title: Comparing the ambulatory care and outcomes for rural and urban patients with chronic ischemic heart disease: a population-based cohort study.
abstract: BACKGROUND
  Little is known about variations in the quality of ambulatory care between urban and rural communities for patients with stable ischemic heart disease. The objectives of this study were to understand the effect of rurality on variations of ambulatory processes of care and outcomes for patients with stable ischemic heart disease.
  
  
  RESULTS
  A population-based cohort study was conducted, which included all Ontario patients with stable ischemic heart disease confirmed on cardiac catheterization between October 1, 2008, and September 30, 2011. Patients were categorized as rural or urban based on the Rurality Index for Ontario score. Ambulatory processes of care of interest were diagnostic testing, medication usage, and access to general/speciality physicians over a 1-year time-horizon. Primary outcome was 1-year mortality. Secondary outcomes included 1-year myocardial infarction, repeat cardiac/all-cause hospitalization, and emergency department visits. The cohort consisted of 38 804 patients, of whom 34 949 (90%) were urban and 3855 (10%) were rural patients. After risk-adjustment, rural patients had lower rates of cholesterol assessment (odds ratios 0.41; 95% confidence interval [CI], 0.38-0.44; P<0.001), hemoglobin A1C assessment (odds ratios 0.41; 95% CI, 0.38-0.44; P<0.001), and statin use (odds ratios 0.67; 95% CI, 0.57-0.79; P<0.001) compared with urban patients. Rural patients had fewer total ambulatory physician visits (rate ratio 0.76; 95% CI, 0.75-0.78; P<0.001)), primary care (0.76; 95% CI, 0.74-0.78; P<0.001), and cardiology visits (0.71; 95% CI, 0.68-0.74; P<0.001) over 1 year. Emergency department utilization was higher among rural patients (odds ratios 1.82; 95% CI, 1.70-1.96; P<0.001), but myocardial infarction, hospitalization, and mortality rates were similar.
  
  
  CONCLUSIONS
  Despite variation in ambulatory processes of care between urban and rural patients with stable ischemic heart disease, there were no outcome differences.
authors.affiliation: From the Institute for Clinical Evaluative Sciences (C.T., H.C.W., F.Q., J.V.T., R.S.B.), Women's College Hospital Institute for Health Systems Solutions and Virtual Care (R.S.B.), Institute for Health Policy, Management and Evaluation (H.C.W., J.V.T., R.S.B.), Division of Cardiology, Sunnybrook Health Sciences Center (H.C.W., J.V.T.), and Peter Munk Cardiac Center of the University Health Network - Toronto General Hospital (R.S.B.), University of Toronto Medical School, University of Toronto, Toronto, Ontario, Canada (C.T.).
authors.forename: Christopher
authors.initials: C
authors.lastname: Tran
authors.affiliation: From the Institute for Clinical Evaluative Sciences (C.T., H.C.W., F.Q., J.V.T., R.S.B.), Women's College Hospital Institute for Health Systems Solutions and Virtual Care (R.S.B.), Institute for Health Policy, Management and Evaluation (H.C.W., J.V.T., R.S.B.), Division of Cardiology, Sunnybrook Health Sciences Center (H.C.W., J.V.T.), and Peter Munk Cardiac Center of the University Health Network - Toronto General Hospital (R.S.B.), University of Toronto Medical School, University of Toronto, Toronto, Ontario, Canada (C.T.).
authors.forename: Harindra C
authors.initials: HC
authors.lastname: Wijeysundera
authors.affiliation: From the Institute for Clinical Evaluative Sciences (C.T., H.C.W., F.Q., J.V.T., R.S.B.), Women's College Hospital Institute for Health Systems Solutions and Virtual Care (R.S.B.), Institute for Health Policy, Management and Evaluation (H.C.W., J.V.T., R.S.B.), Division of Cardiology, Sunnybrook Health Sciences Center (H.C.W., J.V.T.), and Peter Munk Cardiac Center of the University Health Network - Toronto General Hospital (R.S.B.), University of Toronto Medical School, University of Toronto, Toronto, Ontario, Canada (C.T.).
authors.forename: Feng
authors.initials: F
authors.lastname: Qui
authors.affiliation: From the Institute for Clinical Evaluative Sciences (C.T., H.C.W., F.Q., J.V.T., R.S.B.), Women's College Hospital Institute for Health Systems Solutions and Virtual Care (R.S.B.), Institute for Health Policy, Management and Evaluation (H.C.W., J.V.T., R.S.B.), Division of Cardiology, Sunnybrook Health Sciences Center (H.C.W., J.V.T.), and Peter Munk Cardiac Center of the University Health Network - Toronto General Hospital (R.S.B.), University of Toronto Medical School, University of Toronto, Toronto, Ontario, Canada (C.T.).
authors.forename: Jack V
authors.initials: JV
authors.lastname: Tu
authors.affiliation: From the Institute for Clinical Evaluative Sciences (C.T., H.C.W., F.Q., J.V.T., R.S.B.), Women's College Hospital Institute for Health Systems Solutions and Virtual Care (R.S.B.), Institute for Health Policy, Management and Evaluation (H.C.W., J.V.T., R.S.B.), Division of Cardiology, Sunnybrook Health Sciences Center (H.C.W., J.V.T.), and Peter Munk Cardiac Center of the University Health Network - Toronto General Hospital (R.S.B.), University of Toronto Medical School, University of Toronto, Toronto, Ontario, Canada (C.T.). sacha.r.bhatia@wchospital.ca.
authors.forename: R Sacha
authors.initials: RS
authors.lastname: Bhatia
mesh_terms: D000368:Aged; D000553:Ambulatory Care / Q000379:methods*; D006328:Cardiac Catheterization; D002908:Chronic Disease; D017023:Coronary Angiography; D005260:Female; D005500:Follow-Up Studies; D006297:Health Services Accessibility / Q000639:trends*; D006801:Humans; D008297:Male; D009017:Morbidity / Q000639:trends; D017202:Myocardial Ischemia / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D009864:Ontario / Q000453:epidemiology; D011159:Population Surveillance / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012424:Rural Population; D016896:Treatment Outcome; D014505:Urban Population
keywords: ambulatory care; coronary artery disease; health services research; quality improvement; rural