PO:27:112 | The impact of rurality in chronic inflammatory rheumatic diseases in the province of Udine (2014-2023): analysis of clinical outcomes and potential complications

Simone Longhino¹, Luigi Castrista², Yvonne Beorchia², Marco Driutti², Elena Treppo¹, Silvio Brusaferro³, Luca Quartuccio¹ | ¹Clinica di Reumatologia, Dipartimento di Medicina Specialistica; ²Istituto di Igiene ed Epidemiologia Valutativa; ³Accreditamento, Gestione del Rischio Clinico e Valutazione delle Performance Sanitarie, ASUFC, Udine, Italy

Background. Chronic inflammatory rheumatic diseases (IRDs) are immune-mediated disorders that may be affected by geographical barriers, such as rurality and distance from specialized centers, potentially limiting access to care. Evidence regarding the impact of these factors on clinical outcomes remains scarce and mostly derived from non-European settings. This study investigates, within an Italian hub-and-spoke healthcare model, the influence of rurality, distance from the referral center, and other factors, such as comorbidities, sex, age, and type of IRD, on clinical outcomes among patients residing in the province of Udine.

Materials and Methods. The study conducted a retrospective cohort analysis using administrative healthcare data, encompassing all incident diagnoses of IRDs (chronic arthritis, connective tissue diseases, and systemic vasculitis) from 2014 to 2023. Rurality was defined as residence in areas with a population density <150 inhabitants/km²; distance from the specialized center was measured in kilometers, with a threshold of 27 km (75th percentile). Comorbidities were classified according to the Charlson Comorbidity Index (CCI): mild (CCI=1), moderate (CCI=2), severe (CCI≥3). Outcomes analyzed included first hospitalizations and emergency department (ED) visits for avoidable IRD-related complications (infections, cardiovascular events, osteoporotic complications) and all-cause mortality. Statistical analysis: multivariable Cox regression.

Results. A total of 3,044 patients were included, 66.33% female, with a median follow-up of 4.9 (2.4–7.3) years. Median age at diagnosis was 57 (47–67) years. The distribution of IRDs was as follows: chronic arthritis (73.95%), connective tissue diseases (17.53%), and vasculitis (8.51%). Overall, 32.95% of patients lived in rural areas, and 24.31% resided more than 27 km from the center. Rurality and distance did not correlate with an elevated risk of hospitalization, emergency department visits, or mortality (p>0.05). Female sex was protective against ED visits and infection-related hospitalizations but associated with a higher risk of osteoporotic fractures. Being older and having more than one health problem at the same time were both strong predictors of hospitalization for all avoidable complications, especially in patients with moderate (CCI=2) and severe (CCI≥3) comorbidities. A similar trend was noted for preventable emergency department visits, with an increased risk in patients with CCI=2, CCI≥3, and older age; no emergency department visits were documented for osteoporotic complications. The risk of death went up with age and was higher in people with CCI=2 or CCI≥3. Women had a lower risk than men. Connective tissue diseases were also associated with increased mortality risk. All statistically significant hazard ratios are reported in the Figure.

Conclusions: In the Province of Udine, rurality and distance do not influence clinical outcomes in patients with IRDs, suggesting that a centralized healthcare system may help mitigate inequalities in access to care. However, age, male sex, and comorbidity burden remain key negative determinants, underscoring the importance of early identification of high-risk patients and the adoption of integrated management strategies.