Sex-Specific Trends in Incidence and Mortality for Urban and Rural Ambulatory Patients with Heart Failure in Eastern Ontario from 1994 to 2013

•We found an overall decrease in ambulatory HF incidence and mortality in both urban and rural settings from 1994 to 2013.•The incidence of HF was greater for men than for women and greater in rural than in urban areas. Mortality rates in rural men remained higher than in rural women at most time points.•There have been important increases in many chronic diseases associated with morbidity and mortality.•The delivery of health care and provision of outreach programs for HF patients should be tailored to rurality and sex. Differences in outcomes have previously been reported between urban and rural settings across a multitude of chronic diseases. Whether these discrepancies have changed over time, and how sex may influence these findings is unknown for patients with ambulatory heart failure (HF). We examined the temporal incidence and mortality trends by geography in these patients. We conducted a retrospective cohort study of 36,175 eastern Ontario residents who were diagnosed with HF in an outpatient setting from 1994 to 2013. The primary outcome was 1-year mortality. We examined temporal changes in mortality risk factors with the use of multivariable Cox proportional hazard models. The incidence of HF decreased in women and men across both rural and urban settings. Age-standardized mortality rates also decreased over time in both sexes but remained greater in rural men compared with rural women. The incidence of HF in the ambulatory setting was greater for men than women and greater in rural than urban areas, but mortality rates remained higher in rural men compared with rural women. Further research should focus on ways to reduce this gap in the outcomes of men and women with HF.