Mortality post in-patient catheter ablation of atrial fibrillation in rural versus urban areas: Insights from national inpatient sample database

Background: A growing body of evidence is supportive of early atrial fibrillation (AF) ablation to maintain sinus rhythm. Disparities in health care between rural and urban areas in the United States are well known. Catheter ablation (CA) of AF is a complex procedure and its outcomes among rural versus urban areas has not been studied in the past.Methods: The national inpatient sample database 2016-2020 was queried for all hospitalization with the primary diagnosis of AF who underwent AF catheter ablation at the index hospitalization. Then, hospitalizations were stratified into rural versus urban. The primary outcome was in -hospital mortality. Secondary outcomes were total hospitalization costs and likelihood for longer length of stay. Results: A total of 78,735 patients underwent inpatient CA of AF between January 2016 and December 2020, mean age was 68.5 +/- 11 with 44 % being females. 27,180 (35 %) CA were performed in rural areas, while the remaining CA 51,555 (65 %) were done in urban areas. While, there was very low risk of mortality, patients who underwent CA in rural areas had more comorbidities and also was associated with a 79 % increase in post-procedural in-hospital mortality compared with urban areas (aOR 1.79, 0.8 % vs 0.4 %, CI: 1.15-2.78, P < 0.01). CA of AF in rural areas had a longer length of hospital stay (aOR 1.11, 4.21 vs 3.79 days, 95 % CI: 1.02-1.2, P = 0.02), lower overall cost compared with urban areas (49,698 +/- 1251 vs. $53,252 +/- 1339, P = 0.03). Multivariate regression analysis showed end stage renal disease and congestive heart failure were independent risk factors associated with increase in post CA in-hospital mortality exceeding two-fold.Conclusion: Inpatient CA of AF in rural areas was associated with higher in-hospital mortality, longer length of stay and a lower overall cost when compared with urban areas.