagement. Moreover, the importance of mental healthcare integration into the management of HIV and HF is strongly advocated to improve patient outcomes. By taking a comprehensive look at the various social challenges, embracing integrated care models, and making sure everyone has fair access to healthcare services, we can make real progress in enhancing the lives of those affected by HIV and HF. This approach cannot only lower death rates but also significantly improve the quality of life for these individuals.

Rurality and race in heart failure risk: Insights from the Southern Community Cohort Study

INTRODUCTION

Rural-urban health disparities are apparent in the burden of disease and health outcomes, including cardiovascular disease (CVD), specifically heart failure (HF). However, the factors influencing these disparities are not fully understood. Study and results: Among 27,115 participants in the Southern Community Cohort Study (SCCS) (mean age: 54 years (47-65)), 18,647 (68.8%) were black, 8,468 (32.3%) were white, and 20% resided in rural areas. Over a median 13-year follow-up period, 7,542 HF events occurred (rural = 1,865 vs. urban = 5,677). The age-adjusted HF incidence was 29.6 (95% CI, 28.9-30.5) and 36.5 (95% CI, 34.9-38.3) per 1,000 person-years for urban and rural participants, respectively (P < .001). The risk of HF associated with rurality varied by race and sex. Rural black men had the highest risk across all groups (HR, 1.34; 95% CI, 1.19-1.51) (age-adjusted incidence rate: 40.4/1000 person-years (95% CI, 36.8-44.3)) followed by black women (HR, 1.18; 95% CI, 1.08-1.28) and white women (HR, 1.22; 95% CI, 1.07-1.39). Rurality was not associated with HF risk among white men (HR, 0.97; 95% CI, 0.81-1.16).

LESSONS LEARNED

This large study shows that rural populations have an increased incidence of HF, which is particularly striking among women and black men, independent of individual-level biological, behavioral, and sociocultural risk factors. It also shows the need for further investigation into the rurality-associated risk of HF, the impact of preventive care utilization on the risk of HF and interpersonal, community, or societal factors that could contribute to rural-urban disparities. This will help to guide public health efforts aimed at HF prevention among rural populations.

Regional variations in heart failure: a global perspective

Heart failure (HF) is a global public health concern that affects millions of people worldwide. While there have been significant therapeutic advancements in HF over the last few decades, there remain major disparities in risk factors, treatment patterns and outcomes across race, ethnicity, socioeconomic status, country and region. Recent research has provided insight into many of these disparities, but there remain large gaps in our understanding of worldwide variations in HF care. Although the majority of the global population resides across Asia, Africa and South America, these regions remain poorly represented in epidemiological studies and HF trials. Recent efforts and registries have provided insight into the clinical profiles and outcomes across HF patterns globally. The prevalence of HF and associated risk factors has been reported and varies by country and region ranges, with minimal data on regional variations in treatment patterns and long-term outcomes. It is critical to improve our understanding of the different factors that contribute to global disparities in HF care so we can build interventions that improve our general cardiovascular health and mitigate the social and economic cost of HF. In this narrative review, we hope to provide an overview of the global and regional variations in HF care and outcomes.

Determinants of survival in patients with chronic heart failure: a population-based study in Reggio Emilia, Italy

AIMS

We aim to monitor and improve the quality of the heart failure (HF) integrated assistance model defined by national and regional guidelines and implemented in the province of Reggio Emilia, Italy. Specific aims of the audit were to estimate the prevalence of HF, describe the characteristics of patients with HF and the rate of patients enrolled in the integrated care treated in primary care, and identify socioeconomic and geographic determinants of the 4-year survival of these patients.

METHODS AND RESULTS

Retrospective analysis of a cohort of prevalent cases of HF, diagnosed before 31 December 2015 in Reggio Emilia, Italy, alive on 1 January 2016, and residing at the time of diagnosis on the provincial territory. Age and sex-adjusted prevalence of HF by area of residence were calculated according to the standard European population 2013. Patients were followed until death or 31 December 2019, whatever came first. The outcome measure of the study was four-year case fatality. Cox proportional hazards models, adjusted for age, sex, and duration of disease were used to determine the association between socio-geographic factors and death. The 4-year case-fatality rate was 36.7%, and it was the highest in the mountains (50.8%) compared with hills (34.6%), lowland (35.4%) and city (37.7%). The prevalence of HF was the lowest in the mountain [149.9, 95% confidence interval (CI) 112.1-187.7] and the highest in the lowland (340.8, 95% CI 308.7-372.9) and city (308, 95% CI 276.0-321.2). Patients living in the mountains had a lower deprivation index, and fewer hospitalizations prior to official diagnosis, although these characteristics were not statistically significant determinants of HF death in multivariate analysis. Behavioural (smoking and obesity) and socio-geographic characteristics (educational level, deprivation index and area of residence) were not significantly associated with mortality in both univariable and multivariable analysis; however, patients who live in mountains (hazard ratio 1.10, 95% CI 0.73-1.66) or hills (hazard ratio 1.11, 95% CI 0.90-1.37) had a slightly higher risk of death than those living in the city. Only 197 (12.1%) of patients in the cohort were enrolled in the integrated care pathway over the course of 4 years.

CONCLUSIONS

Although clinical determinants outweigh the geographic and behavioural disparities in the survival of patients with CHF treated in primary care, effective prevention strategies are needed to address environmental and socio-geographic inequalities in access to primary care and to hasten equitable linkage to integrated care.

Self-care Problems and Management Strategies Experienced by Rural Patient/Caregiver Dyads Living With Heart Failure: A Qualitative Study

BACKGROUND

Rural patients with heart failure (HF) have higher mortality and hospitalization rates compared with their urban counterparts. Although research supports the inclusion of informal caregivers in daily self-care activities, data are limited regarding the problems encountered by rural patient/caregiver dyads living with HF in managing HF in the home and how these problems are managed.

OBJECTIVE

The aim of this study was to identify and describe HF self-care problems experienced by rural dyads in the home and how these problems are managed.

METHODS

Using a descriptive qualitative design, data were collected from rural patient/caregiver dyads living with HF via individual, semistructured, telephone interviews and analyzed using schematic content analysis. Interviews and data analysis occurred concurrently until data saturation was reached.

RESULTS

Thematic data saturation was obtained with 11 dyads. On average, patients were 65.3 (±13.9) years old, and caregivers were 62 (±12.37) years old. Four themes illustrating dyadic HF self-care problems and management strategies emerged: (1) HF self-care components, namely, maintenance, symptom monitoring, and management (diet, exercise, activities, strategies); (2) environment (rural barriers, COVID-19); (3) caregiver contributors (confidence, role); and (4) dyadic contributors (dyadic relationship). Dyads described various self-care problems, with the type of relationship and presence of mutuality influencing the problem-solving process and development of management strategies.

CONCLUSIONS

The identified themes emphasize the self-care problems experienced by rural dyads living with HF and the contributions of both dyad members to effectively manage these challenges. Findings support the need for culturally sensitive, tailored interventions targeting self-care in rural dyads living with HF.

Effect of Chronic Disease Home Telehealth Monitoring in the Veterans Health Administration on Healthcare Utilization and Mortality

BACKGROUND

The high prevalence of chronic diseases, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM), accounts for a large burden of cost and poor health outcomes in US hospitals, and home telehealth (HT) monitoring has been proposed to improve outcomes.

OBJECTIVE

To measure the association between HT initiation and 12-month inpatient hospitalizations, emergency department (ED) visits, and mortality in veterans with CHF, COPD, or DM.

DESIGN

Comparative effectiveness matched cohort study.

PATIENTS

Veterans aged 65 years and older treated for CHF, COPD, or DM.

MAIN MEASURES

We matched veterans initiating HT with veterans with similar demographics who did not use HT (1:3). Our outcome measures included a 12-month risk of inpatient hospitalization, ED visits, and all-cause mortality.

KEY RESULTS

A total of 139,790 veterans with CHF, 65,966 with COPD, and 192,633 with DM were included in this study. In the year after HT initiation, the risk of hospitalization was not different in those with CHF (adjusted odds ratio [aOR] 1.01, 95% confidence interval [95%CI] 0.98-1.05) or DM (aOR 1.00, 95%CI 0.97-1.03), but it was higher in those with COPD (aOR 1.15, 95%CI 1.09-1.21). The risk of ED visits was higher among HT users with CHF (aOR 1.09, 95%CI 1.05-1.13), COPD (1.24, 95%CI 1.18-1.31), and DM (aOR 1.03, 95%CI 1.00-1.06). All-cause 12-month mortality was lower in those initiating HT monitoring with CHF (aOR 0.70, 95%CI 0.67-0.73) and DM (aOR 0.79, 95%CI 0.75-0.83), but higher in COPD (aOR 1.08, 95%CI 1.00-1.16).

CONCLUSIONS

The initiation of HT was associated with increased ED visits, no change in hospitalizations, and lower all-cause mortality in patients with CHF or DM, while those with COPD had both higher healthcare utilization and all-cause mortality.

Telehealth and Health Equity in Older Adults With Heart Failure: A Scientific Statement From the American Heart Association

Enhancing access to care using telehealth is a priority for improving outcomes among older adults with heart failure, increasing quality of care, and decreasing costs. Telehealth has the potential to increase access to care for patients who live in underresourced geographic regions, have physical disabilities or poor access to transportation, and may not otherwise have access to cardiologists with expertise in heart failure. During the COVID-19 pandemic, access to telehealth expanded, and yet barriers to access, including broadband inequality, low digital literacy, and structural barriers, prevented many of the disadvantaged patients from getting equitable access. Using a health equity lens, this scientific statement reviews the literature on telehealth for older adults with heart failure; provides an overview of structural, organizational, and personal barriers to telehealth; and presents novel interventions that pair telemedicine with in-person services to mitigate existing barriers and structural inequities.

Co-Occurrence of Social Risk Factors and Associated Outcomes in Patients With Heart Failure

Background Among patients with heart failure (HF), social risk factors (SRFs) are associated with poor outcomes. However, less is known about how co-occurrence of SRFs affect all-cause health care utilization for patients with HF. The objective was to address this gap using a novel approach to classify co-occurrence of SRFs. Methods and Results This was a cohort study of residents living in an 11-county region of southeast Minnesota, aged ≥18 years with a first-ever diagnosis for HF between January 2013 and June 2017. SRFs, including education, health literacy, social isolation, and race and ethnicity, were obtained via surveys. Area-deprivation index and rural-urban commuting area codes were determined from patient addresses. Associations between SRFs and outcomes (emergency department visits and hospitalizations) were assessed using Andersen-Gill models. Latent class analysis was used to identify subgroups of SRFs; associations with outcomes were examined. A total of 3142 patients with HF (mean age, 73.4 years; 45% women) had SRF data available. The SRFs with the strongest association with hospitalizations were education, social isolation, and area-deprivation index. We identified 4 groups using latent class analysis, with group 3, characterized by more SRFs, at increased risk of emergency department visits (hazard ratio [HR], 1.33 [95% CI, 1.23-1.45]) and hospitalizations (HR, 1.42 [95% CI, 1.28-1.58]). Conclusions Low educational attainment, high social isolation, and high area-deprivation index had the strongest associations. We identified meaningful subgroups with respect to SRFs, and these subgroups were associated with outcomes. These findings suggest that it is possible to apply latent class analysis to better understand the co-occurrence of SRFs among patients with HF.

Association of Rurality With Risk of Heart Failure

Importance

Rural populations experience an increased burden of heart failure (HF) mortality compared with urban populations. Whether HF incidence is greater among rural individuals is less known. Additionally, the intersection between racial and rural health inequities is understudied.

Objective

To determine whether rurality is associated with increased risk of HF, independent of cardiovascular (CV) disease and socioeconomic status (SES), and whether rurality-associated HF risk varies by race and sex.

Design, Setting, and Participants

This prospective cohort study analyzed data for Black and White participants of the Southern Community Cohort Study (SCCS) without HF at enrollment who receive care via Centers for Medicare & Medicaid Services (CMS). The SCCS is a population-based cohort of low-income, underserved participants from 12 states across the southeastern United States. Participants were enrolled between 2002 and 2009 and followed up until December 31, 2016. Data were analyzed from October 2021 to November 2022.

Exposures

Rurality as defined by Rural-Urban Commuting Area codes at the census-tract level.

Main Outcomes and Measures

Heart failure was defined using diagnosis codes via CMS linkage through 2016. Incidence of HF was calculated by person-years of follow-up and age-standardized. Sequentially adjusted Cox proportional hazards regression models tested the association between rurality and incident HF.

Results

Among 27 115 participants, the median (IQR) age was 54 years (47-65), 18 647 (68.8%) were Black, and 8468 (32.3%) were White; 5556 participants (20%) resided in rural areas. Over a median 13-year follow-up, age-adjusted HF incidence was 29.6 (95% CI, 28.9-30.5) per 1000 person-years for urban participants and 36.5 (95% CI, 34.9-38.3) per 1000 person-years for rural participants (P < .001). After adjustment for demographic information, CV risk factors, health behaviors, and SES, rural participants had a 19% greater risk of incident HF (hazard ratio [HR], 1.19; 95% CI, 1.13-1.26) compared with their urban counterparts. The rurality-associated risk of HF varied across race and sex and was greatest among Black men (HR, 1.34; 95% CI, 1.19-1.51), followed by White women (HR, 1.22; 95% CI, 1.07-1.39) and Black women (HR, 1.18; 95% CI, 1.08-1.28). Among White men, rurality was not associated with greater risk of incident HF (HR, 0.97; 95% CI, 0.81-1.16).

Conclusions and Relevance

Among predominantly low-income individuals in the southeastern United States, rurality was associated with an increased risk of HF among women and Black men, which persisted after adjustment for CV risk factors and SES. This inequity points to a need for additional emphasis on primary prevention of HF among rural populations.

Thirty-day readmission in patients with heart failure with preserved ejection fraction: Insights from the nationwide readmission database

BACKGROUND

There are rising numbers of patients who have heart failure with preserved ejection fraction (HFpEF). Poorly understood pathophysiology of heart failure with preserved and reduced ejection fraction and due to a sparsity of studies, the management of HFpEF is challenging.

AIM

To determine the hospital readmission rate within 30 d of acute or acute on chronic heart failure with preserved ejection fraction and its effect on mortality and burden on health care in the United States.

METHODS

We performed a retrospective study using the Agency for Health-care Research and Quality Health-care Cost and Utilization Project, Nationwide Readmissions Database for the year 2017. We collected data on hospital readmissions of 60514 adults hospitalized for acute or acute on chronic HFpEF. The primary outcome was the rate of all-cause readmission within 30 d of discharge. Secondary outcomes were cause of readmission, mortality rate in readmitted and index patients, length of stay, total hospitalization costs and charges. Independent risk factors for readmission were identified using Cox regression analysis.

RESULTS

The thirty day readmission rate was 21%. Approximately 9.17% of readmissions were in the setting of acute on chronic diastolic heart failure. Hypertensive chronic kidney disease with heart failure (1245; 9.7%) was the most common readmission diagnosis. Readmitted patients had higher in-hospital mortality (7.9% vs 2.9%, P = 0.000). Our study showed that Medicaid insurance, higher Charlson co-morbidity score, patient admitted to a teaching hospital and longer hospital stay were significant variables associated with higher readmission rates. Lower readmission rate was found in residents of small metropolitan or micropolitan areas, older age, female gender, and private insurance or no insurance were associated with lower risk of readmission.

CONCLUSION

We found that patients hospitalized for acute or acute on chronic HFpEF, the thirty day readmission rate was 21%. Readmission cases had a higher mortality rate and increased healthcare resource utilization. The most common cause of readmission was cardio-renal syndrome.

Disparities in Cardio-oncology: Effects On Outcomes and Opportunities for Improvement

Purpose of Review

The purpose of this article is to provide a comprehensive review of available data on health disparities and the interconnected social determinants of health (SDOH) in cardio-oncology. We identify the gaps in the literature and suggest areas for future research. In addition, we propose strategies to address these disparities at various levels.

Recent Findings

There has been increasing recognition of health disparities and the role of SODH on an individual’s access to health care, quality of care, and outcomes of the illness. There is growing evidence of sex and race-based differences in cancer therapy-related cardiotoxicity. Recent studies have shown how access and quality of health care are affected by financial stability and rurality. Our recent study utilizing the social vulnerability index (SVI) and county-level patient data found graded increase in county-level cardio-oncology mortality with greater social vulnerability. The incremental impact of social vulnerability was higher for cardio-oncology mortality than for mortality related to either cancer or CVD alone. The mortality rates in these patients were higher in rural areas compared to urban areas regardless of social vulnerability. Additionally, for those within the counties within highest social vulnerability, Black individuals had significantly higher cardio-oncology mortality compared with White individuals.

Summary

Disparities in the cardio-oncology population are deep-rooted and widespread, leading to poor quality of life and increased mortality. It is crucial to integrate SDOH, not only in clinical care delivery but also in future research, and registry data to improve our understanding and the outcomes in our unique subset of cardio-oncology patients.

Rurality, Death, and Healthcare Utilization in Heart Failure in the Community

Background Prior reports indicate that living in a rural area may be associated with worse health outcomes. However, data on rurality and heart failure (HF) outcomes are scarce. Methods and Results Residents from 6 southeastern Minnesota counties with a first-ever code for HF (International Classification of Diseases, Ninth Revision [ICD-9], code 428, and International Classification of Diseases, Tenth Revision [ICD-10] code I50) between January 1, 2013 and December 31, 2016, were identified. Resident address was classified according to the rural-urban commuting area codes. Rurality was defined as living in a nonmetropolitan area. Cox regression was used to analyze the association between living in a rural versus urban area and death; Andersen-Gill models were used for hospitalization and emergency department visits. Among 6003 patients with HF (mean age 74 years, 48% women), 43% lived in a rural area. Rural patients were older and had a lower educational attainment and less comorbidity compared with patients living in urban areas (P<0.001). After a mean (SD) follow-up of 2.8 (1.7) years, 2440 deaths, 20 506 emergency department visits, and 11 311 hospitalizations occurred. After adjustment, rurality was independently associated with an increased risk of death (hazard ratio [HR], 1.18; 95% CI, 1.09-1.29) and a reduced risk of emergency department visits (HR, 0.89; 95% CI, 0.82-0.97) and hospitalizations (HR, 0.78; 95% CI, 0.73-0.84). Conclusions Among patients with HF, living in a rural area is associated with an increased risk of death and fewer emergency department visits and hospitalizations. Further study to identify and address the mechanisms through which rural residence influences mortality and healthcare utilization in HF is needed in order to reduce disparities in rural health.