Context: 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.
Purpose: 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
Findings: 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.