Intersection of Patient and Hospital Rurality in Heart Failure Care and Outcomes

Importance: Rural-urban disparities in heart failure (HF) care delivery and outcomes are well documented. However, it remains unclear if differences in outcomes after HF hospitalization are primarily driven by patient rural residence, hospital resources, or both. Objective: To evaluate associations of patient and hospital rurality with quality of care and postdischarge outcomes after hospitalization for HF with reduced ejection fraction (HFrEF). Design, Setting, and Participants: This was a retrospective cohort study of Medicare beneficiaries in US hospitals with HFrEF with an index hospitalization from January 1, 2013, to December 31, 2021. Included were Medicare beneficiaries discharged alive after an index hospitalization for HFrEF. Participants were classified as rural patients hospitalized in rural hospitals (rural-rural), rural patients in urban hospitals (rural-urban), urban patients in urban hospitals (urban-urban), and urban patients in rural hospitals (urban-rural). Study data were analyzed from July to September 2026. Exposures: Patient rural residence and hospital rurality. Main Outcomes and Measures: Primary outcome was 90-day all-cause mortality after hospitalization. Secondary outcomes included inpatient cardiology consultation, 90-day postdischarge guideline-directed medical therapy (GDMT) use based on prescription fills, and HF readmission at 30 days, 90 days, and 1 year. Results: Among 735 460 beneficiaries (median [IQR] age, 77 [70-85] years; 415 077 male [56.4%]), 69 061 (9.4%) were rural-rural, 65 510 (8.9%) rural-urban, 582 947 (79.3%) urban-urban, and 17 942 (2.4%) urban-rural. Compared with rural patients treated in rural hospitals, rural patients treated in urban hospitals were more likely to receive inpatient cardiology consultation (odds ratio [OR], 2.02; 95% CI, 1.84-2.22) and initiation of several GDMT classes, including β-blockers (OR, 1.20; 95% CI, 1.16-1.25), ARNIs (OR, 1.23; 95% CI, 1.13-1.34), MRAs (OR, 1.23; 95% CI, 1.15-1.31), and SGLT2Is (OR, 1.48; 95% CI, 1.32-1.67). They also had lower rates of HF readmission and mortality at all time points (HF readmission 1-year: OR, 0.85; 95% CI, 0.82-0.88; mortality 1-year: OR, 0.91; 95% CI, 0.89-0.94) than rural-rural patients. Compared with urban patients hospitalized at urban hospitals, rural patients hospitalized at urban hospitals more often received inpatient cardiology consultation (OR, 1.38; 95% CI, 1.31-1.44), whereas postdischarge GDMT differences were modest (absolute difference in GDMT score 0.09 points; 95% CI, 0.05-0.14). Rural patients also had lower HF readmission (1-year OR, 0.81; 95% CI, 0.79-0.82) but higher 30- and 90-day mortality than urban patients (30-day OR, 1.10; 95% CI, 1.06-1.14; 90-day OR, 1.05; 95% CI, 1.02-1.08). Conclusions and Relevance: Results suggest that hospital rurality was associated with lower odds of GDMT use and higher rates of all-cause mortality, whereas rural residence was associated with mortality differences despite treatment in urban hospitals. Interventions addressing both inpatient resource disparities and postdischarge transitions of care may reduce rural-urban inequities in HF outcomes.