Regional Disparities in Atrial Fibrillation Management: An IMPACT-AF Substudy

In rural regions, atrial fibrillation (AF) management is performed predominately by local primary care professionals (PCPs). Prior work has suggested that a disparity in outcomes in AF occurs for those patients living in a rural, vs urban, location.

This post hoc analysis of the cluster randomized trial Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) compared a clinical decision support system to standard of care. Patients were classified as living in a rural (population < 10,000) or urban location. The outcomes were as follows: AF-related emergency department (ED) visits, unplanned cardiovascular (CV) hospitalizations, AF-related referrals and guideline adherence for AF treatment.

A total of 1133 patients were enrolled from 2016 to 2018; 54.1% (n = 613) were classified as living in a rural location. No differences were present in age (mean, 72 ± 9.63 vs 72.5 ± 10.42 years) or Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS₂) score (mean, 2.1 ± 1.36 vs 2.16 ± 1.34). Referral rates to general internists were higher in the rural population (13.4% vs 3.9%, P < 0.001), whereas the rate of cardiology referrals was higher in the urban population (10% vs 15%, P = 0.0098). At 12 months, no difference in the composite outcome of AF-related ED visits and CV hospitalizations was seen. Fewer recurrent AF-related ED visits and CV hospitalizations occurred in the urban group (incidence rate ratio [IRR], 0.65 [95% confidence interval (0.44, 0.95), P = 0.0262). The incidence of guideline adherence was similar between the rural (IRR, 3.7 ± 1.2) and urban (IRR, 3.6 ± 1.2; P = 0.11) groups.

AF patients living in rural locations had higher rates of recurrent AF-related ED visits and unplanned CV hospitalizations. Further research to optimize AF-related outcomes is needed to ensure equitable delivery of care to all Canadians, irrespective of geography.

NCT01927367.