An estimated 60 million people comprising one-fifth of the United States (US) population, reside in areas defined as rural.1 These individuals face numerous disparities in both health outcomes and health care access compared to those living in urban areas. The prevalence of cardiovascular disease (CVD) is 40% higher among rural vs urban residents, and mortality rates associated with all types of CVD and stroke are also higher in rural areas.1-3
The availability of specialists, including cardiologists, is especially sparse in the rural US, and researchers have found significant inequities between patients receiving cardiology treatment in rural vs urban hospitals.4,5 In a retrospective study published in January 2022 in the Journal of the American College of Cardiology, Loccoh et al examined differences in outcomes between Medicare beneficiaries (n=2,182,903) presenting to rural or urban hospitals with acute cardiovascular conditions.5
Patients receiving treatment for acute myocardial infarction (AMI) at rural hospitals showed lower rates of cardiac catheterization (49.7% vs 63.6%; P <.001), percutaneous coronary intervention (42.1% vs 45.7%; P <.001), and coronary artery bypass graft (9.0% vs 10.2%; P <.001) compared with those treated at urban hospitals.5
Among patients with ischemic stroke, rates of thrombolysis (3.1% vs 10.1%; P <.001) and endovascular therapy (1.8% vs 3.6%; P <.001) were also lower at rural vs urban hospitals.5
In addition, 30-day mortality was higher among rural vs urban patients with AMI (HR, 1.10; 95% CI, 1.08-1.12), heart failure (HR, 1.15; 95% CI, 1.13-1.16), and ischemic stroke (HR, 1.20; 95% CI, 1.18-1.22) after adjustment for demographic factors and comorbidities. The most pronounced differences in mortality were observed among patients receiving treatment at critical access hospitals in remote rural areas.5
Improving cardiology care and outcomes in the rural US will require a range of efforts from various stakeholders. “Governmental or health care systems that incentivize physician practices in these areas are needed – such as programs that pay down student loans and provide loan forgiveness, for example,” Deirdre Mattina, MD, FACC, general cardiologist in the section of regional cardiovascular medicine at the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic in Ohio, told Cardiology Advisor.
Additionally, she noted, “Medicaid services are often reimbursed at lower rates than commercial insurance plans, which creates disparities in health care delivery by disincentivizing physicians to offer care to this vulnerable population.”
Along with better reimbursement models and programs that provide benefits to physicians practicing in underserved locations including the rural US, the further integration of telehealth into cardiology practices is needed to provide a “bridge to infrequent in-person care,” Dr Mattina said.6
To learn more about these regional disparities in access to cardiology care, we interviewed Laxmi Mehta, MD, clinical professor of internal medicine and section director of preventative cardiology and women’s cardiovascular health at The Ohio State University Wexner Medical Center in Columbus; Sameed Khatana MD, MPH, senior fellow and assistant professor of cardiovascular medicine in the Perelman School of Medicine at the University of Pennsylvania, and staff cardiologist at the Philadelphia VA Medical Center; and Basera Sabharwal, MD, chief cardiology fellow at Mount Sinai Morningside in New York.
What factors are driving the shortage in access to cardiology care in the rural US?
Dr Mehta: Transportation issues including lack of vehicle access, long travel distances, high costs of transportation, and inadequate infrastructure in transportation means can contribute to poor access to care. Rural hospitals are often designated as critical access hospitals, which are typically smaller and have less capacity for intensive care or rehabilitation services. As rural hospitals continue to close nationwide, access is even more challenging for rural patients. Furthermore, workforce shortages also impact staffing in rural areas and in turn limit access to adequate care. High rates of uninsurance amongst rural populations also result in financial strain and impact access to care.
Dr Khatana: Access to cardiology care, like other types of health care, is determined by many different factors including the supply of health care providers, availability of emergency departments and hospitals, as well as health insurance coverage. The number of physicians in rural areas has been declining for decades. Rural hospitals have also been closing at a greater rate than urban hospitals due to factors such as low reimbursement, staffing shortages, and low patient volume. Additionally, we know that many states with large rural populations in the South and Midwest have not expanded Medicaid health insurance, therefore depriving many rural low-income individuals of health insurance.
Dr Sabharwal: Battling health care disparities between rural and urban areas has been ongoing for over a decade now. In general, life expectancy in urban populations is about 3 to 4 years higher than in rural areas, with some indigenous populations having a life expectancy that is 5 to 6 years lower than people living in urban areas.1 Multiple factors are responsible for this, including higher rates of common but treatable risk factors such as high blood pressure, diabetes, smoking, and high cholesterol.
Another primary reason for health care disparities is social determinants of health including income, education, employment, housing, distance from a health care center, transportation, food insecurity, and limited or no health insurance. All of these factors, as well as scarcity of primary care providers for screening and treatment of common conditions like high blood pressure, and less favorable mental and behavioral health care availability, lead to an increase CVD and stroke.
Regarding acute care, distance to a hospital center is extremely important. On average, rural residents live more than 10 miles from a hospital, which is twice as far than those living in urban locations. Moreover, hospitals in rural areas see a lower volume of complex and critical diseases, leading to lack of experience in these areas and thus differential disease outcomes between urban and rural hospitals. This gap becomes even wider for complex CVDs. Health practitioners in urban areas are super-specialized, and the high volumes they deal with lead to improved health metrics of those diseases. On the other hand, care in rural areas is less specialized and practitioners practice more widely.
Data shows that less than 10% of US physicians practice in rural areas, and even fewer have more specialized training.7 Health care centers including both clinics and hospitals are finding it tougher to retain specialized physicians in these communities. There’s even a shortage of nurses and support staff in these regions, which adds tremendously to the problem.
What are some of the measures needed to help reduce these gaps?
Dr Mehta: New models and site of care delivery are essential, including expanding telehealth services and digital technology, as well as training of the entire care team so that community health care workers and other care team members can provide care and expand access for patients. Flexible payment and funding models are necessary to support rural delivery of care. Expanding affordable health care insurance may also be impactful.
Dr Khatana: Shoring up the financial health of rural hospitals so that they can continue to operate is an important step. In Pennsylvania, the state is testing a model called the Pennsylvania Rural Health Model, which will provide hospitals with a “global budget” in which CMS and other participating health insurance payers will pay certain rural hospitals a fixed amount of money to cover all costs of hospital-based care. The goal of this program is to provide more predictable finances to rural hospitals.8
Additionally, training programs need to be set up in rural areas with a focus on providing for the needs of rural programs. Expanding the scope of practice of advanced practice providers such as nurse practitioners and physician assistants to provide cardiovascular care may also address the issue of the shortage of providers.
Dr Sabharwal: Access to health care has changed in the last few years with the rise in telehealth since the pandemic began. This is extremely important and useful, especially in rural areas where long distance travel for routine care is a barrier. With telehealth, these patients can get regular screening, monitoring, and treatment of diseases including CVDs, and they must travel to specialized centers only when necessary. If we can improve primary prevention of heart disease by treating the risk factors, there will be less heart disease requiring treatment. This requires routine health checks and follow-ups, which can be easily done via telehealth.
Another helpful measure would be to include mandatory rotations in rural outreach centers during residency and fellowship training. This will increase care at those centers with a probable increase in physicians ultimately staying at those practices.9
Other measures would be to make rural practices more attractive to physicians at the end of their training, such as through loan forgiveness programs to those willing to work in rural areas, or by combining practices with urban centers wherein physicians agreeing to practice with the majority of their time in rural centers are still able to rotate monthly or every 3 months, for example, through urban centers with exposure to complex diseases.
Churches and other faith-based organizations are cornerstones of rural communities. Collaboration with these organizations for routine health care workshops with cardiologists and other specialists from urban areas would improve care provided in rural populations. Economic development in rural areas as well as improvement in insurance availability for policies like Medicaid would also decrease the health care disparity gap between rural and urban areas.
What are your recommendations for clinicians interested in providing and advocating for increased access to cardiology care in rural areas?
Dr Mehta: Clinicians should work on expanding their virtual care of patients and be creative in utilizing technology to address health equity. Development of a diverse workforce that incorporates people with differing training will help expand the reach of care for rural patients. Community education is mandatory regarding cardiovascular risk factors, and healthy lifestyle may be beneficial in improving overall cardiovascular health.
The AHA is committed to bringing equitable care to rural communities through its Rural Health Care Outcomes Accelerator, which includes the Get with the Guidelines Quality Program at no cost for rural hospitals, as well as access to participate in rural learning collaboratives and access to the AHA’s Lifelong Learning Center.11
Dr Khatana: Clinicians interested in providing care in rural areas need to form connections with providers already in these areas. Specialty care, including cardiology, is hard to access, so having formal and informal relationships with rural health care providers can help.
Clinicians can also advocate to health system leaders to partner with rural hospitals to help coordinate necessary cardiovascular care when needed. They should also advocate for the expansion of health insurance coverage for low-income patients in rural areas in states that have not yet expanded Medicaid health insurance.
Dr Sabharwal: Caring for these medically underserved patients can be challenging. For those interested in providing cardiovascular care in this high-risk population, they should begin in their early years of training so they can understand the needs of the community and learn to navigate their practice and the system to provide optimal care in these areas. There are multiple organizations within the health care system that are focusing on such efforts, including the American Heart Association (AHA) as well as community groups. Getting involved with such organizations will help achieve the goal of improving cardiovascular care in these communities.
What are remaining research needs regarding this topic?
Dr Mehta: Research is necessary to determine optimal delivery of care models, including how best to leverage digital technology. Research on effective rural-based quality measures and how to best support community-centered approaches to care is also needed.
Dr Khatana: Unanswered questions include whether improving the finances of rural hospitals will prevent such hospitals from closing. A study by my colleagues and I, published in JAMA in 2021, showed that cardiovascular health was associated with economic prosperity of an area.10 Future research needs to study whether improving the economic prospects of an area can lead to improvement in health outcomes, including for CVD.
Dr Sabharwal: Health care centers in rural areas lack patient volume and quality metrics. Some metrics require a large sample size to be reliable. These 2 factors combined make data from rural centers difficult to interpret. Further research in this area is needed to better understand the needs of rural communities. In addition, research to analyze how telemedicine performs in these populations would help to better strategize care in these communities.
- Harrington RA, Califf RM, Balamurugan A, et al. Call to action: rural health: a presidential advisory from the American Heart Association and American Stroke Association. Circulation. Published online February 10, 2020. doi:10.1161/CIR.0000000000000753
- Pierce JB, Shah NS, Petito LC, et al. Trends in heart failure-related cardiovascular mortality in rural versus urban United States counties, 2011-2018: a cross-sectional study. PLoS One. Published online March 3, 2021. doi:10.1371/journal.pone.0246813
- Cross SH, Mehra MR, Bhatt DL, et al. Rural-urban differences in cardiovascular mortality in the US, 1999-2017. JAMA. Published online May 12, 2020. doi:10.1001/jama.2020.2047
- Gruca TS, Pyo TH, Nelson GC. Providing cardiology care in rural areas through visiting consultant clinics. J Am Heart Assoc. 2016;5(7):e002909. doi:10.1161/JAHA.115.002909
- Loccoh EC, Joynt Maddox KE, Wang Y, Kazi DS, Yeh RW, Wadhera RK. Rural-urban disparities in outcomes of myocardial infarction, heart failure, and stroke in the United States. J Am Coll Cardiol. Published online January 17, 2022. doi:10.1016/j.jacc.2021.10.045
- Schopfer DW. Rural health disparities in chronic heart disease. Prev Med. Published online September 7, 2021. doi:10.1016/j.ypmed.2021.106782
- American Hospital Association. Rural report: challenges facing rural communities and the roadmap to ensure local access to high-quality, affordable care. 2019. Accessed November 15, 2022.
- Scanlon D, Sciegaj M, Wolf LJ, et al. The Pennsylvania Rural Health Model: hospitals’ early experiences with global payment for rural communities. J Healthc Manag. 2022;67(3):162-172. doi:10.1097/JHM-D-20-00347
- Elma A, Nasser M, Yang L, Chang I, Bakker D, Grierson L. Medical education interventions influencing physician distribution into underserved communities: a scoping review. Hum Resour Health. Published online April 7, 2022. doi:10.1186/s12960-022-00726-z
- Khatana SAM, Venkataramani AS, Nathan AS, et al. Association between county-level change in economic prosperity and change in cardiovascular mortality among middle-aged US adults. JAMA. Published online February 2, 2021. doi:10.1001/jama.2020.26141
- American Heart Association. Rural healthcare outcomes accelerator. Accessed November 15, 2022.