Provider Density and Systemic Contributors to Rural Cardiovascular Disease Mortality in New England
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Introduction
Rural disparities in cardiovascular disease (CVD)-related mortality may be compounded by limited access to primary care and specialist providers. This study sought to quantify the relationship between CVD-related mortality and the availability of providers in rural and non-rural areas of New England, with consideration of systemic socioeconomic factors.
Methods
Thirty-day mortality rates for inpatient heart failure (HF) and heart attacks (HA) at 182 hospitals in the New England region from July 1, 2019, to June 30, 2022, were analyzed using data from the Centers for Medicare and Medicaid Services. Provider density was derived from the Area Health Resource Database. Differences in mortality rates and provider densities between rural and non-rural areas were assessed using ANOVA models. General linear models were employed to explore the relationships between provider density and mortality outcomes, both with and without adjustments for socioeconomic confounders such as median income, median age, poverty, educational attainment, and racial demographics.
Results
Rural counties had a significantly lower density of cardiologists than non-rural counties (B = -0.612, p < .001) which persisted when socioeconomic confounders were included in the model (B = 0.418, p = 0.023). A similar effect was not observed for primary care provider (PCP) density. Rural hospitals also exhibited significantly higher 30-day HF mortality rates compared to non-rural hospitals (B = 1.671, p < .001), yet this disparity diminished when structural factors were included in the model (B = 0.161, p = .692). No significant difference in HA mortality rates was observed between rural and non-rural hospitals (B = -0.52, p = .897). Cardiologist density was significantly associated with HF mortality in unadjusted models (B = -0.634, p < .001), but its effect weakened after controlling for confounders (B = -0.298, p = .100). Relationships between PCP density and HA mortality were not significant.
Conclusion
Rural disparities in heart failure mortality in New England persist, likely due in part to insufficient access to cardiologists to provide appropriate long-term care for chronic cardiovascular conditions. There exists a complex intersection between socioeconomic gradients and rurality, underscoring the importance of addressing structural inequities to reduce rural-urban health disparities. Furthermore, greater emphasis needs to be placed on workforce innovations in the recruitment, retention, distribution, and support of rural specialist physicians.
