Rural-urban disparities in the management and outcomes of atrial fibrillation in emergency departments in Canada

Background — In a universal health care system, geographic disparities in atrial fibrillation (AF) outcomes remain poorly understood. This study aimed to evaluate rural-urban differences in clinical outcomes among patients presenting to the emergency department (ED) with AF.

Methods — We conducted a population-based retrospective cohort study of all adults (aged ≥18 years) presenting to an ED in Ontario, Canada, with a primary diagnosis of AF between April 1, 2012, and March 31, 2022. Rural residence was defined as living in a community with a population of ≤10 000. The primary outcome was a composite of all-cause mortality or hospital admission within 1 year; secondary outcomes included the individual components of the primary outcome and all-cause ED visits. Comparisons were adjusted for demographics and baseline comorbidities using inverse probability of treatment weighting. Cox regression was used for end points that included death.

Results — Among 104 195 eligible patients, 16 860 (16.2%) resided in rural communities. After inverse probability of treatment weighting, baseline characteristics were well balanced (standardized differences <0.1) as the mean age was 69.4 years in rural and urban groups; 47.2% were women in the rural group versus 47.1% in the urban group. Within 1 year, patients with AF presenting to the ED in rural Ontario had higher rate of all-cause mortality or admission compared with the urban group (34.6% versus 33.5%; hazard ratio, 1.04 [95% CI, 1.01-1.07]), driven primarily by increased hospital admission rates (31.3% versus 29.7%; hazard ratio, 1.06 [95% CI, 1.03-1.09]). ED visit rates were higher in rural patients (63.8% versus 55.3%; hazard ratio, 1.27 [95% CI, 1.25-1.30]), while mortality was similar (9.8% versus 9.9%; hazard ratio, 1.00 [95% CI, 0.95-1.04]).

Conclusions — Despite universal health care coverage, rural-urban disparities in AF outcomes persist. Rural patients with AF had higher acute care utilization compared with urban patients. System interventions are needed to address inequities for rural populations.