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Editor's Correspondence
October 22, 2001

Urban-Rural Differences in the Quality of Care for Medicare Patients With Acute Myocardial Infarction

Arch Intern Med. 2001;161(19):2386-2387. doi:

In a survey on 6 major quality indicators of inpatient care provided to patients with acute myocardial infarction, Sheikh and Bullock1 showed how lower performance was achieved in rural than in urban hospitals. The authors concluded that there were greater opportunities for improving delivery of care in rural areas compared with metropolitan regions. While interesting, I feel this assertion only applies to the contexts studied to date and does not automatically apply to any setting. For example, a prospective Italian study recently compared 2 defined populations admitted for coronary angiography between June l, 1992, and May 31, 1993: the residents of central Padua, classified as urban, and the residents of the Cittadella Health Authority, classified as rural.2 The utilization rate was 8 per 10 000 of the population in the urban group and 10 per 10 000 of the population in the mini-group. In accordance with American College of Cardiology/American Heart Association (ACC/AHA) guidelines,3 coronary angiography procedures were classified as appropriate in 69.9% and 68% of cases and inappropriate in 11.7% and 6% of cases in the urban group and rural group, respectively. On the whole, more services were rendered to the rural residents and, all things considered, a little less inappropriately than to the urban ones. I believe this can be explained by the fact that while some cornerstones in caregiving quality, such as availability of economic resources and volume of activity, are more likely to characterize urban and metropolitan settings, others, like scientific know-how, professionalism, and organizational models (the role of which warrants closer examination) are, instead, relatively widespread.

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