Rural-Urban Disparities in the Management and Outcomes of Atrial Fibrillation in Emergency Departments in Canada

In a universal health care system, geographic disparities in atrial fibrillation (AF) outcomes remain poorly understood. This study aimed to evaluate rural-urban differences in clinical outcomes among patients presenting to the emergency department (ED) with AF.

We conducted a population-based retrospective cohort study of all adults (aged ≥18 years) presenting to an ED in Ontario, Canada, with a primary diagnosis of AF between April 1, 2012, and March 31, 2022. Rural residence was defined as living in a community with a population of ≤10 000. The primary outcome was a composite of all-cause mortality or hospital admission within 1 year; secondary outcomes included the individual components of the primary outcome and all-cause ED visits. Comparisons were adjusted for demographics and baseline comorbidities using inverse probability of treatment weighting. Cox regression was used for end points that included death.

Among 104 195 eligible patients, 16 860 (16.2%) resided in rural communities. After inverse probability of treatment weighting, baseline characteristics were well balanced (standardized differences <0.1) as the mean age was 69.4 years in rural and urban groups; 47.2% were women in the rural group versus 47.1% in the urban group. Within 1 year, patients with AF presenting to the ED in rural Ontario had higher rate of all-cause mortality or admission compared with the urban group (34.6% versus 33.5%; hazard ratio, 1.04 [95% CI, 1.01-1.07]), driven primarily by increased hospital admission rates (31.3% versus 29.7%; hazard ratio, 1.06 [95% CI, 1.03-1.09]). ED visit rates were higher in rural patients (63.8% versus 55.3%; hazard ratio, 1.27 [95% CI, 1.25-1.30]), while mortality was similar (9.8% versus 9.9%; hazard ratio, 1.00 [95% CI, 0.95-1.04]).

Despite universal health care coverage, rural-urban disparities in AF outcomes persist. Rural patients with AF had higher acute care utilization compared with urban patients. System interventions are needed to address inequities for rural populations.