Patients with atrial fibrillation at greater risk of death in rural hospitals than in urban hospitals

AF patients admitted to rural hospitals have a 17 percent increased risk of death during hospitalization, according to a new study published in HeartRhythm

Philadelphia, December 11, 2017

Patients with atrial fibrillation (AF) admitted to rural hospitals in the United States have a greater chance of dying during their hospital stay than patients admitted to urban hospitals for the same condition, according to a new report in HeartRhythm.

AF is a common problem, consisting of skipped or irregular heartbeats (arrhythmias) that can lead to blood clots, stroke, heart failure, and other cardiovascular complications. Left untreated, AF doubles the risk of heart-related deaths and is associated with a five-fold increased risk for stroke, according to the American Heart Association.

“The identification of healthcare disparities is of utmost importance at this time to improve the overall care that is delivered in our healthcare system,” explained lead investigator Wesley T. O'Neal, MD, MPH, of the Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA. “Our research shows that urban-rural differences exist regarding the risk of hospital mortality among patients who are admitted for AF.”

Investigators used data from the National Inpatient Sample (NIS), a database representative of discharged patients from US community hospitals, to compare the in-hospital mortality of patients admitted for AF in rural versus urban hospitals. The NIS approximates a 20 percent stratified sample of all discharges and excludes rehabilitation and long-term acute care hospitals. The data are drawn from 44 states, plus the District of Columbia, representing more than 96 percent of the United States population. The analysis employed a cross-sectional examination of the NIS database of AF hospitalizations between 2012 and 2014 to determine if admission to a rural hospital was associated with an increased risk of in-hospital mortality compared with patients admitted to urban hospitals.

Looking at death due to any cause during hospitalization of patients with AF, the study found that patients admitted to rural hospitals had a 17 percent increased risk of death during hospitalization compared with urban hospitals. Analysis accounted for differences in patient characteristics and potential confounders. The five most common secondary diagnoses for patients hospitalized for AF were heart failure, hypertension, hyperlipidemia, diabetes, and acute kidney injury.

“Since we have identified rural hospitals as locations where in-hospital mortality for atrial fibrillation admission is possibly higher than other areas of the country, our findings will drive future research endeavors to uncover the reasons for this difference, and to develop strategies to improve the medical care for patients with this heart rhythm disturbance,” Dr. O’Neal concluded.

Although the reasons for this difference are unclear at this time, these data likely are of interest to providers and policy makers who are working towards the reduction of mortality in rural regions.

In an accompanying editorial, Thomas F. Deering, MD, FHRS, and Ashish A. Bhimani, MD, FHRS, both from the Arrhythmia Center, Piedmont Heart Institute, Atlanta, GA, commend O’Neal et al for their detailed analysis, increasing awareness in the medical community about a potentially important arrhythmic healthcare issue, and placing their findings into the appropriate context. They also point out that the study raises important clinical and epidemiological questions.

They stress that factors such as associated comorbidities and their severity, access to care, patient lifestyle decisions, patient compliance, physician adherence to diagnostic and therapeutic guideline recommendations, physician referral patterns, etc., which may have contributed to the observed outcomes, remain unknown.

“Accordingly, claims-based analyses, such as these, should be viewed as hypothesis-generating instead of categorical in nature. The electrophysiology and medical communities should look at the findings presented in this study as a motivational call to initiate prospective studies with the goal of identifying gaps in AF care, which can then be used to create effective healthcare policies, designed to reduce AF-related mortality,” commented Dr. Deering and Dr. Bhimani.


Notes for editors
The article is “Urban-Rural Differences in Mortality for Atrial Fibrillation Hospitalizations in the United States,” by Wesley T. O'Neal, MD, MPH, Pratik B Sandesara, MD, Heval Kelli, MD, Sanjay Venkatesh, MD, and Elsayed Z Soliman, MD, MSc, MS ( The editorial is “Atrial Fibrillation: Location, Location, Location – Does It Matter?” by Thomas F. Deering, MD, FHRS, and Ashish A. Bhimani, MD, FHRS (

Both will appear in HeartRhythm, volume 15, issue 2 (February 2018) published by Elsevier.

Full text of this study and editorial is available to credentialed journalists upon request; contact Jane Grochowski at +1 406-542-8397 or Journalists wishing to reach the study authors should contact Wesley T. O'Neal at Thomas F. Deering may be reached for comment at +1 404-605-2888 or

Research reported in the study was supported by the National Heart, Lung, And Blood Institute of the National Institutes of Health under award number F32-HL134290.

About HeartRhythm
HeartRhythm, the official Journal of the Heart Rhythm Society and the Cardiac Electrophysiology Society, is a unique journal for fundamental discovery and clinical applicability. It integrates the entire cardiac electrophysiology (EP) community from basic and clinical academic researchers, private practitioners, engineers, allied professionals, industry, and trainees, all of whom are vital and interdependent members of our EP community.

About the Heart Rhythm Society
The Heart Rhythm Society is the international leader in science, education, and advocacy for cardiac arrhythmia professionals and patients, and the primary information resource on heart rhythm disorders. Its mission is to improve the care of patients by promoting research, education, and optimal healthcare policies and standards. The Heart Rhythm Society is the preeminent professional group representing more than 5,100 specialists in cardiac pacing and electrophysiology from more than 70 countries.

About Elsevier
Elsevier is a global information analytics business that helps scientists and clinicians to find new answers, reshape human knowledge, and tackle the most urgent human crises. For 140 years, we have partnered with the research world to curate and verify scientific knowledge. Today, we’re committed to bringing that rigor to a new generation of platforms. Elsevier provides digital solutions and tools in the areas of strategic research management, R&D performance, clinical decision support, and professional education; including ScienceDirect, Scopus, SciVal, ClinicalKey and Sherpath. Elsevier publishes over 2,500 digitized journals, including The Lancet and Cell, 39,000 e-book titles and many iconic reference works, including Gray's Anatomy. Elsevier is part of RELX, a global provider of information-based analytics and decision tools for professional and business customers.

Media contact
Jane Grochowski, Publisher
+1 406-542-8397