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Cardiovascular medication utilization and adherence among adults living in rural and urban areas: a systematic review and meta-analysis

Gaetanne K Murphy1, Finlay A McAlister2, Daniala L Weir13, Lisa Tjosvold3 and Dean T Eurich13*

Author Affiliations

1 2-040 Li Ka Shing Center for Health Research Innovation, School of Public Health, University of Alberta, Edmonton, AB T6G 2E1, Canada

2 Division of General Internal Medicine, Department of Medicine, Medicine and Dentistry, University of Alberta, Edmonton, Canada

3 Alliance for Canadian Health Outcomes Research in Diabetes, School of Public Health, University of Alberta, Edmonton, Canada

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BMC Public Health 2014, 14:544  doi:10.1186/1471-2458-14-544

Published: 2 June 2014



Rural residents face numerous barriers to healthcare access and studies suggest poorer health outcomes for rural patients. Therefore we undertook a systematic review to determine if cardiovascular medication utilization and adherence patterns differ for rural versus urban patients.


A comprehensive search of major electronic datasets was undertaken for controlled clinical trials and observational studies comparing utilization or adherence to cardiovascular medications in rural versus urban adults with cardiovascular disease or diabetes. Two reviewers independently identified citations, extracted data, and evaluated quality using the STROBE checklist. Risk estimates were abstracted and pooled where appropriate using random effects models. Methods and reporting were in accordance with MOOSE guidelines.


Fifty-one studies were included of fair to good quality (median STROBE score 17.5). Although pooled unadjusted analyses suggested that patients in rural areas were less likely to receive evidence-based cardiovascular medications (23 studies, OR 0.88, 95% CI 0.79, 0.98), pooled data from 21 studies adjusted for potential confounders indicated no rural–urban differences (adjusted OR 1.02, 95% CI 0.91, 1.13). The high heterogeneity observed (I2 = 97%) was partially explained by treatment setting (hospital, ambulatory care, or community-based sample), age, and disease. Adherence did not differ between urban versus rural patients (3 studies, OR 0.94, 95% CI 0.39, 2.27, I2 = 91%).


We found no consistent differences in rates of cardiovascular medication utilization or adherence among adults with cardiovascular disease or diabetes living in rural versus urban settings. Higher quality evidence is needed to determine if differences truly exist between urban and rural patients in the use of, and adherence to, evidence-based medications.

Cardiovascular diseases; Rural population; Urban population; Medication adherence; Drug utilization