Use of rhythm control therapy for atrial fibrillation among Veterans in the Southeastern United States by rurality

BACKGROUND: Atrial fibrillation (AF) affects up to 6 million adults, approximately 1 million of whom receive care through the Veterans Health Administration (VA). Considering advanced rhythm control interventions like catheter ablation are often limited to higher-resourced urban care settings, disparities may disproportionately affect the VA patient population given the 4.6 million Veterans who live in rural communities. OBJECTIVE: To assess differences in use of or time to rhythm control therapy based on rurality. METHODS: This was a retrospective study of 21,600 Veterans with AF and no preceding heart failure (HF) in the VA Mid-Atlantic Health Care Network. Utilization of diagnostic testing and therapeutic interventions were assessed by total use and time from AF diagnosis. RESULTS: Mean age at AF diagnosis was 72 years, 97.9% were male, 79.8% self-identified as White, and 24.9% lived in rural communities. No differences were observed in the use of rhythm control therapies based on rurality (antiarrhythmic prescriptions 20.1%, 20.9%, and 20.6% and catheter ablation 2.2%, 1.6%, and 2.1% for urban, large rural, and isolated rural settings, respectively; p>0.05 for both comparisons). However, low utilization rates and delays in time to rhythm control therapy, including catheter ablation (median time 2.6 years), were appreciated across the rural-urban spectrum. CONCLUSIONS: No major clinical differences were revealed in use of or time to rhythm control therapy based on rurality in the VA. However, low utilization rates and delays to therapy across the rural-urban spectrum warrants additional investigation to identify systemic drivers that may disproportionately affect the VA patient population.