The Chasm in Percutaneous Coronary Intervention and In-Hospital Mortality Rates Among Acute Myocardial Infarction Patients in Rural and Urban Hospitals in China: A Mediation Analysis

Objectives: To determine to what extent the inequality in the ability to provide percutaneous coronary intervention (PCI) translates into outcomes for AMI patients in China.Methods: We identified 82,677 patients who had primary diagnoses of AMI and were hospitalized in Shanxi Province, China, between 2013 and 2017. We applied logistic regressions with inverse probability weighting based on propensity scores and mediation analyses to examine the association of hospital rurality with in-hospital mortality and the potential mediating effects of PCI.Results: In multivariate models where PCI was not adjusted for, rural hospitals were associated with a significantly higher risk of in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.03-1.37). However, this association was nullified (OR: 0.94, 95% CI: 0.81-1.08) when PCI was included as a covariate. Mediation analyses revealed that PCI significantly mediated 132.3% (95% CI: 104.1-256.6%) of the effect of hospital rurality on in-hospital mortality. The direct effect of hospital rurality on in-hospital mortality was insignificant.Conclusion: The results highlight the need to improve rural hospitals' infrastructure and address the inequalities of treatments and outcomes in rural and urban hospitals.