Urban-Rural Disparity in Cardiac Implantable Electronic Device Use: A 10-Year Statewide Cohort

Background: We examined cardiac implantable electronic device (CIED) implantation and outcomes related to geographical remoteness. Methods: This was a retrospective cohort study of adult cardiovascular hospitalisations in New South Wales, Australia (2008-2018). The primary outcome was CIED implantation in arrhythmia, cardiomyopathy, and syncope groups (and subcategories) among rural and regional residents. Secondary outcomes included CIED subtypes: pacemaker (PPM), implantable defibrillator (ICD) and cardiac resynchronisation therapy (CRT), examination of 10-year implant trends, and 5-year mortality rates adjusted for age and comorbidities. Results: Of the 1,291,258 cardiovascular admissions, 880,972 patients were from major cities (urban), 304,961 from inner regional (regional), and 105,325 from outer regional, rural, or remote areas (rural). Regional and rural patients received less PPMs (regional: aOR = 0.66; 95% CI 0.64-0.69; rural: aOR = 0.75; 95% CI 0.71-0.79), CRTs (regional: aOR = 0.71; 95% CI 0.65-0.78, rural: aOR = 0.72; 95% CI 0.83-0.94), and ICDs for regional patients (aOR = 0.72; 95% CI 0.67-0.77). Differences persisted in subcategories, including PPMs for complete heart block (regional: aOR = 0.58; 95% CI 0.56-0.60, rural: aOR = 0.66; 95% CI 0.62-0.70) and ICDs for ischaemic (regional: aOR = 0.44; 0.34-0.56, rural: aOR = 0.74; 95% CI 0.54-0.99) and non-ischaemic cardiomyopathy (regional: aOR = 0.64; 95% CI 0.56-0.73, rural: aOR = 0.72; 95% CI 0.59-0.87). Five-year mortality rates were higher in rural patients receiving PPM (urban = 23.7%; 95% CI23.2-24.2, rural = 26.4%; 95% CI 25.8-27.0), ICD (urban = 29.5%; 95% CI 28.2-30.7, rural = 32.5%; 95% CI 31.3-33.8) and CRT (urban = 24.2%; 95% CI 22.9-25.5, rural = 26.9%; 95% CI 25.5-28.3). Conclusion: Regional and rural patients had less CIED implantation, with higher 5-year rural mortality rates. Our study highlights the geographical disparity that occurs for patients requiring CIED and the need for further examination to determine the underlying causes and address these inequities.