2. Quality of Care and In-Hospital Outcomes in Patients With Coronary Heart Disease in Rural and Urban Hospitals (from Get With the Guidelines– Coronary Artery Disease Program) Amrut V. Ambardekar, MD, Gregg C. Fonarow, MDc, David Dai, PhD, Eric D. Peterson, MD, MPH, Adrian F. Hernandez, MD, MHS, Christopher P. Cannon, MD, and Mori J. Krantz, MD

3. Background Previous reports have demonstrated that participation in Get With The Guidelines- Coronary Artery Disease(GWTG-CAD), a national quality initiative of the American Heart Association, is associated with improved guideline adherence for patients hospitalized with CAD. We sought to establish whether these benefits from participation in GWTG-CAD were sustained over time.

4. Introduction Previous studies have suggested that patients with coronary artery disease (CAD) in rural areas may have worse outcomes due to limited availability of specialists, fewer resources, and less institutional funding. Based on 2000 US census data, 6.4% of the US population resides in rural areas within towns of 10,000 residents and another 10.1% live in areas of 10,000 to 50,000 residents.

5. Objective The present study sought to determine the characteristics, treatments, quality of care, and in- hospital outcomes of patients with CAD treated in rural versus urban hospitals participating in the Get With the Guidelines–Coronary Artery Disease Program (GWTG- CAD).

6. Methods Data were collected from 22,096 patients at 71 rural centers and 329,938 patients at 477 urban centers from January 2000 to December 2008. The hospitals were participating in the Get With the Guidelines– Coronary Artery Disease Program (GWTGCAD) In-hospital outcomes and quality of care were stratified by care at rural versus urban hospitals. Multivariate logistic regression analysis was used to determine the association of rural locale with in-hospital mortality, length of stay, and compliance with the GWTG-CAD performance measurements. These performance measurements include: (1) early aspirin use, (2) smoking cessation counseling and discharge prescriptions (3) aspirin, (4) ACE-I, or ARBs for left ventricular systolic dysfunction, (5) -blockers, and (6) lipid-lowering therapy and a composite of all 6 measurements.

7. Results Unadjusted rates of compliance with performance measurements were lower in rural (range 82.4% to 90.5%) compared to urban (range 81.3% to 95.0%) hospitals including the composite (74.7% vs. 80.6%, p <0.0001). In multivariate analysis, rural status was not independently associated with lower compliance with any of the performance measurements. Unadjusted mortality rates were higher in rural versus urban hospitals (5.7% vs. 4.4%, p <0.0001), but this was not significant in multivariate analysis (odds ratio 1.05, 95% confidence interval 0.87 to 1.26).

8. Limitations The GWTG-CAD is a voluntary program and could over- represent high-performing hospitals. Data were collected by chart review and thus depend on the accuracy and completeness of documentation. Rural centers were defined as being located outside a CBSA, so only areas of 10,000 residents were considered rural in this analysis. CBSAs are based on population density, and data regarding physician practice patterns, patient transfer patterns, and per-capita specialist availability are lacking. Critical-access hospital status was not determined. Critical- access hospitals have very limited resources and are only beginning the accreditation process, so greater disparities could exist in this setting. The GWTG-CAD database does not track inpatient provider specialty, and this may influence mortality, length of stay, and quality of care.

9. Conclusion Within the GWTG-CAD quality improvement initiative, patients with CAD treated at rural hospitals receive similar quality of care and have similar outcomes as those at urban centers.