Background. Prior studies suggest rural patients are less likely to receive coronary procedures. This finding may represent the fact that rural patients live further than urban patients from the closest cath lab, but these studies failed to incorporate a direct measure of distance to cath lab. Accordingly, we incorporated patient distance to cath lab with rural location on the likelihood to undergo elective coronary angiography as a better explanation of this relationship. Methods. Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all patients who underwent elective coronary angiography from October 2007 through September 2010. We calculated geodesic distance from patient home to cath. Patient rural status was determined using the VA Urban/Rural/Highly Rural (URH) system. Normal coronary angiography (an indirect measure of patient selection for elective coronary angiography) was defined as <20% stenosis in all vessels. Using generalized linear mixed modeling, we estimated the probability of angiographically normal coronaries as a function of distance to cath, modified by patient rural status. Results. Among 22,523 patients undergoing elective coronary angiography, 22.8% of patients had normal coronaries. Rural patients were more likely to have high Framingham risk (highly rural 44.2% vs. rural 39.8% vs. urban 36.9%, p<0.001). Rural patients who lived further from cath labs were associated with a lower probability of normal coronaries compared to rural patients closer to cath labs and urban patients across all distances(p=0.0014). For patients living within 50 miles of a cath lab, urban/rural status did not influence the probability of normal coronary angiography. From 50 to 150 miles, rural patients were less likely to have normal coronaries at angiography. (Figure 1). Conclusions. Among patients undergoing elective angiography in the VA, those who lived further from cath labs in rural locations were less likely to have normal coronaries. These findings suggest that patient location, rather than clinical factors, may affect the use of coronary procedures. Further study to understand the causes of this relationship, including potential for under- or over-use based on distance and rural status, may help optimize patient access for coronary procedures.
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