Abstract 4367909: Distance as a Determinant: The Negative Impact of Rurality on Health Outcomes Among Adults with Congenital Heart Disease on Medicaid

Introduction: Access to specialized care is associated with improved health outcomes for adults with congenital heart disease (CHD). Accordingly, proximity to an ACHD-accredited medical center represents an important social determinant of health that needs recognition. Research Question/ Hypothesis: In the United States, ACHD-accredited centers are overwhelmingly located in major cities. In this study, we sought to understand how urban versus rural residence may influence health outcomes among adults with CHD on Medicaid insurance, which is a strong proxy for poverty in the U.S. Methods: The Transformed Medicaid Statistical Information System (T-MSIS) collects comprehensive public health insurance data from 48 states (Medicaid and Children's Health Insurance Program). We identified 306,843 adults (>18 years of age) with ICD-10 diagnosis codes consistent with CHD spanning the years 2016-2018, all of whom are Medicaid recipients. Rurality of residence was classified according to the Rural-Urban Commuting Area (RUCA) coding system, which draws from ZIP code and population density data, as well as national commuting patterns. Descriptive statistics were used to compare groups. Results: Of the 306,843 adults with CHD studied, 63.1% were female with a mean age of 42.0±19.3 years. Per RUCA categorization, 17.3% lived rurally ( Figure 1 ). 26.8% had moderate or severe complexity of CHD, and a higher proportion of those lived in a rural area (28.3% vs. 26.5%) [p<0.001]. Rural residence was associated with lower income than urban residence, with 86.8% of rural participants earning ≤100% of the federal poverty level (urban: 80.6%). Those living rurally also had a higher burden of disability (30.3% vs. 25.4%) [p<0.001] and higher rates of comorbidities, including any mental health diagnosis (51.4% vs. 43.9%), coronary artery disease (28.2% vs. 23.9%), and hypertension (50.0% vs. 44.3%) [p<0.001 for all]. Utilization of emergency care was higher in those from rural residence (51.8% vs. 49.1%) [p<0.001]. Discussion: Rural residence among adults with CHD represents a barrier to care that may exacerbate health disparities in a medically complex patient population with high healthcare utilization. In our study, we found that rurality is associated with lower income, greater prevalence of moderate and complex CHD, more comorbid conditions, and higher burden of disability.