Processes of care for patients with ischemic heart disease appear to differ between rural and urban health care systems, but there is no difference in outcomes between the two settings, according to recent findings.
In a population-based cohort study, researchers evaluated 38,804 patients aged at least 20 years who underwent outpatient cardiac catheterization in Ontario, Canada, from October 2008 to September 2011 to evaluate stable ischemic heart disease. Participants were identified through data from the Cardiac Care Network of Ontario registry, and all had signs of CAD on angiography. Of the participants, 34,949 were considered to live in urban areas and 3,855 in rural areas, as indicated by the Rurality Index for Ontario scoring system.
The researchers evaluated and recorded the following categories of process measures:
- Receipt of diagnostic testing and procedures, including revascularization within 90 days of index angiogram; assessment of left ventricular ejection fraction; stress, exercise or nuclear stress testing; repeat cardiac catheterization; and cholesterol or HbA1c assessment.
- Access to physician care, as indicated by the total number of unique physician visits, cardiology visits, primary care consultations and general internal medicine visits per year.
- Receipt of ACE inhibitors, angiotensin II receptor blockers, beta-blockers, antiplatelet medication, aldosterone receptor blockers or statins within 1 year of index angiogram among patients aged at least 65 years.
The primary outcome was all-cause mortality at 1 year, with secondary outcomes including MI at 1 year, repeat cardiac or all-cause hospitalization and ED visits.
After risk adjustment, patients in rural settings were less likely to have undergone cholesterol evaluation (OR=0.41; 95% CI, 0.38-0.44) or HbA1c assessment (OR=0.41; 95% CI, 0.38-0.44) compared with patients in urban environments. Use of statins (OR=0.67; 95% CI, 0.57-0.79) was less common among patients in rural areas, whereas aldosterone receptor antagonist use was significantly more common (OR=1.24; 95% CI, 1.04-1.48).
Within the year after index angiogram, rural patients had fewer total overall physician visits (RR=0.76; 95% CI, 0.75-0.78), primary care visits (RR=0.76; 95% CI, 0.74-0.78) and cardiology visits (RR=0.71; 95% CI, 0.68-0.74) compared with urban patients. However, rural patients also presented to the ED more frequently (OR=1.82; 95% CI, 1.7-1.96).
Death occurred in 2.6% of the cohort within 1 year of index angiogram. The unadjusted mortality rate was significantly higher among rural patients (3.2% vs. 2.6%; P=.017), but the adjusted rates were similar between the groups. The rates of MI and hospitalization also were similar between rural and urban patients at 1 year.
“We found variations in processes of care and access to health services between urban and rural patients, but these variations did not seem to affect clinical outcomes,” the researchers concluded. “Greater study of the link between process of care metrics, outcomes and costs are needed in cardiac patients before widespread implementation of performance measures and associated incentives.”
Disclosure: The researchers report no relevant financial disclosures.