Rural Hospitals Less Likely than Urban Hospitals to Prescribe GDMT in Heart Failure


Using the GWTG-HF registry, new data elucidates the differences in the likelihood of being prescribed GDMT among patients hospitalized with heart failure in rural compared to urban settings.

Stephen Greene, MD

Stephen Greene, MD
Courtest: Duke University School of Medicine

For patients hospitalized with heart failure, where you are hospitalized could play a significant role in whether or not a patient is prescribed guideline-directed medical therapy (GDMT) prior to discharge, according to a new study.

Leveraging data from nearly 775,000 patients within the Get With The Guidelines-Heart Failure (GWTG-HF) Registry, results of the study indicate hospitalization at a rural hospital was independently associated with lower use of ACEs/ARBs and ARNIs relative to their counterparts hospitalized in an urban health care setting, but investigators pointed 30-day outcomes did not differ based on location of care setting.

“In this study of US patients admitted to rural vs urban hospitals for heart failure, although most quality metrics were similar, patients at rural hospitals were less likely to receive multiple elements of guideline-directed heart failure care, such as [cardiac resynchronization therapy], ACEI/ARB, and ARNI therapies,” wrote investigators. “Despite these differences in heart failure care, there were no significant differences between rural and urban hospitals regarding in-hospital mortality or 30-day postdischarge outcomes.”

After struggling without effective therapies for years, heart failure has seen an onslaught of new therapies revolutionize care since the turn of the century. With many of these new therapies now establish as GDMT for heart failure, the focus among the community has now shifted to realizing the potential of the agents through optimized implementation efforts.2 In the current study, which was led by Stephen Greene, MD, associate professor of medicine at Duke University School of Medicine, was launched with the intent of describing contemporary differences between rural and urban hospitals for quality of care and clinical outcomes among patients hospitalized for heart failure.

With this in mind, the research endeavor was designed as a retrospective cohort study of data obtained from the GWTG-HF registry. Searching the registry for patients hospitalized for heart failure between January 1, 2014, and September 30, 2021, investigators identified 774,419 patients hospitalized from 569 sites. Investigators pointed out postdischarge outcomes were assessed using a subset of 161,996 patients for the overall cohort with linked data to Medicare claims.

The primary outcomes of interest for the study included the GWTG-HF quality measures, in-hospital mortality, length of stay, 30-day mortality, and readmissions outcomes. Investigators pointed out multivariable logistic regression models were used to estimate differences between rural and urban hospitals for the primary outcomes of interest and Cox proportional hazards models were used to evaluate the 30-day postdischarge outcomes.

Of the 774,419 patients identified for inclusion, 19,832 received care at 49 rural hospitals and 754,587 received care at 520 urban hospitals. The overall study cohort had a median age of 73 (Interquartile Range [IQR], 62 to 83) years and 47.3% were female. Compared to their counterparts who received care at an urban hospital, patients at rural hospitals were older (median [IQR] age, 74 [64 to 84] years vs 73 [61 to 83] years; standardized difference, 10.63) more likely to be non-Hispanic White (73.5% vs 66.1%; standardized difference, 34.47), and more likely to have Medicare insurance (58.4% vs 51.1%; standardized difference, 16.88).

Upon analysis, results indicated those at rural hospitals were likely to be prescribed cardiac resynchronization therapy (adjusted risk difference [aRD], -13.5%; adjusted odds ratio [aOR], 0.44 [95% CI, 0.22 to 0.92]), ACEi or ARB (aRD, -3.7%; aOR, 0.71 [95% CI, 0.53 to 0.96]), and an ARNI (aRD, -5.0%; aOR, 0.68 [95% CI, 0.47 to 0.98]) at discharge than their counterparts at rural hospitals. Further analysis suggested in-hospital mortality was similar between rural and urban hospitals (2.3% vs 2.7%; aOR, 0.86 [95% CI, 0.70 to 1.07]), despite those at rural hospitals less likely to have a stay of 4 days or longer (aOR, 0.75 [95% CI, 0.67 to 0.85]).

Analyses of postdischarge outcomes among Medicare beneficiaries revealed there were no significant differences between rural and urban hospitals for 30-day HF readmission (adjusted hazard ratio [aHR], 1.03 [95%CI, 0.90 to1.19]), all-cause readmission (aHR, 0.97 [95% CI, 0.91 to 1.04]), and all-cause mortality (aHR, 1.05 [95% CI, 0.91 to 1.21]).

“To our knowledge, this is the first study to examine patient-level and hospital-level differences in heart failure quality of care and outcomes in a contemporary nationwide cohort of patients hospitalized with heart failure at rural and urban hospitals,” investigators added.


  1. Pierce JB, Ikeaba U, Peters AE, et al. Quality of Care and Outcomes Among Patients Hospitalized for Heart Failure in Rural vs Urban US Hospitals: The Get With The Guidelines–Heart Failure RegistryJAMA Cardiol. Published online February 20, 2023. doi:10.1001/jamacardio.2023.0241
  2. Campbell P. STRONG-HF: In-hospital initiation of GDMT reduces rehospitalization, mortality risk in heart failure patients. Practical Cardiology. Published November 17, 2022. Accessed February 21, 2023.
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