Too Many HF Patients Exiting Rural Hospitals Miss Out on Endorsed Therapies

GWTG-HF registry data show urban centers are more apt to prescribe CRT, ACE inhibitors/ARBs, and ARNIs at discharge.

Too Many HF Patients Exiting Rural Hospitals Miss Out on Endorsed Therapies

Patients treated for heart failure (HF) at rural hospitals in the United States are less likely to be discharged on certain guideline-recommended therapies than those hospitalized at urban centers, contemporary registry data show.

Prescriptions for cardiac resynchronization therapy (CRT), ACE inhibitors/ARBs, and angiotensin receptor–neprilysin inhibitors (ARNIs) all fell short, though there was seemingly no impact on in-hospital or 30-day mortality, or on readmissions.

“We found that most quality-of-care measures were similar between rural and urban hospitals, but we did find some that were notably different,” senior study author Stephen J. Greene, MD (Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC), told TCTMD. He noted that while numerous prior studies have explored rural versus urban outcomes, including HF mortality, these didn’t take as a close look at the quality of care patients receive during their hospital stay.

In the current analysis, “some of the differences we found were actually for very important therapies . . . . that are all definitively proven for reducing risk of mortality and heart failure readmission,” he noted. Other studies, such as STRONG-HF, have demonstrated that starting and uptitrating guideline-directed therapies at the time of heart failure hospitalizations can improve clinical outcomes down the road.

And while there were no ill effects seen at the 30-day time point, what happens at discharge can set the course for later access to therapy and perhaps explains some gaps that have been seen in long-term outcomes, Greene explained. “Not discharging someone on therapy despite eligibility really destines them to never getting that therapy prescribed at all or at best getting it with a significant delay.”

The results, from an analysis of more than a quarter million patients in the Get With The Guidelines–Heart Failure (GWTG-HF) registry, were published online recently in JAMA Cardiology, ahead of their presentation at the upcoming American College of Cardiology/World Congress of Cardiology (ACC/WCC) 2023 meeting.

“We need to think of heart failure hospitalization as an opportunity. Yes, the patient is unfortunately not feeling well, they’re in the hospital, but we need to take advantage of the hospitalization to initiate and titrate therapies proven to reduce mortality, proven to reduce readmission,” Greene stressed, referring to discharge as a “pivotal time point.”


Led by Jacob B. Pierce, MD, MPH (Duke University School of Medicine), who will present the data at ACC/WCC 2023, the researchers analyzed data on 774,419 patients (median age 73 years; 47.3% female) in the GWTG-HF registry who were hospitalized for HF between January 2014 and September 2021 across 569 US sites. Most of the hospitals (91.4%) were urban. Accordingly, 97.4% of patients were hospitalized at urban centers and 2.6% at rural centers. The rural hospitals were more often in the Midwest and South, less likely to be teaching hospitals, and less likely to offer interventional cardiac catheterization and heart transplantation.

Individuals admitted to rural hospitals tended to be slightly older (median age 74 vs 73 years) and were more apt to be non-Hispanic white (73.5% vs 66.1%) than those in urban areas. Patients in the rural group were also less likely to have a hospital stay lasting 4 days or longer (adjusted OR 0.75; 95% CI 0.67-0.85).

Adjusted for baseline differences in patient and hospital characteristics, patients treated at rural centers were less likely to be prescribed CRT, ACE inhibitors/ARBs, and ARNIs at discharge but more apt to receive hydralazine/nitrate. There were no imbalances when it came to beta-blockers and mineralocorticoid receptor antagonists.

HF Therapies at Discharge: Rural vs Urban Hospitals


Adjusted Risk Difference

Adjusted OR (95% CI)



0.44 (0.22-0.92)

ACE Inhibitor/ARB


0.71 (0.53-0.96)



0.68 (0.47-0.98)



1.62 (1.14-2.30)

Yet in-hospital mortality did not differ between the rural and urban groups (2.3% vs 2.7%; adjusted OR 0.86; 95% CI 0.70-1.07). And in a subanalysis of 161,996 Medicare beneficiaries, all-cause mortality risks again were similar for the two groups at 30 days, as were HF and all-cause readmission risks.

It’s possible that the magnitude of differences in therapy were too small to affect outcomes, or that the 30-day follow-up period is too brief to detect any dissimilarities, the investigators say. Still, they add, their findings support the need for research on strategies to reduce imbalances between urban and rural settings.

Greene acknowledged that this analysis doesn’t speak to the mechanisms driving differences in quality of HF care between rural and urban settings, but said it does characterize the type and magnitude of the disparities. Additionally, there are concrete efforts by the American Heart Association to try to better understand and close these gaps, he pointed out.

Caitlin E. Cox is News Editor of TCTMD and Associate Director, Editorial Content at the Cardiovascular Research Foundation. She produces the…

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  • Pierce reports receiving grants from the American Heart Association during the conduct of the study.
  • Greene reports having received research support from the Duke University Department of Medicine Chair’s Research Award, the American Heart Association, the National Heart, Lung, and Blood Institute, Amgen, AstraZeneca, Bristol Myers Squibb, Cytokinetics, Merck, Novartis, Pfizer, and Sanofi; and personal fees from Amgen, AstraZeneca, Bayer, Bristol Myers Squibb, Boehringer Ingelheim/Eli Lilly, Corteria Therapeutics, Cytokinetics, CSL Vifor, Merck, PharmaIN, Tricog Health, Sanofi, Urovant Pharmaceuticals, Roche Diagnostics, and scPharmaceuticals outside the submitted work.