Barriers to Timely Percutaneous Coronary Intervention (PCI) in Rural vs. Urban Settings: A Health System Approach

INTRODUCTION: Timely primary percutaneous coronary intervention (PCI) is crucial for reducing morbidity and mortality in ST-elevation myocardial infarction (STEMI). Delays in rural populations are often driven by geographic, patient-related, and system-level barriers. OBJECTIVE: The objective of the study is to evaluate and compare barriers to timely PCI in rural versus urban STEMI patients, identify independent predictors of treatment delay, and quantify their impact on reperfusion times. METHODS: This cross-sectional study enrolled 273 adult STEMI patients undergoing primary PCI at District Headquarter (DHQ) Teaching Hospital, Mardan, over 12 months (137 rural and 136 urban). Patients who received prior fibrinolysis, were referred from other PCI-capable centers, or declined participation were excluded. Patient- and system-level barriers were operationally defined and measured using a structured, pre-tested questionnaire supplemented by medical record review. Patient-level barriers included delayed symptom recognition, transport difficulties, and financial constraints; system-level barriers included off-hour PCI unavailability, inter-facility transfer delays, and referral inefficiencies. Door-to-balloon and symptom-to-door times were recorded and analyzed, adjusting for age, gender, comorbidities, and transport mode. Missing data were handled via listwise deletion. Multivariate logistic regression was conducted after testing model assumptions and assessing multicollinearity to identify independent predictors of PCI delay. RESULTS: Rural patients had significantly longer door-to-balloon (105.5 ± 15.8 vs. 84.1 ± 11.9 min, p < 0.001) and symptom-to-door (295 ± 80 vs. 145 ± 50 min, p < 0.001) times compared to urban patients. Delays > 90 minutes occurred in 82.5% of rural versus 27.9% of urban patients. Multivariate logistic regression identified rural residence (adjusted odds ratio (AOR) 4.75, 95% confidence interval (CI) 2.95-7.65), patient-related barriers (AOR 2.35, 95% CI 1.50-3.68), and system-related barriers (AOR 2.80, 95% CI 1.85-4.25) as independent predictors of PCI delay. CONCLUSION: Rural STEMI patients experience significant delays in receiving primary PCI, primarily due to patient- and system-level barriers. Interventions targeting health education, pre-hospital transport, and referral streamlining are essential to reduce rural-urban disparities and improve clinical outcomes, in line with international guideline recommendations for timely reperfusion.