There has been an increase in implantation of cardiac implantable electronic devices (CIEDs) in recent years. The incidence of adverse events associated with these procedures are expected to increase. The implications of these developments are particularly concerning in rural areas of the United States (US), where public health challenges are frequent and access to specialized medical providers is limited [1Cyr M.E. et al.Access to specialty healthcare in urban versus rural US populations: a systematic literature review.BMC Health Serv Res. 2019; 19: 974Crossref PubMed Scopus (116) Google Scholar]. Our study aimed to evaluate rural and urban disparities related to CIED mortality in the US from 1999 to 2020. We extracted mortality data from the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research database spanning the years 1999 to 2020 [2Center for Disease Control and Prevention National Center for Health Statistics. CDC wonder: multiple cause of death 1999–2018. Center for Disease Control and Prevention. .Google Scholar]. We identified all decedents associated with the International Classification of Diseases, 10th Revision (ICD10) code of T82.1 (mechanical complication of cardiac electronic device) within the multiple cause-of-death records, which covers mechanical complications from CIED implantations such as obstruction, breakdown, leakage, malposition, displacement, protrusion, or perforation. These deaths were classified into rural or urban categories based on the 2013 National Center for Health Statistics criteria. We collected demographic details from all included deaths, including age, sex, race, and US census region, from the death certificates. To adjust death counts for age, we utilized the direct method with the year 2000 US standard population. This allowed us to calculate and compare age-adjusted mortality rates (AAMR) per 1,000,000 population between urban and rural areas, both cumulatively and across demographic groups. Rate ratios (RR) were calculated by dividing AAMR of rural deaths by that of urban deaths. Using the Delta method, the 95% confidence intervals were initially estimated on the natural log scale of the RRs and were then established by exponentiating the lower and upper bounds of the CI. Institutional Review Board was not required given the use of government-issued publicly available data. Our study adhered to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines. There were a total of 419 deaths in rural regions and 1,129 deaths in urban regions. The AAMR was higher among rural regions (AAMR 0.31 [95% CI, 0.28-0.34]) compared to urban regions (0.18 [95% CI, 0.17-0.20]) (Table 1). Among individuals < 65 years, mortality was similar among rural (AAMR 0.05 [95% CI, 0.03-0.06]) and urban (AAMR 0.03 [95% CI, 0.02-0.03]) regions. Conversely, mortality was higher among adults ≥ 65 years in rural regions (AAMR 2.16 [95% CI, 1.93-2.38]) compared to urban regions (AAMR 1.28 [95% CI, 1.20-0.37]).Table 1Cardiac Implantable Electronic Device Related Death. Table depicts the CIED related death counts, corresponding population size, and age-adjusted mortality rates in the cumulative US population and among demographic groups.PopulationRuralUrbanDeath CountPopulation SizeAAMR (95% CI)Death CountPopulationSizeAAMR (95% CI)RR (95% CI)All4191,006,871,6520.31 (0.28-0.34)1,1295,739,475,6490.18 (0.17-0.20)1.72 (1.54-1.93)Age< 65 years55838,893,1050.05 (0.03-0.06)1724,978,979,0010.03 (0.02-0.03)1.67 (1.23-2.26)≥ 65 years364167,978,5472.16 (1.93-2.38)957760,496,6481.28 (1.20-1.37)1.69 (1.50-1.90)SexMales210502,292,4000.40 (0.34 - 0.46)5342,815,055,4900.22 (0.20 - 0.24)1.82 (1.55-2.13)Females209504,579,2520.26 (0.23 - 0.30)5952,924,420,1590.16 (0.15 - 0.17)1.63 (1.39-1.90)RaceBlack2188,267,9940.28 (0.17 - 0.42)137830,766,8510.21 (0.17 - 0.24)1.33 (0.84-2.11)White393881,053,1530.31 (0.28 - 0.35)9704,485,984,6570.17 (0.16 - 0.19)1.82 (1.62-2.05)US Census RegionNortheast47101,993,5850.34 (0.25 - 0.46)2511,111,001,3370.18 (0.15 - 0.20)1.89 (1.38-2.58)Midwest145333,404,5720.29 (0.24 - 0.34)2481,132,716,6420.20 (0.17 - 0.22)1.45 (1.18-1.78)South163429,500,2940.30 (0.25 - 0.35)3952,068,317,7870.19 (0.17 - 0.21)1.58 (1.32-1.90)West64141,973,2010.37 (0.29 - 0.48)2351,427,439,8830.17 (0.14 - 0.19)2.18 (1.65-2.87)*Rate ratios = rates of rural AAMRs compared to urban.*Abbreviations: AAMR=age-adjusted mortality rate, CIED=cardiac electronic device, CI=confidence interval, RR=rate ratio, US=United States. Open table in a new tab *Rate ratios = rates of rural AAMRs compared to urban. *Abbreviations: AAMR=age-adjusted mortality rate, CIED=cardiac electronic device, CI=confidence interval, RR=rate ratio, US=United States. Within rural US regions, both male (0.40 [95% CI, 0.34-0.46]) and female (0.26 [95% CI, 0.23-0.30]) decedents had higher AAMR compared to their male (0.22 [95% CI, 0.20-0.24]) and female (0.16 [95% CI, 0.15-0.17]) decedent counterparts in urban regions. Black populations were disproportionately impacted by higher mortality in rural regions (AAMR 0.28 [95% CI, 0.17-0.42]) compared to urban regions (AAMR 0.21 [95% CI, 0.17-0.24]). Similarly, White populations were impacted by higher mortality in rural regions (AAMR 0.31 [95% CI, 0.28-0.35]) compared to urban regions (AAMR 0.17 [95% CI, 0.16-0.19]). Within Northeastern US regions, mortality was higher in rural areas (AAMR 0.34 [95% CI, 0.25-0.46]) compared urban areas (AAMR 0.18 [95% CI, 0.15-0.20]). Similarly, mortality in rural regions was higher along the other US census regions (Midwest AAMR 0.29 [95% CI, 0.24-0.34], South AAMR 0.30 [95% CI, 0.25-0.35], and West AAMR 0.37 [95% CI, 0.29-0.48]) compared to urban regions in the same US census regions (Midwest AAMR 0.20 [95% CI, 0.17-0.22], South AAMR 0.19 [95% CI, 0.17-0.21], and West AAMR 0.17 [95% CI, 0.14-0.19]). This rural-urban outcome disparity is likely to be multifactorial, including CIED operator characteristics and healthcare access barriers. The shortage of cardiac specialists in rural areas has led to an increased reliance on general cardiologists to perform CIED procedures, increasing risk of procedural complications and higher mortality [3Curtis J.P. et al.Association of physician certification and outcomes among patients receiving an implantable cardioverter-defibrillator.Jama. 2009; 301: 1661-1670Crossref PubMed Scopus (155) Google Scholar]. Higher prevalence of tertiary hospitals with advanced facility and equipment also contributes to lower procedure-related complications and lower mortality in urban regions compared to resource-limited regions [1Cyr M.E. et al.Access to specialty healthcare in urban versus rural US populations: a systematic literature review.BMC Health Serv Res. 2019; 19: 974Crossref PubMed Scopus (116) Google Scholar]. Greater annual procedure volume in these tertiary hospitals is also associated with less adverse outcome after CIED procedures [4Freeman J.V. et al.The relation between hospital procedure volume and complications of cardioverter-defibrillator implantation from the implantable cardioverter-defibrillator registry.Journal of the American College of Cardiology. 2010; 56: 1133-1139Crossref PubMed Scopus (67) Google Scholar]. Furthermore, the disparity in access to healthcare, poor health literacy, and poverty in rural areas may lead to missed post-procedure follow-up or delayed management of post-procedure complications [5Chen X. et al.Differences in Rural and Urban Health Information Access and Use.J Rural Health. 2019; 35: 405-417Crossref PubMed Scopus (154) Google Scholar]. Finally, our analysis identified that Black populations showed no significant variance in mortality rates between rural and urban settings. This finding suggests a possible uniformity in access to healthcare resources for Black populations, irrespective of their urbanization status [6Wallace J. et al.Disparities in Health Care Spending and Utilization Among Black and White Medicaid Enrollees.JAMA Health Forum. 2022; 3: e221398Crossref PubMed Scopus (8) Google Scholar]. There are limitations to our study. This includes misclassification errors from use of ICD-10 codes, undifferentiated reporting between CIED types, and the absence of individual-level data, which constrained our ability to account for residual confounding. Additionally, the potential for ecological fallacy must be acknowledged, as it constrains the extent to which these findings can be applied to the patient-level. Finally, our analysis did not account for the time elapsed from the procedure to the occurrence of death. Despite these limitations, our analysis is strengthened by utilization of the CDC database, a nationally representative sample. Our results revealed CIED related mortality disparities among the rural regions in the US. These findings warrant further investigation into individual-level socioeconomic factors that contribute to this healthcare inequity.
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