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

作者：Emily P. Zeitler, Joanna M. Joly, Christopher Leggett, Sandra L. Wong, A. James O’Malley, Sally A Kraft, Matthew B. Mackwood, Sarah T. Jones, Jonathan Skinner · 发表于：The Journal of Rural Health · 年份：2023 · DOI：10.1111/jrh.12803 · 被引用次数：8 · 研究领域：Heart Failure Treatment and Management、Chronic Disease Management Strategies、Acute Myocardial Infarction Research

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 f...