Publications

IMPORTANCE: Improving cardiovascular health in rural areas is a national priority in the US. However, little is known about the current state of rural cardiovascular health and the underlying drivers of any rural-urban disparities.

OBJECTIVE: To compare rates of cardiometabolic risk factors and cardiovascular diseases between rural and urban US adults and to evaluate the extent to which health care access, lifestyle factors, and social risk factors contribute to any rural-urban differences.

DESIGN, SETTING, AND PARTICIPANTS: This nationally representative cross-sectional study analyzed data from US adults aged 20 years or older residing in rural vs urban areas using the 2022 National Health Interview Survey. Data were analyzed between August 2024 and February 2025.

EXPOSURE: County-level rurality.

MAIN OUTCOMES AND MEASURES: The primary outcomes were age-standardized rates of cardiometabolic risk factors (hypertension, hyperlipidemia, obesity, and diabetes) and cardiovascular diseases (coronary heart disease [CHD] and stroke).

RESULTS: The study population consisted of 27 172 adults, including 4256 adults (14.0%) residing in rural areas, 14 741 (54.8%) in small or medium metropolitan areas, and 8175 (31.2%) in urban areas. Mean (SD) participant age was 49.1 (17.8) years, and 4399 participants (50.8%) were female. Compared with their urban counterparts, rural adults were more likely to smoke, be insufficiently physically active, and have more social risk factors. Age-standardized rates of cardiometabolic risk factors were significantly higher in rural areas, including hypertension (37.1% vs 30.9%; rate ratio [RR], 1.20; 95% CI, 1.13-1.27), hyperlipidemia (29.3% vs 26.7%; RR, 1.10; 95% CI, 1.03-1.18), obesity (41.1% vs 30.0%; RR, 1.37; 95% CI, 1.27-1.47), and diabetes (11.2% vs 9.8%; RR, 1.15; 95% CI, 1.02-1.29). The same pattern was observed for CHD (6.7% vs 4.3%; RR, 1.58; 95% CI, 1.35-1.85), but no differences were observed for stroke. The magnitude of rural-urban disparities was largest among young adults (aged 20-39 years) for hypertension (RR, 1.44; 95% CI, 1.12-1.86), obesity (RR, 1.54; 95% CI, 1.34-1.77), and diabetes (RR, 2.59; 95% CI, 1.54-4.38). Rural-urban disparities in cardiovascular health were not meaningfully attenuated after adjustment for measures of health care access (insurance coverage, usual source of care, and recent health care utilization) and lifestyle factors (smoking and physical activity). However, accounting for social risk factors (poverty, education level, food insecurity, and home ownership) completely attenuated rural-urban disparities in hypertension (adjusted RR [aRR], 0.99; 95% CI, 0.93-1.06), diabetes (aRR, 1.02; 95% CI, 0.90-1.15), and CHD (aRR, 1.08; 95% CI, 0.91-1.29), but only partially attenuated disparities in obesity (aRR, 1.29; 95% CI, 1.20-1.39).

CONCLUSIONS AND RELEVANCE: This national cross-sectional study found substantial rural-urban disparities in cardiometabolic risk factors and cardiovascular diseases, which were largest among younger adults and almost entirely explained by social risk factors. These findings suggest that efforts to improve socioeconomic conditions in rural communities may be critical to address the rural-urban gap in cardiovascular health.

The study examines effects of the Centers for Medicaid and Medicare Services State Innovation Models (SIM) on capturing social risk factors in adults hospitalized with atherosclerotic cardiovascular disease (ASCVD). Using a difference-in-differences (DID) approach with propensity score weights, the study compared documentation of secondary diagnosis of social determinants of health (SDOH)/social factors using ICD-9 V codes ("SDOH codes") in adults hospitalized with ASCVD as a primary diagnosis (n = 1 485 354). Data were gathered from January 1, 2010, to September 30, 2015, covering the period before and after the SIM implementation in October 2013. From January 2010 to September 2015, SDOH codes were infrequently utilized among adults with ASCVD (0.55%; 95% CI, 0.43%-0.67%). The SDOH codes with ASCVD increased from pre- to postperiod in SIM states (0.56%-0.93%) and comparison states (0.46%-0.56%). State Innovation Models implementation was associated with greater improvement in SDOH codes utilization (adjusted OR 1.30; 95% CI, 1.18-1.43) during ASCVD hospitalizations. The odds of SDOH codes utilization were 86% higher in emergency department admissions (AOR, 1.86; 95% CI, 1.76-1.97) than in routine admissions with ASCVD. Findings were similar when limiting population to older adults (≥65 years) enrolled in Medicare (AOR 1.50; 95% CI, 1.31-1.71), whereas not significant for Medicaid beneficiaries. The study points to challenges for healthcare providers in documenting SDOH in adults with ASCVD.

BACKGROUND: Private equity firms have rapidly acquired U.S. hospitals and increasingly invested in cardiology over the past decade. However, little is known about how private equity acquisition of hospitals affects care and outcomes for patients with heart failure.

OBJECTIVES: The purpose of this study was to evaluate whether clinical care and outcomes changed for patients with heart failure after the acquisition of U.S. hospitals by private equity firms compared with matched control hospitals.

METHODS: This study identified U.S. hospitals acquired by private equity firms and matched control hospitals from 2012 through 2019. A quasiexperimental difference-in-differences analysis was used to evaluate changes in clinical outcomes, the case mix of admissions and transfers, as well as cardiac procedure utilization among Medicare fee-for-service beneficiaries aged 65 years or older with heart failure.

RESULTS: There were 41 private equity-acquired hospitals and 192 matched control hospitals. After private equity acquisition of hospitals, there was no change in 30-day mortality rates (difference-in-differences [DiD] +0.7 percentage points [95% CI: -0.4 to 1.8]) or 30-day hospital revisit rates (DiD -0.2 percentage points [95% CI: -0.9 to 0.5]), despite a significant decrease in the clinical risk of patients with heart failure when compared with those at matched control (nonacquired) hospitals. Overall hospital transfer rates did not change, but Black patients were significantly more likely to be transferred out to another site after private equity acquisition (DiD +7.1 percentage points [95% CI: 0.7-13.4]), a change not observed across other racial groups. In addition, there was a significant increase in cardiac catheterization rates (DiD estimate, +0.7 percentage points [95% CI: 0.1-1.2]) among heart failure patients at private equity-acquired vs control hospitals.

CONCLUSIONS: These findings suggest that private equity acquisitions of U.S. hospitals do not improve outcomes among older adults with heart failure, despite a decrease in the clinical risk of patients admitted to these sites.

IMPORTANCE: Cardiovascular disease is the leading cause of death in the US. However, it remains unclear how the burden of cardiovascular events in the US compares with that of other high-income countries with distinct health care systems like Denmark, both overall and by income.

OBJECTIVE: To compare cardiovascular hospitalization rates (acute myocardial infarction [MI], heart failure [HF], ischemic stroke) and associated outcomes among adults 65 years or older, overall and by income, between the US and Denmark.

DESIGN, SETTING, AND PARTICIPANTS: This population-based cross-sectional study used national data from the US and Denmark from January 1, 2021, to January 1, 2022. The study population included all Medicare beneficiaries 65 years or older in the US and all adults 65 years or older in Denmark.

MAIN OUTCOMES AND MEASURES: The primary outcome was age- and sex-standardized hospitalization rates for MI, HF, and ischemic stroke, as well as 30-day all-cause mortality rates.

RESULTS: The US study population included 58 614 110 adults 65 years or older (mean [SE] age, 74.6 [7.7] years; 32 179 146 female [54.9%]) of whom 1 171 058 (2.0%) were hospitalized for a cardiovascular event. The Danish study population included 1 176 542 adults 65 years or older (mean [SE] age, 75.3 [7.1] years; 634 217 female [53.9%]) of whom 16 305 (1.4%) were hospitalized with a cardiovascular event. The overall age- and sex-standardized cardiovascular hospitalization rate was significantly higher in the US compared with Denmark (risk ratio [RR], 1.50; 95% CI, 1.47-1.52), as were associated 30-day all-cause mortality rates (RR, 1.12; 95% CI, 1.06-1.17). Across conditions, the risk of hospitalization for MI (RR, 1.56; 95% CI, 1.51-1.61) and HF (RR, 2.37; 95% CI, 2.31-2.43) was significantly higher in the US compared with Denmark, whereas hospitalizations for ischemic stroke were lower (RR, 0.90; 95% CI, 0.88-0.93). Overall cardiovascular hospitalization rates in the US were more than 2-fold higher among low-income adults compared with higher-income adults (RR, 2.38; 95% CI, 2.25-2.47), whereas the magnitude of income-based disparities was smaller in Denmark (RR, 1.45; 95% CI, 1.39-1.50).

CONCLUSIONS AND RELEVANCE: In this international cross-sectional study, cardiovascular hospitalization rates were significantly higher in the US compared with Denmark. There were income-based differences in the burden of cardiovascular hospitalizations in both countries, although the magnitude of these disparities was much greater in the US.