Invasive Management and In-Hospital Outcomes of Myocardial Infarction Patients in Rural Versus Urban Hospitals in the United States

Abstract

ObjectivesThe variation in the management and outcome of acute myocardial infarction (AMI) between rural and urban settings has been previously recognized, but there has previously been no nationwide data reported that is inclusive of the whole adult population. MethodsAll discharge records between 2004 and 2018 with AMI diagnosis were extracted from the National Inpatient Sample (NIS) database and stratified by hospital location. The primary outcome was in-hospital mortality, and secondary outcomes included (a) major adverse cardiovascular and cerebrovascular events (MACCE), (b) major bleeding, (c) acute ischemic stroke, the utilization of invasive management in the form of (d) coronary angiography (CA), and (e) percutaneous coronary intervention (PCI). The adjusted odds ratios (aOR) and 95 % confidence interval (95 % CI) were determined using multivariable logistic regression. Results9,728,878 records with AMI were identified, of which 1,011,637 (10.4 %) discharges were from rural hospitals. Rural patients were older (median of 71 years vs. 67 years, p < 0.001) and had lower prevalence of the highest risk presentations of AMI than their urban counterparts. After multivariable adjustment, patients from rural hospitals had increased aOR of all-cause mortality (aOR 1.15 95 % CI 1.13–1.16) and MACCE (aOR 1.04 95 % CI 1.04–1.05), as well as the decreased aOR of coronary angiography (aOR 0.29, 95 % CI 0.29–0.29, p < 0.001) and PCI (aOR 0.40, 95 % CI 0.39–0.40, p < 0.001), compared to their urban counterparts. ConclusionBetween 2004 and 2018, the risk of in-hospital mortality and MACCE in AMI patients was significantly higher in rural hospitals, with considerably lower utilization of invasive angiography and revascularization.