Are degree of urbanisation and travel times to healthcare services associated with the processes of care and outcomes of heart failure? A retrospective cohort study based on administrative data

Autoři: Jacopo Lenzi aff001;  Vera Maria Avaldi aff001;  Dario Molinazzi aff003;  Carlo Descovich aff002;  Stefano Urbinati aff004;  Veronica Cappelli aff005;  Maria Pia Fantini aff001
Působiště autorů: Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Bologna, Italy aff001;  Department of Clinical Governance and Quality, Bologna Local Healthcare Authority, Bologna, Italy aff002;  Department of Management Control and Administrative Data, Bologna Local Healthcare Authority, Bologna, Italy aff003;  Department of Cardiology, Bellaria Hospital, Bologna, Italy aff004;  Directorate of Assistance, Technology and Rehabilitation, Bologna Local Healthcare Authority, Bologna, Italy aff005
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article


A few studies have found that patients with heart failure (HF) living in less densely populated areas have reduced use of services and poorer outcomes. However, there is a lack of evidence regarding transport accessibility measured as the actual distance between the patient’s home and the healthcare facility. The aim of this study was to investigate if different urbanisation levels and travel times to healthcare services are associated with the processes of care and the outcomes of HF. This retrospective cohort study included patients residing in the Local Healthcare Authority of Bologna (2915 square kilometres) who were discharged from hospital with a diagnosis of HF between 1 January and 31 December 2017. Six-month study outcomes included both process (cardiology follow-up visits) and outcome measures (all-cause readmissions, emergency room visits, all-cause mortality). Of the 2022 study patients, 963 (47.6%) lived in urban areas, 639 (31.6%) in intermediate density areas, and 420 (20.8%) in rural communities. Most patients lived ≤30 minutes away from the nearest healthcare facility, either inpatient or outpatient. After controlling for a number of individual factors, no significant association between travel times and outcomes was present. However, rural patients as opposed to urban patients were more likely to see a cardiologist during follow-up (OR 1.42, 99% CI 1.03–1.96). These follow-up visits were associated with reduced mortality within 6 months of discharge (OR 0.53, 99% CI 0.32–0.87). We also found that multidisciplinary interventions for HF were more common in rural than in urban settings (18.8% vs. 4.0%). In conclusion, travel times had no impact on the quality of care for patients with HF. Differences between urban and rural patients were possibly mediated by more proximal factors, some of which are potential targets for intervention such as the availability and utilisation of follow-up cardiology services and multidisciplinary models of care.

Klíčová slova:

Allied health care professionals – Cardiology – Critical care and emergency medicine – Health care facilities – Heart failure – Hospitals – Inpatients – Outpatients


1. Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart. 2007;93:1137–46. doi: 10.1136/hrt.2003.025270 17699180

2. Dunlay SM, Roger VL. Understanding the epidemic of heart failure: past, present, and future. Curr Heart Fail Rep. 2014;11:404–15. doi: 10.1007/s11897-014-0220-x 25182014

3. Nieminen MS, Brutsaert D, Dickstein K, Drexler H, Follath F, Harjola VP, et al. EuroHeart Failure Survey II (EHEART FAILURES II): a survey on hospitalized acute heart failure patients: description of population. Eur Heart J. 2006;27:2725–36. doi: 10.1093/eurheartj/ehl193 17000631

4. Bueno H, Ross JS, Wang Y, Chen J, Vidán MT, Normand SL, et al. Trends in length of stay and short-term outcomes among Medicare patients hospitalized for Heart failure, 1993–2006. JAMA. 2010;303:2141–7. doi: 10.1001/jama.2010.748 20516414

5. Kociol RD, Hammill BG, Fonarow GC, Klaskala W, Mills RM, Hernandez AF, et al. Generalizability and longitudinal outcomes of a national heart failure clinical registry: Comparison of Acute Decompensated Heart Failure National Registry (ADHERE) and non-ADHERE Medicare beneficiaries. Am Heart J. 2010;160:885–92. doi: 10.1016/j.ahj.2010.07.020 21095276

6. Maggioni AP, Dahlstrom U, Filippatos G, Chioncel O, Leiro MC, Drozdz J, et al. EURObservational Research Programme: the Heart Failure Pilot Survey (ESC-HEART FAILURE Pilot). Eur J Heart Fail. 2010;12:1076–84. doi: 10.1093/eurjhf/hfq154 20805094

7. Maggioni AP, Dahlstrom U, Filippatos G, Chioncel O, Crespo Leiro M, Drozdz J, et al. EURObservational Research Programme: regional differences and 1-year follow-up results of the Heart Failure Pilot Survey (ESC-HEART FAILURE Pilot). Eur J Heart Fail. 2013;15:808–17. doi: 10.1093/eurjhf/hft050 23537547

8. Solomon SD, Dobson J, Pocock S, Skali H, McMurray JJ, Granger CB, et al. Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure. Circulation. 2007;116:1482–7. doi: 10.1161/CIRCULATIONAHA.107.696906 17724259

9. Ambrosy AP, Fonarow GC, Butler J, Chioncel O, Greene SJ, Vaduganathan M, et al. The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries. J Am Coll Cardiol. 2014;63:1123–33. doi: 10.1016/j.jacc.2013.11.053 24491689

10. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133:e38–360. doi: 10.1161/CIR.0000000000000350 26673558

11. Ziaeian B, Fonarow GC. The Prevention of Hospital Readmissions in Heart Failure. Prog Cardiovasc Dis. 2016;58:379–85. doi: 10.1016/j.pcad.2015.09.004 26432556

12. Avaldi VM, Lenzi J, Castaldini I, Urbinati S, Di Pasquale G, Morini M, et al. Hospital readmissions of patients with heart failure: the impact of hospital and primary care organizational factors in Northern Italy. PLoS One. 2015;10:e0127796. doi: 10.1371/journal.pone.0127796 26010223

13. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18:891–975. doi: 10.1002/ejhf.592 27207191

14. McAlister FA, Stewart S, Ferrua S, McMurray JJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol. 2004;44:810–9. doi: 10.1016/j.jacc.2004.05.055 15312864

15. Kelly C, Hulme C, Farragher T, Clarke G. Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review. BMJ Open. 2016;6:e013059. doi: 10.1136/bmjopen-2016-013059 27884848

16. Gamble JM, Eurich DT, Ezekowitz JA, Kaul P, Quan H, McAlister FA. Patterns of care and outcomes differ for urban versus rural patients with newly diagnosed heart failure, even in a universal healthcare system. Circ Heart Fail. 2011;4:317–23. doi: 10.1161/CIRCHEARTFAILURE.110.959262 21430285

17. Cook NL, Lauer MS. The socio-geography of heart failure: why it matters. Circ Heart Fail. 2011;4:244–5. doi: 10.1161/CIRCHEARTFAILURE.111.962191 21586735

18. Verdejo HE, Ferreccio C, Castro PF. Heart Failure in Rural Communities. Heart Fail Clin. 2015;11:515–22. doi: 10.1016/j.hfc.2015.07.011 26462091

19. Avaldi VM, Lenzi J, Urbinati S, Molinazzi D, Descovich C, Campagna A, et al. Effect of cardiologist care on 6-month outcomes in patients discharged with heart failure: results from an observational study based on administrative data. BMJ Open. 2017;7:e018243. doi: 10.1136/bmjopen-2017-018243 29101146

20. Zeigermann L. OPENCAGEGEO: Stata module for forward and reverse geocoding using the OpenCage Geocoder API [software]. 2016 Mar 19 [cited 2019 Jul 15].

21. Weber S, Péclat M. A simple command to calculate travel distance and travel time. Stata Journal. 2017;17:962–71.

22. Selim AM, Mazurek JA, Iqbal M, Wang D, Negassa A, Zolty R. Mortality and readmission rates in patients hospitalized for acute decompensated heart failure: a comparison between cardiology and general-medicine service outcomes in an underserved population. Clin Cardiol. 2015;38:131–8. doi: 10.1002/clc.22372 25694226

23. Uthamalingam S, Kandala J, Selvaraj V, Martin W, Daley M, Patvardhan E, et al. Outcomes of patients with acute decompensated heart failure managed by cardiologists versus noncardiologists. Am J Cardiol. 2015;115:466–71. doi: 10.1016/j.amjcard.2014.11.034 25637324

24. Avaldi VM, Lenzi J. The Role of Cardiologists in the Management of Patients with Heart Failure. Adv Exp Med Biol. 2018;1067:133–44. doi: 10.1007/5584_2017_120 29188455

25. Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43:1130–9. doi: 10.1097/01.mlr.0000182534.19832.83 16224307

26. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136(6):e137–e161. doi: 10.1161/CIR.0000000000000509 28455343

27. Vaduganathan M, Fonarow GC, Gheorghiade M. Drug therapy to reduce early readmission risk in heart failure: ready for prime time? JACC Heart Fail. 2013;1:361–4. doi: 10.1016/j.jchf.2013.04.010 24621940

28. Corrao G, Ghirardi A, Ibrahim B, Merlino L, Maggioni AP. Short- and long-term mortality and hospital readmissions among patients with new hospitalization for heart failure: A population-based investigation from Italy. Int J Cardiol. 2015;181:81–7. doi: 10.1016/j.ijcard.2014.12.004 25497525

29. Takeda A, Martin N, Taylor RS, Taylor SJ. Disease management interventions for heart failure. Cochrane Database Syst Rev. 2019;1:CD002752. doi: 10.1002/14651858.CD002752.pub4 30620776

30. Austin PC, Tu JV. Bootstrap Methods for Developing Predictive Models. The Am Stat. 2004;58:131–7.

31. Italian National Institute of Statistics [Internet]. Confini delle unità amministrative a fini statistici al 1 gennaio 2019; 2019 [cited 2019 May 8].

32. Konerding U, Bowen T, Elkhuizen SG, Faubel R, Forte P, Karampli E, et al. The impact of travel distance, travel time and waiting time on health-related quality of life of diabetes patients: An investigation in six European countries. Diabetes Res Clin Pract. 2017;126:16–24. doi: 10.1016/j.diabres.2017.01.014 28189950

33. Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38:976–93. doi: 10.1007/s10900-013-9681-1 23543372

34. Díaz-Toro F, Verdejo HE, Castro PF. Socioeconomic Inequalities in Heart Failure. Heart Fail Clin. 2015;11:507–13. doi: 10.1016/j.hfc.2015.07.012 26462090

35. Foraker RE, Rose KM, Suchindran CM, Chang PP, McNeill AM, Rosamond WD. Socioeconomic status, Medicaid coverage, clinical comorbidity, and rehospitalization or death after an incident heart failure hospitalization: Atherosclerosis Risk in Communities cohort (1987 to 2004). Circ Heart Fail. 2011;4:308–16 doi: 10.1161/CIRCHEARTFAILURE.110.959031 21430286

36. Teng TH, Katzenellenbogen JM, Hung J, Knuiman M, Sanfilippo FM, Geelhoed E, et al. Rural-urban differentials in 30-day and 1-year mortality following first-ever heart failure hospitalisation in Western Australia: a population-based study using data linkage. BMJ Open. 2014;4:e004724. doi: 10.1136/bmjopen-2013-004724 24793254

37. Garcia R, Abellana R, Real J, Del Val JL, Verdú-Rotellar JM, Muñoz MA. Health inequalities in hospitalisation and mortality in patients diagnosed with heart failure in a universal healthcare coverage system. J Epidemiol Community Health. 2018;72:845–51. doi: 10.1136/jech-2017-210146 29899056

38. Cook NL, Ayanian JZ, Orav EJ, Hicks LS. Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance status, and site of primary care. Circulation. 2009;119:2463–70. doi: 10.1161/CIRCULATIONAHA.108.825133 19398667

39. Komajda M, Cowie MR, Tavazzi L, Ponikowski P, Anker SD, Filippatos GS, et al. Physicians’ guideline adherence is associated with better prognosis in outpatients with heart failure with reduced ejection fraction: the QUALIFY international registry. Eur J Heart Fail. 2017;19:1414–23. doi: 10.1002/ejhf.887 28463464

40. Shrout PE, Bolger N. Mediation in experimental and nonexperimental studies: new procedures and recommendations. Psychol Methods. 2002;7:422–45. 12530702

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