Geographic access to cardiac rehabilitation and cardiovascular disease outcomes: A study of rural United States counties.

Prior studies have examined rural-urban disparities in access to cardiac rehabilitation (CR). However, few have examined the relationship between disparate access to CR and cardiovascular disease outcomes in rural areas. In this analysis of 1975 nonmetro United States counties, we investigated the relationship between number of hospitals with CR and Medicare-population hospitalization rates (per 1000 adults ≥65 years) and county-population mortality rates (per 100,000 adults ≥18 years) due to coronary heart disease (CHD), heart failure (HF), or stroke, using multivariable linear-regression-modeling adjusting for socio-demographic and comorbid conditions. Median CHD hospitalization (13.0 vs. 12.2), HF hospitalization (16.1 vs. 13.3), HF death (114.2 vs. 110.9), stroke hospitalization (12.0 vs. 10.9), and stroke death (39.6 vs. 37.1) rates were higher in nonmetro counties without versus with a CR facility (p-values< 0.001). There were inverse correlations between number of hospitals with CR and CHD (r= -0.161), HF (r= -0.261) and stroke (r= -0.237) hospitalization rates, and stroke mortality (r= -0.144) rates (p-values< 0.001). After adjustment, as the number of hospitals with CR increased, there were decreases in hospitalization rates of 1.78 for CHD, 7.20 for HF, and 2.43 for stroke, per 1000 in the population (p-values < 0.001) and decreases in stroke deaths of 9.17 per 100,000 in the population (p= 0.02). Access to hospitals with CR in US nonmetro counties is inversely related to CHD, HF, and stroke hospitalization, and stroke mortality. Our findings call for reducing barriers to CR in nonmetro communities and further exploring the relationship between CR and stroke outcomes.