In our study, based on a community cohort of HF patients at the most advanced stages of the disease, we observed that mortality was 35% higher in those residing in rural setting. Being men, aged, and presenting higher comorbidity were also found to be related to a greater risk of dying. We found an inverse gradient in primary healthcare resources utilization regarding socio-economic deprivation among urban patients, those residing in the most deprived socio-economic areas had the highest health services utilization.
Compared to the rest of Europe, the population density in the study region is among one of the highest, the distribution is, however, irregular with more than 40% of the inhabitants concentrated in the metropolitan area of Barcelona. Although a number of small hospitals are distributed across the territory, most tertiary hospitals are located in this large metropolitan area which can limit accessibility of rural patients to highly specialized care.
With respect to place of residence, we did not observe differences in clinical characteristics or HF medication prescribed. Although rural women were slightly older, urban patients presented higher comorbidity and reported more social isolation. This last finding concurs with a previous study reporting that in a rural environment it is easier to rely on family members 26.
Although the bivariate analyses found statistical differences in the characteristics associated with mortality depending on rural or urban setting, these differences were not clinically relevant.
We found a considerable number of consultations, particularly with primary care nurses, among the urban patients living in the most deprived areas. In this regard, it has already been reported that low income and other psycho-social disadvantages imply greater healthcare resource utilization 27
The higher mortality described for men, older HF patients, and in those with decreased body mass index, chronic kidney disease, and lower blood pressure levels, concurs with previous studies, particularly in the advanced stages of the disease 28-30. Moreover, higher mortality in rural patients is in agreement with a previous study 6.
It has been hypothesized that populations residing in urban areas have better health due to easier accessibility to health services, in addition to better jobs and income 3.
Regarding cardiovascular diseases, inequalities in rural patients have been reported with respect to access to treatment, such as percutaneous coronary interventions, which require a longer travelling distance 31.
Another possible factor contributing higher mortality among rural HF patients in our sample could be the differences reported in the use of health services, although we cannot affirm that highest primary care services utilization by urban patients determines longer survival.
There is a widespread network of primary healthcare out-of-hours centers, nevertheless, its distribution and characteristics vary. These centers are more complete in large cities, offering services such as radiology and laboratory tests, which may improve the diagnosis and treatment of complications whilst in the rural areas more complex assistance needs to be provided in small hospitals.
Many rural patients lack daily access to their family doctors which can lead to delay in the treatment of decompensations. Urban primary healthcare centers are opened between 8 am and 8 pm every day, whilst many rural villages do not have general practitioner accessible all days, and population must travel long distances to be attended, especially in out of hours.
Other factors might be involved in explaining in these differences such as the decision to die at home allows patients to maintain control over their lives. The approach to the end of life could be culturally different in a rural setting compared to an urban one. A recent systematic review oriented to analyse the socio-economic factors determining the place of death found that dying at home was associated with living in rural areas but, potential causes remain unsolved. 32 Mean survival time among patients who died in our study was slightly higher among the urban ones. Nevertheless, considering the considerable limitations such patients undergo in their daily activities, it may be questioned whether this increased survival time is cost effective in terms of quality of life.
Evidence regarding socioeconomic deprivation among urban residents is controversial. Hawkins et al., employing a geographical composite deprivation index similar to ours, and analyzing data from 2000 to 2007, did not describe differences regarding outcomes in HF patients 33. In a more recent article, Witte et al., using the same deprivation index as Hawkins, reported that socioeconomic deprivation was linked to an increased risk of death in HF patients, but only as a consequence of non-cardiovascular causes 34. In addition, a study performed with the same population in our country showed a protective, although not significant, effect regarding mortality in the most deprived urban patients 17.
The National Health Service in our country provides universal healthcare, which may reduce social inequalities in health by facilitating access to primary care, prescriptions and hospitals to populations lacking economic resources, but the distribution of healthcare premises in rural and remote areas is conditioned by geographical limitations.
Nevertheless, future research will be needed to explain why, with no differences in either cardiovascular comorbidities or treatment, rural HF patients had the highest mortality rates.
Strengths and Limitations
Although different approaches have been employed to define rurality, our definition concurs with others used in similar articles. Nevertheless, due to data limitations, we could not fully discriminate the analyses between patients living in the most isolated areas from the other rural ones to ascertain whether differences in accessibility related to mortality are proportional to distance and frequency of healthcare service provision. The deprivation index used to study urban socioeconomic differences assumes homogeneity among the population living in the same geographical area, but may imply an ecological fallacy because it is possible to find both poor and affluent individuals in the same areas, sometimes divided by only one street. Moreover, we lack information in order to discriminate the presence of socio-economic differences within rural populations and thus considered them homogeneous in terms of social status.
Since administrative databases are used for clinical purposes can lead to missing data. In the case of HF some variables such as ejection fraction are not always available to have proper diagnoses according to guidelines35. Nevertheless in our study this fact is not relevant because all patients were at final stages of the disease. Regarding other possible missing values we performed multiple imputation models to minimize such an effect.
It would be advantageous to possess data regarding quality of life in order to analyze differences among rural and urban patients.
The results of our study are potentially valid for areas of the rest of our country with similar characteristics, concentrating population in large cities. Nevertheless, in Spain and in Europe there are many areas where the rural depopulation is remarkable, and the accessibility to healthcare services could be different.
Since our results are based on information coming from more than 80% of the Catalan population, it is expected to think that they could be extrapolated to the rest.
Prospective studies would be needed, not just to observe the presence of differences depending on the place of living but oriented towards specifically analyse their causes, to be more precise in measuring the differences in the accessibility, the characteristics of patients, exploring their perceptions and needs as well as their beliefs and preferences regarding the treatment received at the end of life.
To our knowledge, evidence about differences between rural and urban heart failure patients, particularly at advances stages of the disease is scarce. This article specifically analyse real world evidence from elderly HF patients at advanced stages of the disease through a large database.