Cardiovascular medication utilization and adherence among heart failure patients in rural and urban areas: a retrospective cohort study.

BACKGROUND: Rural residence is a negative prognostic factor for heart failure (HF). The objective was to explore rural and urban differences in the utilization, adherence, and persistence with medications, and mortality among incident HF patients. METHODS: Using administrative databases from Alberta (Canada), subjects > 65 years old with a first hospitalization for HF between 1999 and 2008 who survived ≥ 90 days after discharge were identified. Pharmacy claims for renin-angiotensin system (RAS) agents, ß-blockers (BBs), digoxin, or spironolactone were identified. The association between rural and urban residence and medication utilization, adherence (optimal adherence defined as ≥ 80% adherence over 1 year), persistence, and 1-year mortality was assessed. RESULTS: The cohort included 10,430 patients, with a mean age of 80.2 (SD, 7.7) years, 47% were male, and 25% were rural residents. Rural residents were less likely to receive RAS agents (74% vs 79%, adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.69-0.89) or BBs (44% vs 54%; aOR, 0.83; 95% CI, 0.73-0.93) than urban residents, but had similar use of other medications. Although < 69% of patients who received RAS agents and 53% who received BBs had optimal adherence, few differences in adherence or persistence were detected among patients in rural vs urban areas. The 1-year mortality rate was significantly lower for patients who demonstrated optimal adherence to RAS agents or BBs (aOR, 0.78; 95% CI, 0.65-0.94) with no significant differences in the first 6 months between patients residing in rural vs urban areas. CONCLUSIONS: Rural residents with HF were less likely to receive RAS agents or BBs, but few differences in adherence were noted compared with their urban counterparts. Suboptimal adherence with evidence-based HF therapy was associated with increased risk of mortality.

Cardiovascular medication utilization and adherence among adults living in rural and urban areas: a systematic review and meta-analysis.

BACKGROUND: Rural residents face numerous barriers to healthcare access and studies suggest poorer health outcomes for rural patients. Therefore we undertook a systematic review to determine if cardiovascular medication utilization and adherence patterns differ for rural versus urban patients. METHODS: A comprehensive search of major electronic datasets was undertaken for controlled clinical trials and observational studies comparing utilization or adherence to cardiovascular medications in rural versus urban adults with cardiovascular disease or diabetes. Two reviewers independently identified citations, extracted data, and evaluated quality using the STROBE checklist. Risk estimates were abstracted and pooled where appropriate using random effects models. Methods and reporting were in accordance with MOOSE guidelines. RESULTS: Fifty-one studies were included of fair to good quality (median STROBE score 17.5). Although pooled unadjusted analyses suggested that patients in rural areas were less likely to receive evidence-based cardiovascular medications (23 studies, OR 0.88, 95% CI 0.79, 0.98), pooled data from 21 studies adjusted for potential confounders indicated no rural-urban differences (adjusted OR 1.02, 95% CI 0.91, 1.13). The high heterogeneity observed (I(2) = 97%) was partially explained by treatment setting (hospital, ambulatory care, or community-based sample), age, and disease. Adherence did not differ between urban versus rural patients (3 studies, OR 0.94, 95% CI 0.39, 2.27, I(2) = 91%). CONCLUSIONS: We found no consistent differences in rates of cardiovascular medication utilization or adherence among adults with cardiovascular disease or diabetes living in rural versus urban settings. Higher quality evidence is needed to determine if differences truly exist between urban and rural patients in the use of, and adherence to, evidence-based medications.