Quality of care for acute myocardial infarction in rural and urban US hospitals.
BACKGROUND
Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care.


OBJECTIVE
To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers.


METHODS
This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality.


RESULTS
Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals' patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]).


CONCLUSIONS
Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI.
Baldwin
Laura-Mae
LM
University of Washington, Department of Family Medicine, Box 354982, Seattle, WA 98195, USA. lmb@fammed.washington.edu
MacLehose
Richard F
RF
Hart
L Gary
LG
Beaver
Shelli K
SK
Every
Nathan
N
Chan
Leighton
L
D000368:Aged; D015331:Cohort Studies; D005260:Female; D019538:Health Care Surveys; D006742:Hospital Bed Capacity / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006780:Hospitals, Rural / Q000592:standards*; D006786:Hospitals, Urban / Q000592:standards*; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D010343:Patient Admission / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology