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Comparing the ambulatory care and outcomes for rural and urban patients with chronic ischemic heart disease: a population-based cohort study

Tran C, Wijeysundera HC, Qui F, Tu JV, Bhatia RS. Circ Cardiovasc Qual Outcomes. 2014; 7(6):835-43. Epub 2014 Oct 28.

Background — Little is known about variations in the quality of ambulatory care between urban and rural communities for patients with stable ischemic heart disease (SIHD). The objectives of this study were to understand the impact of rurality on variations of ambulatory processes of care and outcomes for patients with SIHD.

Methods and Results — A population-based cohort study was conducted, which included all Ontario patients with SIHD confirmed on cardiac catheterization between Oct 1, 2008 and Sept 30, 2011. Patients were categorized as rural or urban based on the Rurality Index for Ontario (RIO) score. Ambulatory processes of care of interest were diagnostic testing, medication usage, and access to general/speciality physicians over a 1-year time-horizon. Primary outcome was 1-year mortality. Secondary outcomes included 1-year myocardial infarction (MI), repeat cardiac/all-cause hospitalization, and emergency department (ED) visits. The cohort consisted of 38,804 patients, of whom 34,949 (90%) were urban and 3,855 (10%) were rural patients. After risk-adjustment, rural patients had lower rates of cholesterol assessment (Odds Ratios (OR) 0.41, 95% CI [0.38-0.44], p<0.001), HbA1c assessment (OR 0.41, 95% CI [0.38-0.44], p<0.001), and statin use (OR 0.67, 95% CI [0.57-0.79], p<0.001) compared to urban patients. Rural patients had fewer total ambulatory physician visits (Rate Ratio (RR) (0.76, 95% CI [0.75, 0.78], p<0.001)), primary care (0.76, 95% CI [0.74, 0.78], p<0.001) and cardiology visits (0.71, 95% CI [0.68, 0.74], p<0.001) over one year. ED utilization was higher among rural patients (OR 1.82, 95% CI [1.70-1.96], p<0.001), but MI, hospitalization and mortality rates were similar.

Conclusions — Despite variation in ambulatory processes of care between urban and rural patients with SIHD, there were no outcome differences.

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Keywords: Ambulatory care Coronary disease/Myocardial infarction Rural/northern health services