Urban-rural differences in mortality for atrial fibrillation hospitalizations in the United States

Published:December 10, 2017DOI:


      Cardiovascular outcomes vary between urban and rural hospitals, with worse outcomes in rural settings.


      The purpose of this study was to examine whether in-hospital mortality for hospitalization for atrial fibrillation (AF) varied between urban and rural hospitals.


      A cross-sectional examination of patients who were hospitalized for AF was performed in the National Inpatient Sample between 2012 and 2014 to compare in-hospital mortality in patients admitted to urban vs rural hospitals. Patients with a principal International Classification of Diseases, Ninth Revision discharge diagnosis of AF were included. Hospitals were classified as urban or rural on the basis of core-based statistical areas. In-hospital mortality was defined as death due to any cause during hospitalization.


      A total of 248,731 (mean age 69 years; 78% white; 48% women) admissions for AF were identified. Of these, 218,946 (88%) were from urban hospitals and 29,785 (12%) were from rural hospitals. Patients admitted to rural hospitals had a 17% increased risk of death as compared with those admitted to urban hospitals in a multivariable model, which accounted for differences in patient characteristics and potential confounders (odds ratio 1.17; 95% confidence interval 1.04–1.32). Similar results were obtained in a propensity score–matched analysis and in subgroup analyses by sex, race, and region.


      In-hospital mortality of AF is higher in rural hospitals than in urban hospitals. Further research is needed to understand this finding and to develop targeted strategies to reduce mortality in patients admitted for AF in rural hospitals.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Go A.S.
        • Hylek E.M.
        • Phillips K.A.
        • Chang Y.
        • Henault L.E.
        • Selby J.V.
        • Singer D.E.
        Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study.
        JAMA. 2001; 285: 2370-2375
        • Patel N.J.
        • Deshmukh A.
        • Pant S.
        • et al.
        Contemporary trends of hospitalization for atrial fibrillation in the United States, 2000 through 2010: implications for healthcare planning.
        Circulation. 2014; 129: 2371-2379
        • Sheikh K.
        • Bullock C.
        Urban-rural differences in the quality of care for Medicare patients with acute myocardial infarction.
        Arch Intern Med. 2001; 161: 737-743
        • Baldwin L.M.
        • MacLehose R.F.
        • Hart L.G.
        • Beaver S.K.
        • Every N.
        • Chan L.
        Quality of care for acute myocardial infarction in rural and urban US hospitals.
        J Rural Health. 2004; 20: 99-108
        • Baldwin L.M.
        • Chan L.
        • Andrilla C.H.
        • Huff E.D.
        • Hart L.G.
        Quality of care for myocardial infarction in rural and urban hospitals.
        J Rural Health. 2010; 26: 51-57
        • Gamble J.M.
        • Eurich D.T.
        • Ezekowitz J.A.
        • Kaul P.
        • Quan H.
        • McAlister F.A.
        Patterns of care and outcomes differ for urban versus rural patients with newly diagnosed heart failure, even in a universal healthcare system.
        Circ Heart Fail. 2011; 4: 317-323
        • Kulshreshtha A.
        • Goyal A.
        • Dabhadkar K.
        • Veledar E.
        • Vaccarino V.
        Urban-rural differences in coronary heart disease mortality in the United States: 1999-2009.
        Public Health Rep. 2014; 129: 19-29
        • Teng T.H.
        • Katzenellenbogen J.M.
        • Hung J.
        • Knuiman M.
        • Sanfilippo F.M.
        • Geelhoed E.
        • Hobbs M.
        • Thompson S.C.
        Rural-urban differentials in 30-day and 1-year mortality following first-ever heart failure hospitalisation in Western Australia: a population-based study using data linkage.
        BMJ Open. 2014; 4: e004724
        • Flaker G.C.
        • McGowan D.J.
        • Boechler M.
        • Fortune G.
        • Gage B.
        Underutilization of antithrombotic therapy in elderly rural patients with atrial fibrillation.
        Am Heart J. 1999; 137: 307-312
        • Slifkin R.T.
        • Randolph R.
        • Ricketts T.C.
        The changing metropolitan designation process and rural America.
        J Rural Health. 2004; 20: 1-6
        • Moore B.J.
        • White S.
        • Washington R.
        • Coenen N.
        • Elixhauser A.
        Identifying increased risk of readmission and in-hospital mortality using hospital administrative data: the AHRQ Elixhauser Comorbidity Index.
        Med Care. 2017; 55: 698-705
        • Quan H.
        • Parsons G.A.
        • Ghali W.A.
        Validity of information on comorbidity derived rom ICD-9-CCM administrative data.
        Med Care. 2002; 40: 675-685
        • Krumholz H.M.
        • Wang Y.
        • Mattera J.A.
        • Wang Y.
        • Han L.F.
        • Ingber M.J.
        • Roman S.
        • Normand S.L.
        An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with heart failure.
        Circulation. 2006; 113: 1693-1701
        • Rochlani Y.M.
        • Shah N.N.
        • Pothineni N.V.
        • Paydak H.
        Utilization and predictors of electrical cardioversion in patients hospitalized for atrial fibrillation.
        Cardiol Res Pract. 2016; 2016: 8956020
        • Kneeland P.P.
        • Fang M.C.
        Trends in catheter ablation for atrial fibrillation in the United States.
        J Hosp Med. 2009; 4: E1-E5
        • Fauchier L.
        • Samson A.
        • Chaize G.
        • Gaudin A.F.
        • Vainchtock A.
        • Bailly C.
        • Cotte F.E.
        Cause of death in patients with atrial fibrillation admitted to French hospitals in 2012: a nationwide database study.
        Open Heart. 2015; 2: e000290
        • Rogers W.J.
        • Frederick P.D.
        • Stoehr E.
        • Canto J.G.
        • Ornato J.P.
        • Gibson C.M.
        • Pollack Jr., C.V.
        • Gore J.M.
        • Chandra-Strobos N.
        • Peterson E.D.
        • French W.J.
        Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006.
        Am Heart J. 2008; 156: 1026-1034
        • Chen J.
        • Dharmarajan K.
        • Wang Y.
        • Krumholz H.M.
        National trends in heart failure hospital stay rates, 2001 to 2009.
        J Am Coll Cardiol. 2013; 61: 1078-1088
        • Chan L.
        • Hart L.G.
        • Goodman D.C.
        Geographic access to health care for rural Medicare beneficiaries.
        J Rural Health. 2006; 22: 140-146
        • Casey M.M.
        • Thiede Call K.
        • Klingner J.M.
        Are rural residents less likely to obtain recommended preventive healthcare services?.
        Am J Prev Med. 2001; 21: 182-188
        • Alonso A.
        • Agarwal S.K.
        • Soliman E.Z.
        • Ambrose M.
        • Chamberlain A.M.
        • Prineas R.J.
        • Folsom A.R.
        Incidence of atrial fibrillation in whites and African-Americans: the Atherosclerosis Risk in Communities (ARIC) study.
        Am Heart J. 2009; 158: 111-117