Cardiovascular Medication Utilization and Adherence Among Heart Failure Patients in Rural and Urban Areas: A Retrospective Cohort Study

Background: Rural residence is a negative prognostic factor for heart failure (HF). The objective was to explore rural and urban differences in the utilization, adherence, and persistence with medications, and mortality among incident HF patients. Methods: Using administrative databases from Alberta (Canada), subjects > 65 years old with a first hospitalization for HF between 1999 and 2008 who survived >= 90 days after discharge were identified. Pharmacy claims for renin-angiotensin system (RAS) agents, beta-blockers (BBs), digoxin, or spironolactone were identified. The association between rural and urban residence and medication utilization, adherence (optimal adherence defined as >= 80% adherence over 1 year), persistence, and 1-year mortality was assessed. Results: The cohort included 10,430 patients, with a mean age of 80.2 (SD, 7.7) years, 47% were male, and 25% were rural residents. Rural residents were less likely to receive RAS agents (74% vs 79%, adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.69-0.89) or BBs (44% vs 54%; aOR, 0.83; 95% CI, 0.73-0.93) than urban residents, but had similar use of other medications. Although < 69% of patients who received RAS agents and 53% who received BBs had optimal adherence, few differences in adherence or persistence were detected among patients in rural vs urban areas. The 1-year mortality rate was significantly lower for patients who demonstrated optimal adherence to RAS agents or BBs (aOR, 0.78; 95% CI, 0.65-0.94) with no significant differences in the first 6 months between patients residing in rural vs urban areas. Conclusions: Rural residents with HF were less likely to receive RAS agents or BBs, but few differences in adherence were noted compared with their urban counterparts. Suboptimal adherence with evidence-based HF therapy was associated with increased risk of mortality.