Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association

From static web to metaverse: reinventing medical education in the post-pandemic era

The World Wide Web and the advancement of computer technology in the 1960s and 1990s respectively set the ground for a substantial and simultaneous change in many facets of our life, including medicine, health care, and medical education. The traditional didactic approach has shifted towards more dynamic and interactive methods, leveraging technologies such as simulation tools, virtual reality, and online platforms. At the forefront is the remarkable evolution that has revolutionized how medical knowledge is accessed, disseminated, and integrated into pedagogical practices. The COVID-19 pandemic also led to rapid and large-scale adoption of e-learning and digital resources in medical education because of widespread lockdowns, social distancing measures, and the closure of medical schools and healthcare training programs. This review paper examines the evolution of medical education from the Flexnerian era to the modern digital age, closely examining the influence of the evolving WWW and its shift from Education 1.0 to Education 4.0. This evolution has been further accentuated by the transition from the static landscapes of Web 2D to the immersive realms of Web 3D, especially considering the growing notion of the metaverse. The application of the metaverse is an interconnected, virtual shared space that includes virtual reality (VR), augmented reality (AR), and mixed reality (MR) to create a fertile ground for simulation-based training, collaborative learning, and experiential skill acquisition for competency development. This review includes the multifaceted applications of the metaverse in medical education, outlining both its benefits and challenges. Through insightful case studies and examples, it highlights the innovative potential of the metaverse as a platform for immersive learning experiences. Moreover, the review addresses the role of emerging technologies in shaping the post-pandemic future of medical education, ultimately culminating in a series of recommendations tailored for medical institutions aiming to successfully capitalize on revolutionary changes.

Metaverse-powered basic sciences medical education: bridging the gaps for lower middle-income countries

BACKGROUND

Traditional medical education often lacks contextual experience, hindering students' ability to effectively apply theoretical knowledge in real-world scenarios. The integration of the metaverse into medical education holds great enormous promise for addressing educational disparities, particularly in lower-middle-income countries (LMICs) accompanied by rapid technological advancements. This commentary paper aimed to address the potential of the metaverse in enhancing basic sciences education within the constraints faced by universities in LMICs. We also addressed learning design challenges by proposing fundamental design elements and a suggested conceptual framework for developing metaverse-based teaching methods.The goal is to assist educators and medical practitioners in comprehensivley understanding key factors in immersive teaching and learning.

DISCUSSION

By immersing medical students in virtual scenarios mimicking real medical settings and patient interactions, the metaverse enables practice in clinical decision-making, interpersonal skills, and exposure to complex medical situations in a controlled environment. These simulations can be customized to reflect local healthcare challenges, preparing medical students to tackle specific community needs. Various disciplines, including anatomy, physiology, pharmacy, dentistry, and pathology, have begun leveraging the metaverse to offer immersive learning experiences, foster interdisciplinary collaborations, and facilitate authentic assessments. However, financial constraints pose a significant barrier to widespread adoption, particularly in resource-limited settings like LMICs. Addressing these challenges is crucial to realizing the full potential of metaverse technology in medical education.

CONCLUSION

The metaverse offers a promising solution for enhancing medical education by providing immersive, context-rich learning experiences. This paper proposes a conceptual framework and fundamental design elements to aid faculty educators and medical practitioners in effectively incorporating metaverse technology into their teaching methods, thus improving educational outcomes in LMICs.

Healthcare Use and Expenditures in Rural Survivors of Hospitalization for Sepsis

OBJECTIVES

Sepsis survivors have greater healthcare use than those surviving hospitalizations for other reasons, yet factors associated with greater healthcare use in this population remain ill-defined. Rural Americans are older, have more chronic illnesses, and face unique barriers to healthcare access, which could affect postsepsis healthcare use. Therefore, we compared healthcare use and expenditures among rural and urban sepsis survivors. We hypothesized that rural survivors would have greater healthcare use and expenditures.

DESIGN, SETTING, AND PATIENTS

To test this hypothesis, we used data from 106,189 adult survivors of a sepsis hospitalization included in the IBM MarketScan Commercial Claims and Encounters database and Medicare Supplemental database between 2013 and 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified hospitalizations for severe sepsis and septic shock using the International Classification of Diseases , 9th Edition (ICD-9) or 1CD-10 codes. We used Metropolitan Statistical Area classifications to categorize rurality. We measured emergency department (ED) visits, inpatient hospitalizations, skilled nursing facility admissions, primary care visits, physical therapy visits, occupational therapy visits, and home healthcare visits for the year following sepsis hospitalizations. We calculated the total expenditures for each of these categories. We compared outcomes between rural and urban patients using multivariable regression and adjusted for covariates. After adjusting for age, sex, comorbidities, admission type, insurance type, U.S. Census Bureau region, employment status, and sepsis severity, those living in rural areas had 17% greater odds of having an ED visit (odds ratio [OR] 1.17; 95% CI, 1.13-1.22; p < 0.001), 9% lower odds of having a primary care visit (OR 0.91; 95% CI, 0.87-0.94; p < 0.001), and 12% lower odds of receiving home healthcare (OR 0.88; 95% CI, 0.84-0.93; p < 0.001). Despite higher levels of ED use and equivalent levels of hospital readmissions, expenditures in these areas were 14% (OR 0.86; 95% CI, 0.80-0.91; p < 0.001) and 9% (OR 0.91; 95% CI, 0.87-0.96; p < 0.001) lower among rural survivors, respectively, suggesting these services may be used for lower-acuity conditions.

CONCLUSIONS

In this large cohort study, we report important differences in healthcare use and expenditures between rural and urban sepsis survivors. Future research and policy work is needed to understand how best to optimize sepsis survivorship across the urban-rural continuum.

Social needs and health outcomes in two rural Veteran populations

BACKGROUND

Addressing social needs is a priority for many health systems, including the Veterans Health Administration (VA). Nearly a quarter of Veterans reside in rural areas and experience a high social need burden. The purpose of this study was to assess the prevalence and association with health outcomes of social needs in two distinct rural Veteran populations.

METHODS

We conducted a survey (n = 1150) of Veterans at 2 rural VA sites, 1 in the Northeast and 1 in the Southeast (SE), assessing 11 social needs (social disconnection, employment, finance, food, transportation, housing, utilities, internet access, legal needs, activities of daily living [ADL], and discrimination). We ran weighted-logistic regression models to predict the probability of experiencing four outcomes (poor access to care, no-show visits, and self-rated physical and mental health) by individual social need.

FINDINGS

More than 80% of Veterans at both sites reported ≥1 social need, with social disconnection the most common; Veterans at the SE site reported much higher rates. A total of 9 out of 11 needs were associated with higher probability of poor physical and mental health, particularly financial needs (average marginal effect [AME]: 0.21-0.32, p < 0.001) and ADL (AME: 0.27-0.34, p < 0.001). We found smaller associations between social needs and poor access to care and no-show visits.

CONCLUSION

High prevalence of social needs in rural Veteran population and significant associations with four health outcomes support the prioritization of addressing social determinants of health for health systems. Differences in the findings between sites support tailoring interventions to specific patient populations.

Process evaluation findings from Strong Hearts, Healthy Communities 2.0: a cardiovascular disease prevention intervention for rural women

BACKGROUND

Strong Hearts, Healthy Communities 2.0 (SHHC-2.0) was a 24-week cardiovascular disease prevention program that was effective in improving physical activity and nutrition behaviors and clinical outcomes among women in 11 rural New York, USA towns. This study evaluated the delivery of SHHC-2.0 to prepare the intervention for further dissemination.

METHODS

This process evaluation was guided by the Medical Research Council recommendations and engaged program leaders and participants (i.e., women over age 40) using quantitative and qualitative methods. The quantitative evaluation included examination of enrollment and retention data, a participant survey, and a fidelity checklist completed after classes. Descriptive and comparative statistics were used to assess implementation measures: program reach, participant attendance, dose delivered, program length, perceived effectiveness, fidelity, and participant satisfaction. The qualitative evaluation included focus groups (n = 13) and interviews (n = 4) using semi-structured guides; audio was recorded and transcripts were deductively coded and analyzed using directed content analysis and iterative categorization approaches. Comparisons across towns and between intervention and waitlist control groups were explored.

RESULTS

Average reach within towns was 7.5% of the eligible population (range 0.7-15.7%). Average attendance was 59.8% of sessions (range 42.0-77.4%). Average dose delivered by leaders was 86.4% of curriculum components (range 73.5-95.2%). Average session length was 51.8 ± 4.8 min across 48 sessions. Leaders' perceived effectiveness rating averaged 4.1 ± 0.3 out of 5. Fidelity to curricular components was 81.8% (range 67.4-93.2%). Participants reported being "more than satisfied" with the overall program (88.8%) and the health benefits they obtained (72.9%). Qualitative analysis revealed that participants: (1) gained new knowledge and enjoyable experiences; (2) perceived improvements in their physical activity, nutrition, and/or health; (3) continued to face some barriers to physical activity and healthy eating, with those relating to social support being reduced; and (4) rated leaders and the group structure highly, with mixed opinions on the research elements.

CONCLUSIONS

SHHC-2.0 had broad reach, was largely delivered as intended, and participants expressed high levels of satisfaction with the program and its health benefits. Our findings expand on best practices for implementing cardiovascular disease prevention programs in rural communities.

CLINICAL TRIALS REGISTRATION

www.

CLINICALTRIALS

gov #NCT03059472.

Primary care physician density and mortality in the United States

BACKGROUND

Geographic physician availability differences are associated with healthcare outcomes. However, the association between primary care physician (PCP) density and mortality outcomes is less well-established.

METHODS

The study analyzed 2019 county-level nonfederal PCP data from the Health Resources and Services Administration Area Health Resource File and mortality data using the CDC WONDER (Wide-ranging Online Data for Epidemiologic Research). All-cause and cardiovascular disease (CVD)- related age-adjusted mortality rates (AAMR) per 100,000 population stratified by the number of PCPs per 100,000 quartiles were extracted. Using AAMRs as continuous variables, linear regression was performed to determine the association of AAMRs with PCPs per 100,000 (reference, first quartile), adjusting for the social vulnerability index (SVI).

RESULTS

A total of 3142 counties were included in the analysis. Among counties stratified by PCPs per 100,000 quartiles, all-cause AAMRs were 828 (95% CI, 824-832) in the first quartile, 798 (95% CI, 796-801) in the second quartile, 737 (95% CI, 735-739) in the third quartile, and 679 (95% CI, 678-680) in the fourth quartile. Similar trends were seen in CVD-related AAMRs, which were 446 (95% CI, 443-449), 439 (95% CI, 437-441), 403 (95% CI, 402-404), and 365 (95% CI, 364-366), respectively. Counties without PCP (221, included in first quartile) had all-cause and CVD-related AAMR of 797 (95%CI, 783-812) and 430 (95%CI, 419-440), respectively. Compared with the first quartile, SVI-adjusted analyses showed β-coefficient (95%CI) of all-cause mortality for the second, third, and fourth quartiles of -4.11 (95% CI, -18.31, 10.08), -35.37 (95% CI, -49.57, -21.17) and -85.79 (95% CI, -100.10, -71.48). Similar results were observed for CVD-related AAMR.

CONCLUSION

Higher PCP per 100,000 is generally associated with better all-cause and CVD-associated mortality outcomes, however complex factors likely play a role in determining these outcomes in counties with lower PCP per 100,000, which warrant further investigation.

A Toolkit to Facilitate the Selection and Measurement of Health Equity Indicators for Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of illness and death in the US and is substantially affected by social determinants of health, such as social, economic, and environmental factors. CVD disproportionately affects groups that have been economically and socially marginalized, yet health care and public health professionals often lack tools for collecting and using data to understand and address CVD inequities among their populations of focus. The Health Equity Indicators for Cardiovascular Disease Toolkit (HEI for CVD Toolkit) seeks to address this gap by providing metrics, measurement guidance, and resources to support users collecting, measuring, and analyzing data relevant to their CVD work. The toolkit includes a conceptual framework (a visual model for understanding health inequities in CVD); a comprehensive list of health equity indicators (metrics of inequities that influence CVD prevention, care, and management); guidance in definitions, measures, and data sources; lessons learned and examples of HEI implementation; and other resources to support health equity measurement. To develop this toolkit, we performed literature scans to identify primary topics and themes relevant to addressing inequities in CVD, engaged with subject matter experts in health equity and CVD, and conducted pilot studies to understand the feasibility of gathering and analyzing data on the social determinants of health in various settings. This comprehensive development process resulted in a toolkit that can help users understand the drivers of inequities in their communities or patient populations, assess progress, evaluate intervention outcomes, and guide actions to address CVD disparities.

Post-COVID changes and disparities in cardiovascular mortality rates in the United States

Introduction

The COVID-19 pandemic disrupted healthcare delivery and increased cardiovascular morbidity and mortality. This study assesses whether cardiovascular mortality rates in the US have recovered post-pandemic and examines the equity of this recovery across different populations.

Methods

We analyzed data from the CDC WONDER database, covering US residents' mortality from 2018-2023. We focused on cardiovascular diseases, categorized by ischemic heart disease (IHD), heart failure (HF), hypertensive diseases (HTN), and cerebrovascular disease. Age-adjusted mortality rates were calculated for three periods: pre-COVID (2018-2019), during COVID (2020-2021), and post-COVID (2022-2023), stratified by demographic and geographic variables.

Results

Cardiovascular age-adjusted mortality rates increased by 5.9% during the pandemic but decreased by 3.4% post-pandemic, resulting in a net increase of 2.4% compared to pre-COVID levels. When compared to pre COVID age-adjusted mortality rates, post COVID IHD mortality age-adjusted mortality rates decreased by 5.0%, while cerebrovascular and HTN age-adjusted mortality rates increased by 5.9% and 28.5%, respectively. Men and younger populations showed higher increases in cardiovascular Age-adjusted mortality rates. Geographic disparities were notable, with significant reductions in cardiovascular mortality in the Northeast and increases in states like Arizona and Oregon.

Conclusion

The COVID-19 pandemic led to a surge in cardiovascular mortality, with partial recovery post-pandemic. Significant differences in mortality changes highlight the need for targeted healthcare interventions to address inequities across demographic and geographic groups.

Rural Hospital Performance in Guideline-Recommended Ischemic Stroke Thrombolysis, Secondary Prevention, and Outcomes

BACKGROUND

Existing data suggested a rural-urban disparity in thrombolytic utilization for ischemic stroke. Here, we examined the use of guideline-recommended stroke care and outcomes in rural hospitals to identify targets for improvement.

METHODS

This retrospective cohort study included patients (aged ≥18 years) treated for acute ischemic stroke at Get With The Guidelines-Stroke hospitals from 2017 to 2019. Multivariable mixed-effect logistic regression was used to compare thrombolysis rates, speed of treatment, secondary stroke prevention metrics, and outcomes after adjusting for patient- and hospital-level characteristics and stroke severity.

RESULTS

Among the 1 127 607 patients admitted to Get With The Guidelines-Stroke hospitals in 2017 to 2019, 692 839 patients met the inclusion criteria. Patients who presented within 4.5 hours were less likely to receive thrombolysis in rural stroke centers compared with urban stroke centers (31.7% versus 43.5%; adjusted odds ratio [aOR], 0.72 [95% CI, 0.68-0.76]) but exceeded rural nonstroke centers (22.1%; aOR, 1.26 [95% CI, 1.15-1.37]). Rural stroke centers were less likely than urban stroke centers to achieve door-to-needle times of ≤45 minutes (33% versus 44.7%; aOR, 0.86 [95% CI, 0.76-0.96]) but more likely than rural nonstroke centers (aOR, 1.24 [95% CI, 1.04-1.49]). For secondary stroke prevention metrics, rural stroke centers were comparable to urban stroke centers but exceeded rural nonstroke centers (aOR of 1.66, 1.94, 2.44, 1.5, and 1.72, for antithrombotics within 48 hours of admission, antithrombotics at discharge, anticoagulation for atrial fibrillation/flutter, statin treatment, and smoking cessation, respectively). In-hospital mortality was similar between rural and urban stroke centers (aOR, 1.11 [95% CI, 0.99-1.24]) or nonstroke centers (aOR, 1.00 [95% CI, 0.84-1.18]).

CONCLUSIONS

Rural hospitals had lower thrombolysis utilization and slower treatment times than urban hospitals. Rural stroke centers provided comparable secondary stroke prevention treatment to urban stroke centers and exceeded rural nonstroke centers. These results reveal important opportunities and specific targets for rural health equity interventions.

The incidence, mortality and disease burden of cardiovascular diseases in China: a comparative study with the United States and Japan based on the GBD 2019 time trend analysis

Background

Cardiovascular diseases (CVDs) are not only the primary cause of mortality in China but also represent a significant financial burden. The World Health Organization highlight that as China undergoes rapid socioeconomic development, its disease spectrum is gradually shifting towards that of developed countries, with increasing prevalence of lifestyle-related diseases such as ischemic heart disease and stroke. We reviewed the rates and trends of CVDs incidence, mortality and disability-adjusted life years (DALYs) burden in China and compared them with those in the United States (US) and Japan for formulating CVDs control policies.

Methods

Data on CVDs incidence, death and DALYs in China, the US and Japan were obtained from the GBD 2019 database. The Joinpoint regression model was used to analyze the trends in CVDs incidence and mortality in China, the US and Japan, calculate the annual percentage change and determine the best-fitting inflection points.

Results

In 2019, there were approximately 12,341,074 new diagnosed cases of CVDs in China, with 4,584,273 CVDs related deaths, causing 91,933,122 DALYs. The CVDs age-standardized incidence rate (ASIR) in China (538.10/100,000) was lower than that in the US and globally, while age-standardized death rate (ASDR) (276.9/100,000) and age-standardized DALY rate (6,463.47/100,000) were higher than those in the two regions. Compared with the US and Japan, from 1990 to 2019, the CVDs incidence rate in China showed an increasing trend, with a lower annual decrease in ASDR and a younger age structure of disease burden. Furthermore, the disease spectrum in China changed minimally, with stroke, ischemic heart disease, and hypertensive heart disease being the top three leading CVDs diseases in terms of incidence and disease burden, also being the major causes of CVDs in the US and Japan.

Conclusion

The prevention and control of CVDs is a global issue. The aging population and increasing unhealthy lifestyles will continue to increase the burden in China. Therefore, relevant departments in China should reference the established practices for CVDs control in developed countries while considering the diversity of CVDs in different regions when adjusting national CVDs control programs.

The Role of Social Determinants of Health in Atherosclerotic Cardiovascular Disease

PURPOSE OF REVIEW

This review seeks to provide important information on each of the major domains of social determinants of health (SDOH) in the context of atherosclerotic cardiovascular disease.

RECENT FINDINGS

SDOH can be classified into five domains: social and community context, health care access and quality, neighborhood and built environment, economic stability, and education access and quality. SDOH are major drivers for cardiovascular health outcomes that exceed the impact from traditional risk factors, and explain inequities in health outcomes observed across different groups of individuals. SDOH profoundly impacts healthcare's receipt, delivery, and outcomes. Many patients fall within various disenfranchised groups (e.g., identify with minority race, low socioeconomic status, low educational attainment, LGBTQ+), which impact overall health status and care. Learning to understand, recognize, and address SDOH as the driving force of disparities are critical for achieving health equity in the prevention and adequate treatment of ASCVD.

Urban-rural inequalities in IV thrombolysis for acute ischemic stroke: A nationwide study

INTRODUCTION

Rural residency has been associated with lower reperfusion treatment rates for acute ischemic stroke in many countries. We aimed to explore urban-rural differences in IV thrombolysis rates in a small country with universal health care, and short transport times to stroke units.

PATIENTS AND METHODS

In this nationwide cohort study, adult ischemic stroke patients registered in the Danish Stroke Registry (DSR) between 2015 and 2020 were included. The exposure was defined by residence rurality. Data from the DSR, Statistics Denmark, and the Danish Health Data Authority, were linked on the individual level using the Civil Registration Number. Adjusted treatment rates were calculated by balancing baseline characteristics using inverse probability of treatment weights.

RESULTS

Among the included 56,175 patients, prehospital delays were shortest for patients residing in capital municipalities (median 4.7 h), and longest for large town residents (median 7.1 h). Large town residents were predominantly admitted directly to a comprehensive stroke center (98.5%), whereas 30.9% of capital residents were admitted to a hospital with no reperfusion therapy available (non-RT unit). Treatment rates were similar among all non-rural residents (18.5%-18.7%), but slightly lower among rural residents (17.2% [95% CI 16.5-17.8]). After adjusting for age, sex, immigrant status, and educational attainment, rural residents reached treatment rates comparable to capital and large town residents at 18.5% (95% CI 17.7-19.4).

DISCUSSION AND CONCLUSION

While treatment rates varied minimally by urban-rural residency, substantial differences in median prehospital delay and admission to non-RT units underscored marked urban-rural differences in potential obstacles to reperfusion therapies.

Rural-urban disparities in cardiovascular disease mortality vary by poverty level and region

PURPOSE

To examine rural and urban disparities in cardiovascular disease (CVD) death rates by poverty level and region.

METHODS

Using 2021 county-level population and mortality data for CVD deaths listed as the underlying cause among adults aged 35-64 years, we calculated age-standardized CVD death rates and rate ratios (RR) for 4 categories of counties: high-poverty rural, high-poverty urban, low-poverty rural, and low-poverty urban (referent). Results are presented nationally and by US Census region.

FINDINGS

Rural and urban disparities in CVD mortality varied markedly by poverty and region. Nationally, the CVD death rate was highest among high-poverty rural areas (191 deaths per 100,000, RR: 1.76, CI: 1.73-1.78). By region, Southern high-poverty rural areas had the highest CVD death rate (256 deaths per 100,000) and largest disparity relative to low-poverty urban areas (RR: 2.05; CI: 2.01-2.09). In the Midwest and West, CVD death rates among high-poverty areas were higher than low-poverty areas, regardless of rural or urban classification.

CONCLUSIONS

Results reinforce the importance of prioritizing high-poverty rural areas, especially in the South, in efforts to reduce CVD mortality. These efforts may need to consider socioeconomic conditions and region, in addition to rural and urban disparities.

Suicide-related mortality in cardiovascular disease in the United States from 1999 to 2019

INTRODUCTION

Research has shown chronic diseases can be associated with suicide but there is limited data on suicide in cardiovascular disease (CVD). Given the substantial psychosocial, financial, quality of life, and health impact of CVD, we aimed to study suicide-related mortality in CVD.

METHODS

We used Center for Disease Control Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) to access Multiple Cause of Death data from 1999 to 2019. Suicide and CVD related deaths in patients ≥ 25 years were identified. Proportionate suicide-related mortality (PSrM) was calculated as suicide-related deaths (listed with CVD) divided by all CVD-related deaths (irrespective of suicide) and reported as PSrM per 100,000 CVD-related deaths. Joinpoint regression was used to examine trend changes using annual percentage change (APC) overall and by sex, race/ethnicity, disease subtype, and age.

RESULTS

Overall, PSrM in CVD increased from 62.8 in 1999 to 90.5 in 2019. The PSrM increased from 1999 to 2002 with an associated APC of 6.2 (95 % CI, 0.0 to 12.7), remained stable from 2002 to 2005, increased from 2005 to 2013 with an APC of 4.8 (95 % CI, 3.4 to 6.3), and decreased from 2013 to 2019 with an APC of -2.1 (95 % CI, -3.6 to -0.5). Among racial/ethnic groups, PSrM was highest in non-hispanic (NH) White (103.8), then Hispanic or Latino (63.6), and then NH Black or African American individuals (29.2). PSrM was highest in the 25-39 years age group (858), then 40-54 years (382.8), 55-69 years (146.2), 70-84 years (55.9), and then 85+ (17). PSrM initially increased in men with APC (3.1 until 2013), women (4.1 until 2014), NH White individuals (3.9 until 2013), Hispanic or Latino (3.5 until 2014), ages 40-54 years (2.9 until 2013), 55-69 years (6.0 until 2013), then stabilized or decreased. AAMR increased in NH Black or AA individuals APC (1.0) and 25-39 years APC (1.4) from 1999 to 2019.

CONCLUSION

PSrM in CVD peaked in the early 2010s, with varying differences across sex, racial/ethnic, and age groups. Further research is needed to understand disparities and develop preventive strategies.

Cardiovascular Risk Profile Among Reproductive-Aged Women in the U.S.: The Behavioral Risk Factor Surveillance System, 2015-2020

Introduction

Suboptimal cardiovascular health is associated with adverse pregnancy outcomes and long-term cardiovascular risk. The authors examined trends in cardiovascular risk factors and correlates of suboptimal cardiovascular risk profiles among reproductive-aged U.S. women.

Methods

With data from 335,959 women in the Behavioral Risk Factor Surveillance System (2015-2020), the authors conducted serial cross-sectional analysis among nonpregnant reproductive-aged women (18-44 years) without cardiovascular disease who self-reported information on 8 cardiovascular risk factors selected on the basis of Life's Essential 8 metrics. The authors estimated the prevalence of each risk factor and suboptimal cardiovascular risk profile (≥2 risk factors) and examined trends overall and by age and race/ethnicity. Using multivariable Poisson regression, the authors assessed the sociodemographic correlates of suboptimal cardiovascular risk profile.

Results

The weighted prevalence of women aged <35 years was approximately 64% in each survey year. The prevalence of suboptimal cardiovascular risk profile increased modestly from 72.4% (71.6%-73.3%) in 2015 to 75.9% (75.0%-76.7%) in 2019 (p<0.001). This increase was mainly driven by increases in overweight/obesity (53.1%-58.4%; p<0.001). Between 2015 and 2019, significant increases in suboptimal cardiovascular risk profile were observed among non-Hispanic White (69.8%-72.6%; p<0.001) and Hispanic (75.1%-80.3%; p<0.001) women but not among non-Hispanic Black (82.7%-83.7%; p=0.48) or Asian (68.1%-73.2%; p=0.09) women. Older age, rural residence, and non-Hispanic Black and Hispanic race and ethnicity were associated with a higher prevalence of suboptimal cardiovascular risk profile.

Conclusions

There has been a modest but significant increase in suboptimal cardiovascular risk profile among U.S. women of reproductive age. Urgent preventive efforts are needed to reverse this trend and improve cardiovascular health, particularly among subgroups at increased risk, to mitigate its implications.

Intracerebral hemorrhage mortality in individuals with atrial fibrillation: a nationwide analysis of mortality trends in the United States

BACKGROUND

Atrial fibrillation (AF) is a risk factor for intracerebral hemorrhage (ICH), both with and without use of anticoagulation. Limited data exists on mortality trends and disparities related to this phenomenon. We aimed to assess ICH mortality trends and disparities based on demographic factors in individuals with atrial fibrillation in the United States (US).

METHODS

Our cross-sectional analysis utilized mortality data from the CDC database through death certificate queries from the years 1999 to 2020 in the US. We queried for all deaths with ICH as the underlying cause of death and atrial fibrillation as the multiple causes of death. Mortality data was obtained for overall population and demographic subpopulations based on sex, race and ethnicity, and geographic region. Trend analysis and average annual-mortality percentage change (AAPC) were completed using log-linear regression models.

RESULTS

ICH age-adjusted mortality rate (AAMR) in patients with AF increased from 0.27 (95% CI 0.25-0.29) in 1999 to 0.30 (95% CI 0.29-0.32) in 2020. A higher mortality rate was observed in males (AAMR 0.33) than in females (AAMR 0.26). The highest mortality was found in Asian/Pacific Islander (AAMR: 0.32) populations, followed by White (AAMR: 0.30), Black (AAMR: 0.15), and American Indian/Alaska Native (AAMR: 0.11) populations. Southern (AAPC: 1.3%) and non-metropolitan US regions (AAPC: + 1.9%) had the highest increase in annual mortality change.

CONCLUSION

Our findings highlight the disparities in ICH mortality in patients with AF. Further investigation is warranted to confirm these findings and evaluate for contributors to the observed disparities.

Palliative Care in Rural Communities

ABSTRACT

Rural communities in the United States are frequently marginalized and misrepresented. These communities face unique challenges, such as limited access to health care, nutritious food, and clean water, that contribute to persistent health disparities. This article presents the CARE (Complex, Access, Resourceful, Extraordinary) framework, which illustrates the dichotomy of rurality-its negative and positive aspects-in order to inform the development of palliative care delivery in rural settings. Various palliative care models are described that address access gaps, bolster provider capacity, and increase the provision of specialty palliative care. However, workforce shortages and reimbursement structures restrict the expansion of these services. Nurses, the largest segment of the health care workforce and the most trusted professionals, must partner with interdisciplinary colleagues and rural communities to advocate for equitable and inclusive care.

Forecasting the Burden of Cardiovascular Disease and Stroke in the United States Through 2050-Prevalence of Risk Factors and Disease: A Presidential Advisory From the American Heart Association

BACKGROUND

Cardiovascular disease and stroke are common and costly, and their prevalence is rising. Forecasts on the prevalence of risk factors and clinical events are crucial.

METHODS

Using the 2015 to March 2020 National Health and Nutrition Examination Survey and 2015 to 2019 Medical Expenditure Panel Survey, we estimated trends in prevalence for cardiovascular risk factors based on adverse levels of Life's Essential 8 and clinical cardiovascular disease and stroke. We projected through 2050, overall and by age and race and ethnicity, accounting for changes in disease prevalence and demographics.

RESULTS

We estimate that among adults, prevalence of hypertension will increase from 51.2% in 2020 to 61.0% in 2050. Diabetes (16.3% to 26.8%) and obesity (43.1% to 60.6%) will increase, whereas hypercholesterolemia will decline (45.8% to 24.0%). The prevalences of poor diet, inadequate physical activity, and smoking are estimated to improve over time, whereas inadequate sleep will worsen. Prevalences of coronary disease (7.8% to 9.2%), heart failure (2.7% to 3.8%), stroke (3.9% to 6.4%), atrial fibrillation (1.7% to 2.4%), and total cardiovascular disease (11.3% to 15.0%) will rise. Clinical CVD will affect 45 million adults, and CVD including hypertension will affect more than 184 million adults by 2050 (>61%). Similar trends are projected in children. Most adverse trends are projected to be worse among people identifying as American Indian/Alaska Native or multiracial, Black, or Hispanic.

CONCLUSIONS

The prevalence of many cardiovascular risk factors and most established diseases will increase over the next 30 years. Clinical and public health interventions are needed to effectively manage, stem, and even reverse these adverse trends.

Rural-Urban Disparities in the Surgical Treatment of Carpal Tunnel Syndrome in the United States

PURPOSE

Rural populations are at risk for poorer access to health services and lower quality care, and recent policy efforts have focused on the reduction of rural-urban health inequities. The objective of this study was to identify differences in (1) patient demographic factors, (2) the utilization of confirmatory electrodiagnostic (EDS) testing, and (3) preoperative EDS severity between rural and urban populations undergoing carpal tunnel release (CTR).

METHODS

We retrospectively identified 1,297 patients who underwent CTR at a tertiary referral center from July 2008 to June 2013. Exclusion criteria were acute trauma or infection, revision surgery, incomplete medical records, neoplasm excision, and the lack of rural-urban commuting area (RUCA) code for rural-urban classification. A final cohort of 1,138 patients who underwent CTR were included. The RUCA was used to classify patients by rural or urban residence. We assessed patient demographic factors including comorbidities, the utilization of confirmatory EDS testing, and preoperative EDS severity. A bivariate screen was performed for associations between rural-urban residence and our outcome variables, and variables with p <0.05 in the bivariate screen were included in a multivariable logistic regression model.

RESULTS

Of the 1,138 patients, 55 patients (5%) resided in a rural area and 1,083 patients (95%) resided in an urban area. No difference was found in the utilization of confirmatory EDS testing between rural and urban patients undergoing CTR. The final multivariable logistic regression model showed that rural residence was independently associated with older age, lower body mass index (BMI), and EDS-negative disease.

CONCLUSIONS

Rural patients undergoing CTR are more likely to have EDS-negative disease, which calls into question the effectiveness of EDS testing as a confirmatory test in this population. There is a paucity of literature on the outcomes of CTR in a rural population, and further studies are needed to ensure rural-urban equity in care.

Working From Within: The Rural Community Participatory Design Framework

OBJECTIVE

This article describes the development of the rural community-based participatory design framework to guide healthcare design teams in their integration of rural community and clinical voice during the planning, design, and construction of a healthcare facility.

BACKGROUND

Rural communities are facing an alarming rate of healthcare facility closures, provider shortages, and dwindling resources, which are negatively impacting population health outcomes. A prioritized focus on rural care access and delivery requires design teams to have a deeper understanding of the contextual considerations necessary for a successful healthcare facility project, made possible through engagement and partnership with rural dwelling community members and healthcare teams.

METHOD

The rural community participatory design framework is adapted from the rural participatory research model, selected due to its capture of key concepts and characteristics of rural communities. Underpinning theories included rural nursing theory and theory of the built environment.

RESULTS

The framework encompasses healthcare facility project phases, key translational concepts, and common traits across rural communities and cultures. As a middle-range theoretical framework, it is being tested in a current healthcare project with a Critical Access Hospital in Montana to facilitate design team and stakeholder collaboration.

CONCLUSION

The rural community participatory design framework may be utilized by design teams as a means of familiarization with rural cultures, norms, values, and critical needs, which relate to meaningful design. The framework further enables design teams to critically appraise best practices of stakeholder engagement throughout the project lifecycle.

Patterns, Prognostic Implications, and Rural-Urban Disparities in Optimal GDMT Following HFrEF Diagnosis Among Medicare Beneficiaries

BACKGROUND

Patterns and disparities in guideline-directed medical therapy (GDMT) uptake for heart failure with reduced ejection fraction (HFrEF) across rural vs urban regions are not well described.

OBJECTIVES

This study aims to evaluate patterns, prognostic implications, and rural-urban differences in GDMT use among Medicare beneficiaries following new-onset HFrEF.

METHODS

Patients with a diagnosis of new-onset HFrEF in a 5% Medicare sample with available data for Part D medication use were identified from January 2015 through December 2020. The primary exposure was residence in rural vs urban zip codes. Optimal triple GDMT was defined as ≥50% of the target daily dose of beta-blockers, ≥50% of the target daily dose of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker or any dose of sacubitril/valsartan, and any dose of mineralocorticoid receptor antagonist. The association between the achievement of optimal GDMT over time following new-onset HFrEF diagnosis and risk of all-cause mortality and subsequent HF hospitalization was also evaluated using adjusted Cox models. The association between living in rural vs urban location and time to optimal GDMT achievement over a 12-month follow-up was assessed using cumulative incidence curves and adjusted Fine-Gray subdistribution hazard models.

RESULTS

A total of 41,296 patients (age: 76.7 years; 15.0% Black; 27.6% rural) were included. Optimal GDMT use over the 12-month follow-up was low, with 22.5% initiated on any dose of triple GDMT and 9.1% on optimal GDMT doses. Optimal GDMT on follow-up was significantly associated with a lower risk of death (HR: 0.89 [95% CI: 0.85-0.94]; P < 0.001) and subsequent HF hospitalization (HR: 0.93 [95% CI: 0.87-0.98]; P = 0.02). Optimal GDMT use at 12 months was significantly lower among patients living in rural (vs urban) areas (8.4% vs 9.3%; P = 0.02). In adjusted analysis, living in rural (vs urban) locations was associated with a significantly lower probability of achieving optimal GDMT (HR: 0.92 [95% CI: 0.86-0.98]; P = 0.01 Differences in optimal GDMT use following HFrEF diagnosis accounted for 16% of excess mortality risk among patients living in rural (vs urban) areas.

CONCLUSIONS

Use of optimal GDMT following new-onset HFrEF diagnosis is low, with substantially lower use noted among patients living in rural vs urban locations. Suboptimal GDMT use following new-onset HFrEF was associated with an increased risk of mortality and subsequent HF hospitalization.

Cost and non-cost factors associated with delays in receiving medical care in adults with atherosclerotic cardiovascular disease

BACKGROUND

The study aims to compare cost and non-cost factors associated with delays in receiving medical care in adults with atherosclerotic cardiovascular disease (ASCVD).

METHODS

Using 2014-2018 data from the Centers for Disease Control and Prevention (CDC) Behaviour Risk Factor Surveillance System (BRFSS) survey (N = 508,203), multivariate logistic regression models were developed to compute the adjusted odds ratio of reasons for delays in medical care in adults with ASCVD.

RESULTS

Our study population of 61,227 adults with ASCVD (9.1%) had higher odds of any medical care delay (aOR 1.50, 95% CI 1.43-1.57), delay due to cost (aOR 1.55, 95% CI 1.45-1.65), long clinic wait times (aOR 1.21, 95% CI 1.04-1.39) and lack of transportation (aOR 1.64, 95% CI 1.47-1.84) than those without ASCVD.

CONCLUSION

Novel public health and health policy approaches are urgently needed to reduce the cost- and non-cost-related barriers that adults with ASCVD encounter when accessing healthcare services.

The mediating effect of uncertainty in illness between heart failure symptoms and health-related quality of life among rural patients with heart failure: A multi-center cross-sectional study

BACKGROUND

The health-related quality of life (HRQoL) of patients with heart failure (HF) in rural settings in China remains unclear. Limited studies explored the mediating effect of uncertainty in illness between heart failure symptoms and HRQoL in this population.

OBJECTIVES

To explore the status of HRQoL in rural patients with HF; assess the impact of HF symptoms and uncertainty in illness on HRQoL; and examine the mediating effect of uncertainty in illness on the relationship between symptoms and HRQoL in rural patients with HF.

METHODS

Overall, 298 rural patients with HF were recruited from five township hospitals of Taishan and Jinzhong City in China between November 2021 and August 2022. Three variables, namely HF symptoms, uncertainty in illness, and HRQoL were measured using three validated scales.

RESULTS

The average score of HRQoL in rural patients with HF was 43.19. Of the participants, 60.4 %, 35.23 %, and 4.37 % exhibited poor, moderate, and good HRQoL, respectively. The HF symptoms (β = -0.47) and uncertainty in illness (β = -0.34) directly influenced HRQoL. Moreover, the HF symptoms also indirectly affected HRQoL through uncertainty in illness (β = -0.07). The indirect effect accounted for 12.96 % of the total effect of HF symptoms on HRQoL.

CONCLUSION

Rural patients with HF exhibited poor HRQoL. In this population, HF symptoms and uncertainty in illness were negatively associated with HRQoL. Uncertainty in illness mediated the relationship between HF symptoms and HRQoL. Tailored healthcare services should be developed for the rural population to alleviate HF symptoms, reduce uncertainty in illness, and enhance their HRQoL.

Addressing Social Determinants of Health in Maternal Cardiovascular Health

Cardiovascular diseases (CVDs) remain the number-one cause of maternal mortality, with over two-thirds of cases being preventable. Social determinants of health (SDoH) encompass the nonmedical social and environmental factors that an individual experiences that have a significant impact on their health. These stressors disproportionately affect socially disadvantaged and minority populations. Pregnancy is a physiologically stressful state that can unmask underlying CVD risk factors and lead to adverse pregnancy outcomes (APOs). Disparities in APOs are particularly pronounced among individuals of color and those from economically disadvantaged backgrounds. This variation underscores healthcare inequity and access, a failure of the healthcare system. Besides short-term negative effects, APOs also are associated strongly with long-term CVDs. APOs therefore must be identified as a cue for early intervention, for the prevention and management of CVD risk factors. This review explores the intricate relationship among maternal morbidity and mortality, SDoH, and cardiovascular health, and the implementation of health policy efforts to reduce the negative impact of SDoH in this patient population. The review emphasizes the importance of comprehensive strategies to improve maternal health outcomes.

Educational status and the risk of adverse outcomes in Asian patients with atrial fibrillation: a report from the prospective APHRS-AF Registry

BACKGROUND

The aim of this study was to evaluate the impact of educational status (ES) on the clinical course of Asian patients with atrial fibrillation (AF).

METHODS

We used data from the prospective APHRS-AF Registry. ES was classified as follows: low (primary school), medium (secondary), and high (University). The primary outcome was a composite of all-cause death, thromboembolic events, acute coronary syndrome, and heart failure. Secondary outcomes were each component of the primary outcome, cardiovascular death, and major bleeding. The one-year risk of primary and secondary outcomes was assessed through Cox-regressions. Adherence to the Atrial fibrillation Better Care (ABC) pathway was assessed.

RESULTS

Among 2697 AF patients (69±12 years, 34.8% females), 34.6% had low ES; 37.3% had medium ES; and 28.1% had high ES. Compared to patients with medium-high ES, patients with low ES were older, more often females, with a higher prevalence of cardiovascular risk factors, and a lower ABC pathway adherence (30.4% vs. 40.2%, P<0.001). On multivariable analysis, low ES was associated with a higher risk for the primary outcome (HR 1.52,95%CI 1.11-2.06) and all-cause death (HR 1.76,95%CI 1.10-2.83) than medium-high ES. A significant interaction was found for the risk of composite outcome among the different age strata, with the higher risk in the elderly (P for int=0.008), whereas the beneficial effect of the ABC pathway was irrespective of ES (P for int=0.691).

CONCLUSIONS

In Asian AF patients, low ES is associated with high mortality. Efforts to improve education and include ES evaluation in the integrated care approach for AF are necessary to reduce the cardiovascular burden in these patients.

Socioeconomic Disparities in Women's Cardiovascular Health in the United States and Canada

Cardiovascular disease has been the leading cause of death in the United States and Canada for decades. Although it affects millions of people across a multitude of backgrounds, notable disparities in cardiovascular health are observed among women and become more apparent when accounting for race and socioeconomic status. Although intrinsic sex-specific physiologic differences predispose women to poorer outcomes, social determinants of health (SDOH) and biases at both the individual provider and the larger health care system levels play an equal, if not greater, role. This review examines socioeconomic disparities in women compared with men regarding cardiovascular risk factors, treatments, and outcomes. Although various at-risk subpopulations exist, we highlight the impact of SDOH in specific populations, including patients with disabilities, transgender persons, and South Asian and Indigenous populations. These groups are underrepresented in studies and experience poorer health outcomes owing to structural barriers to care. These findings emphasise the significance of understanding the interplay of different socioeconomic factors and how their stacking can negatively affect women's cardiovascular health. To address these disparities, we propose a multipronged approach to augment culturally sensitive and patient-centred care. This includes increased cardiovascular workforce diversity, inclusion of underrepresented populations into analyses of cardiovascular metrics, and greater utilisation of technology and telemedicine to improve access to health care. Achieving this goal will necessitate active participation from patients, health care administrators, physicians, and policy makers, and is imperative in closing the cardiovascular health gap for women over the coming decades.

Evidence From the China Family Panel Studies Survey on the Effect of Integrating the Basic Medical Insurance System for Urban and Rural Residents on the Health Equity of Residents: Difference-in-Differences Analysis

BACKGROUND

The fragmentation of the medical insurance system is a major challenge to achieving health equity. In response to this problem, the Chinese government is pushing to establish the unified Urban and Rural Resident Basic Medical Insurance (URRBMI) system by integrating the New Rural Cooperative Medical Scheme and the Urban Resident Basic Medical Insurance. By the end of 2020, URRBMI had been implemented almost entirely across China. Has URRBMI integration promoted health equity for urban and rural residents?

OBJECTIVE

This study aims to examine the effect of URRBMI integration on the health level of residents and whether the integration can contribute to reducing health disparities and promoting health equity.

METHODS

We used the staggered difference-in-differences method based on the China Family Panel Studies survey from 2014 to 2018. Our study had a nationally representative sample of 27,408 individuals from 98 cities. We chose self-rated health as the measurement of health status. In order to more accurately discern whether the sample was covered by URRBMI, we obtained the exact integration time of URRBMI according to the official documents issued by local governments. Finally, we grouped the sample by urban and rural areas, regions, and household income to examine the impact of the integration on health equity.

RESULTS

We found that overall, the URRBMI integration has improved the health level of Chinese residents (B=0.066, 95% CI 0.014-0.123; P=.01). In terms of health equity, the results showed that first, the integration has improved the health level of rural residents (B=0.070, 95% CI 0.012-0.128; P=.02), residents in western China (B=0.159, 95% CI 0.064-0.255; P<.001), and lower-middle-income groups (B=0.113, 95% CI 0.004-0.222, P=.04), so the integration has played a certain role in narrowing the health gap between urban and rural areas, different regions, and different income levels. Through further mechanism analysis, we found that the URRBMI integration reduced health inequity in China by facilitating access to higher-rated hospitals and increasing reimbursement rates for medical expenses. However, the integration did not improve the health of the central region and low-income groups, and the lack of access to health care for low-income groups was not effectively reduced.

CONCLUSIONS

The role of URRBMI integration in promoting health equity among urban and rural residents was significant (P=.02), but in different regions and income groups, it was limited. Focusing on the rational allocation of medical resources between regions and increasing the policy tilt toward low-income groups could help improve the equity of health insurance integration.

Moving towards establishing centres of excellence in cardiac amyloidosis: an International Cardio-Oncology Society statement

The prevalence of amyloidosis has been increasing, driven by a combination of improved awareness, evolution of diagnostic pathways, and effective treatment options for both transthyretin and light chain amyloidosis. Due to the complexity of amyloidosis, centralised expert providers with experience in delineating the nuances of confirmatory diagnosis and management may be beneficial. There are many potential benefits of a centre of excellence designation for the treatment of amyloidosis including recognition of institutions that have been leading the way for the optimal treatment of this condition, establishing the expectations for any centre who is engaging in the treatment of amyloidosis and developing cooperative groups to allow more effective research in this disease space. Standardising the expectations and criteria for these centres is essential for ensuring the highest quality of clinical care and community education. In order to define what components are necessary for an effective centre of excellence for the treatment of amyloidosis, we prepared a survey in cooperation with a multidisciplinary panel of amyloidosis experts representing an international consortium. The purpose of this position statement is to identify the essential elements necessary for highly effective clinical care and to develop a general standard with which practices or institutions could be recognised as a centre of excellence.

Disparities in Cardiovascular Disease-Related Outcomes Among Cancer Survivors in the United States: A Systematic Review of the Literature

BACKGROUND

Cancer and cardiovascular disease (CVD) are major causes of morbidity and mortality in the United States (US). Cancer survivors have increased risks for CVD and CVD-related mortality due to multiple factors including cancer treatment-related cardiotoxicity. Disparities are rooted in differential exposure to risk factors and social determinants of health (SDOH), including systemic racism. This review aimed to assess SDOH's role in disparities, document CVD-related disparities among US cancer survivors, and identify literature gaps for future research.

METHODS

Following the Peer Review of Electronic Search Strategies (PRESS) guidelines, MEDLINE, PsycINFO, and Scopus were searched on March 15, 2021, with an update conducted on September 26, 2023. Articles screening was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, a pre-defined Population, Exposure, Comparison, Outcomes, and Settings (PECOS) framework, and the Rayyan platform. A modified version of the Newcastle-Ottawa Scale was used to assess the risk of bias, and RAW Graphs for alluvial charts. This review is registered with PROSPERO under ID #CRD42021236460.

RESULTS

Out of 7,719 retrieved articles, 24 were included, and discussed diverse SDOH that contribute to CVD-related disparities among cancer survivors. The 24 included studies had a large combined total sample size (n=7,704,645; median=19,707). While various disparities have been investigated, including rural-urban, sex, socioeconomic status, and age, a notable observation is that non-Hispanic Black cancer survivors experience disproportionately adverse CVD outcomes when compared to non-Hispanic White survivors. This underscores historical racism and discrimination against non-Hispanic Black individuals as fundamental drivers of CVD-related disparities.

CONCLUSIONS

Stakeholders should work to eliminate the root causes of disparities. Clinicians should increase screening for risk factors that exacerbate CVD-related disparities among cancer survivors. Researchers should prioritise the investigation of systemic factors driving disparities in cancer and CVD and develop innovative interventions to mitigate risk in cancer survivors.

Rurality of patient residence and access to transplantation among children with kidney failure in the United States

BACKGROUND

Residence in rural areas is often a barrier to health care access. To date, differences in access to kidney transplantation among children who reside in rural and micropolitan areas of the US have not been explored.

METHODS

A retrospective cohort study of children < 18 years who developed kidney failure between 2000 and 2019 according to the United States Renal Data System (USRDS). We examined the association between rurality of patient residence and time to living and/or deceased donor kidney transplantation (primary outcomes) and waitlist registration (secondary outcome) using Fine-Gray models.

RESULTS

We included 18,530 children, of whom 14,175 (76.5%) received a kidney transplant (39.8% from a living and 60.2% from a deceased donor). Residence in micropolitan (subhazard ratio (SHR) 1.16; 95% CI 1.06-1.27) and rural (SHR 1.18; 95% CI 1.06-1.3) areas was associated with better access to living donor transplantation compared with residence in metropolitan areas. There was no statistically significant association between residence in micropolitan (SHR, 0.95; 95%CI 0.88-1.03) and rural (SHR, 0.94; 95%CI 0.86-1.03) areas compared with metropolitan areas in the access of children to deceased donor transplantation. There was also no difference in the time to waitlist registration comparing micropolitan (SHR 1.04; 95%CI 0.98-1.10) and rural (SHR 1.05; 95% CI 0.98-1.13) versus metropolitan areas.

CONCLUSIONS

In children with kidney failure, residence in rural and micropolitan areas was associated with better access to living donor transplantation and similar access to deceased donor transplantation compared with residence in metropolitan areas.

Mortality patterns in older adults with infective endocarditis in the US: A retrospective analysis

BACKGROUND

Infective Endocarditis (IE) has become a significant cause of morbidity and mortality over the last two decades. Despite management advancements, mortality trends in the USA's geriatric population are unexplored. The aim of this study was to assess the trends and regional differences in IE related mortality among geriatric patients in the USA.

METHODS

We analyzed death certificates sourced from the CDC WONDER database spanning 1999 to 2020. The research targeted individuals aged 65 and older. Age-adjusted mortality rates (AAMRs) per 100,000 and annual percent change (APC), along with 95% CI, were calculated through joinpoint regression analysis.

RESULTS

From 1999 to 2020, infective endocarditis caused 222,573 deaths, showing a declining trend (APC: -0.8361). Males had higher AAMR (26.8) than females (22.2). NH White had the highest AAMR (25.8), followed by NH American Indians or Alaska Natives (19.6). Geographically, the Midwest had the highest AAMR (27.4), followed by the Northeast (25.8). Rural areas consistently had higher AAMRs (26.6) than urban areas (23.6), while 80.16% of deaths occurring in urban settings. North Dakota, Nebraska, and Montana had the highest state AAMRs, approximately double than the states with the lowest mortality rates: Mississippi, Hawaii, California, and Massachusetts. Those aged 85 and above accounted for 42.9% of deaths.

CONCLUSION

IE mortality exhibited a clear pattern: rising till 2004, declining from 2004 to 2018, and increasing again till 2020. Key risk factors were male gender, Midwest residence, NH White ethnicity, and age ≥85.Targeted interventions are essential to reduce IE mortality, especially among vulnerable older populations.

Rural/urban disparities in the trends and outcomes of peripartum cardiomyopathy in delivery hospitalizations

BACKGROUND

Rural-urban disparities in peripartum cardiomyopathy (PPCM) are not well known. We examined rural-urban differences in maternal, fetal, and cardiovascular outcomes in PPCM during delivery hospitalizations.

METHODS

We used 2003-2020 data from the National Inpatient Sample for delivery hospitalizations in individuals with PPCM. The 9th and 10th editions of the International Classification of Diseases were used to identify PPCM and cardiovascular, maternal, and fetal outcomes. Rural and urban hospitalizations for PPCM were 1:1 propensity score-matched using relevant clinical and sociodemographic variables. Odds of in-hospital mortality were assessed using logistic regression.

RESULTS

Among 72,880 delivery hospitalizations with PPCM, 4,571 occurred in rural locations, while 68,309 occurred in urban locations. After propensity matching, there were a total of 4,571 rural-urban pairs. There was significantly higher in-hospital mortality in urban compared to rural hospitalizations (adjusted OR 1.54, 95% CI 1.10-1.89). Urban PPCM hospitalizations had significantly higher cardiogenic shock (2.9% vs. 1.3%), mechanical circulatory support (1.0% vs. 0.6%), cardiac arrest (2.3% vs. 0.9%), and VT/VF (4.5% vs. 2.1%, all p <.05). Additionally, urban PPCM hospitalizations had worse maternal and fetal outcomes as compared to rural hospitalizations, including higher preterm delivery, gestational diabetes, and fetal death (all p<.05). Notably, significantly more rural individuals were transferred to a short-term hospital (including tertiary care centers) compared to urban individuals (13.5% vs. 3.2%, p<.0001).

CONCLUSIONS

There are significant rural-urban disparities in delivery hospitalizations with PPCM. Worse outcomes were associated with urban hospitalizations, while rural PPCM hospitalizations were associated with increased transfers, suggesting inadequate resources and advanced sickness.

Rural Veterans' Experiences with Social Risk Factors: Impacts, Challenges, and Care System Recommendations

BACKGROUND

Social risk factors, such as food insecurity and financial needs, are associated with increased risk of cardiovascular diseases, health conditions that are highly prevalent in rural populations. A better understanding of rural Veterans' experiences with social risk factors can inform expansion of Veterans Health Administration (VHA) efforts to address social needs.

OBJECTIVE

To examine social risk and need from rural Veterans' lived experiences and develop recommendations for VHA to address social needs.

DESIGN

We conducted semi-structured interviews with participants purposively sampled for racial diversity. The interview guide was informed by Andersen's Behavioral Model of Health Services Use and the Outcomes from Addressing Social Determinants of Health in Systems framework.

PARTICIPANTS

Rural Veterans with or at risk of cardiovascular disease who participated in a parent survey and agreed to be recontacted.

APPROACH

Interviews were recorded and transcribed. We analyzed transcripts using directed qualitative content analysis to identify themes.

KEY RESULTS

Interviews (n = 29) took place from March to June 2022. We identified four themes: (1) Social needs can impact access to healthcare, (2) Structural factors can make it difficult to get help for social needs, (3) Some Veterans are reluctant to seek help, and (4) Veterans recommended enhancing resource dissemination and navigation support.

CONCLUSIONS

VHA interventions should include active dissemination of information on social needs resources and navigation support to help Veterans access resources. Community-based organizations (e.g., Veteran Service Organizations) could be key partners in the design and implementation of future social need interventions.

Deep learning from latent spatiotemporal information of the heart: Identifying advanced bioimaging markers from echocardiograms

A key strength of echocardiography lies in its integration of comprehensive spatiotemporal cardiac imaging data in real-time, to aid frontline or bedside patient risk stratification and management. Nonetheless, its acquisition, processing, and interpretation are known to all be subject to heterogeneity from its reliance on manual and subjective human tracings, which challenges workflow and protocol standardization and final interpretation accuracy. In the era of advanced computational power, utilization of machine learning algorithms for big data analytics in echocardiography promises reduction in cost, cognitive errors, and intra- and inter-observer variability. Novel spatiotemporal deep learning (DL) models allow the integration of temporal arm information based on unlabeled pixel echocardiographic data for convolution of an adaptive semantic spatiotemporal calibration to construct personalized 4D heart meshes, assess global and regional cardiac function, detect early valve pathology, and differentiate uncommon cardiovascular disorders. Meanwhile, data visualization on spatiotemporal DL prediction models helps extract latent temporal imaging features to develop advanced imaging biomarkers in early disease stages and advance our understanding of pathophysiology to support the development of personalized prevention or treatment strategies. Since portable echocardiograms have been increasingly used as point-of-care imaging tools to aid rural care delivery, the application of these new spatiotemporal DL techniques show the potentials in streamlining echocardiographic acquisition, processing, and data analysis to improve workflow standardization and efficiencies, and provide risk stratification and decision supporting tools in real-time, to prompt the building of new imaging diagnostic networks to enhance rural healthcare engagement.

The role of comorbidities, medications, and social determinants of health in understanding urban-rural outcome differences among patients with heart failure

PURPOSE

There is now a 20% disparity in all-cause, excess deaths between urban and rural areas, much of which is driven by disparities in cardiovascular death. We sought to explain the sources of these disparities for Medicare beneficiaries with heart failure with reduced ejection fraction (HFrEF).

METHODS

Using a sample of Medicare Parts A, B, and D, we created a cohort of 389,528 fee-for-service beneficiaries with at least 1 heart failure hospitalization from 2008 to 2017. The primary outcome was 30-day mortality after discharge; 1-year mortality, readmissions, and return emergency room (ER) admissions were secondary outcomes. We used hierarchical, logistic regression modeling to determine the contribution of comorbidities, guideline-directed medical therapy (GDMT), and social determinants of health (SDOH) to outcomes.

RESULTS

Thirty-day mortality rates after hospital discharge were 6.3% in rural areas compared to 5.7% in urban regions (P < .001); after adjusting for patient health and GDMT receipt, the 30-day mortality odds ratio for rural residence was 1.201 (95% CI 1.164-1.239). Adding the SDOH measure reduced the odds ratio somewhat (1.140, 95% CI 1.103-1.178) but a gap remained. Readmission rates in rural areas were consistently lower for all model specifications, while ER admissions were consistently higher.

CONCLUSIONS

Among patients with HFrEF, living in a rural area is associated with an increased risk of death and return ER visits within 30 days of discharge from HF hospitalization. Differences in SDOH appear to partially explain mortality differences but the remaining gap may be the consequence of rural-urban differences in HF treatment.

Challenges & barriers for real-time integration of drones in emergency cardiac care: Lessons from the United States, Sweden, & Canada

Importance

Out-of-hospital cardiac arrest (OHCA) is a leading cause of morbidity and mortality in the US and Europe (∼600,000 incident events annually) and around the world (∼3.8 million). With every minute that passes without cardiopulmonary resuscitation or defibrillation, the probability of survival decreases by 10%. Preliminary studies suggest that uncrewed aircraft systems, also known as drones, can deliver automated external defibrillators (AEDs) to OHCA victims faster than ground transport and potentially save lives.

Objective

To date, the United States (US), Sweden, and Canada have made significant contributions to the knowledge base regarding AED-equipped drones. The purpose of this Special Communication is to explore the challenges and facilitators impacting the progress of AED-equipped drone integration into emergency medicine research and applications in the US, Sweden, and Canada. We also explore opportunities to propel this innovative and important research forward.

Evidence review

In this narrative review, we summarize the AED-drone research to date from the US, Sweden, and Canada, including the first drone-assisted delivery of an AED to an OHCA. Further, we compare the research environment, emergency medical systems, and aviation regulatory environment in each country as they apply to OHCA, AEDs, and drones. Finally, we provide recommendations for advancing research and implementation of AED-drone technology into emergency care.

Findings

The rates that drone technologies have been integrated into both research and real-life emergency care in each country varies considerably. Based on current research, there is significant potential in incorporating AED-equipped drones into the chain of survival for OHCA emergency response. Comparing the different environments and systems in each country revealed ways that each can serve as a facilitator or barrier to future AED-drone research.

Conclusions and relevance

The US, Sweden, and Canada each offers different challenges and opportunities in this field of research. Together, the international community can learn from one another to optimize integration of AED-equipped drones into emergency systems of care.

Inorganic Nitrite to Amplify the Benefits and Tolerability of Exercise Training in Heart Failure With Preserved Ejection Fraction: The INABLE-Training Trial

OBJECTIVE

To determine whether nitrite can enhance exercise training (ET) effects in heart failure with preserved ejection fraction (HFpEF).

METHODS

In this multicenter, double-blind, placebo-controlled, randomized trial conducted at 1 urban and 9 rural outreach centers between November 22, 2016, and December 9, 2021, patients with HFpEF underwent ET along with inorganic nitrite 40 mg or placebo 3 times daily. The primary end point was peak oxygen consumption (VO2). Secondary end points included Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OSS, range 0 to 100; higher scores reflect better health status), 6-minute walk distance, and actigraphy.

RESULTS

Of 92 patients randomized, 73 completed the trial because of protocol modifications necessitated by loss of drug availability. Most patients were older than 65 years (80%), were obese (75%), and lived in rural settings (63%). At baseline, median peak VO2 (14.1 mL·kg-1·min-1) and KCCQ-OSS (63.7) were severely reduced. Exercise training improved peak VO2 (+0.8 mL·kg-1·min-1; 95% CI, 0.3 to 1.2; P<.001) and KCCQ-OSS (+5.5; 95% CI, 2.5 to 8.6; P<.001). Nitrite was well tolerated, but treatment with nitrite did not affect the change in peak VO2 with ET (nitrite effect, -0.13; 95% CI, -1.03 to 0.76; P=.77) or KCCQ-OSS (-1.2; 95% CI, -7.2 to 4.9; P=.71). This pattern was consistent across other secondary outcomes.

CONCLUSION

For patients with HFpEF, ET administered for 12 weeks in a predominantly rural setting improved exercise capacity and health status, but compared with placebo, treatment with inorganic nitrite did not enhance the benefit from ET.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02713126.

Analysis of the Weekend Effect on Mortality, Diagnostic Coronary Angiography, and Percutaneous Coronary Intervention in Acute Myocardial Infarction Across Rural US Hospitals

BACKGROUND

Rural hospitals face several unique challenges in delivering healthcare to an underserved population. Achieving time-sensitive goals in a resource-scarce facility is often a difficult task without the right team at hand. Resources are further depleted on the weekends, exposing understaffed hospitals to poorer outcomes. Acute myocardial infarction (AMI) mortality depends on timely diagnosis and intervention. It is unknown to what extent resource shortages impact rural hospitals during weekends and how they affect AMI mortality.

METHODS

This cross-sectional study was performed on patients admitted on weekends with AMI using the National Inpatient Sample (NIS) 2019. Patients with type II non-ST-elevation myocardial infarction (NSTEMI) and missing information were excluded. The rates and timing of in-hospital diagnostic coronary angiograms, PCIs (percutaneous coronary interventions), and in-hospital mortality were studied. Regression models were used for data analyses.

RESULTS

A total of 161,625 patients met the inclusion criteria (58,690 females (36%), 114,830 Caucasians (71%), 17,910 African American (11%), 13,920 Hispanic (8.6%); mean (SD) age, 66.5 (0.5) years), including 47,665 (29.5%) ST-elevation myocardial infarction (STEMI) and 113,960 (70.5%) NSTEMI. Patients admitted to rural hospitals were less likely to undergo diagnostic coronary angiogram (adjusted odds ratio (aOR), 0.69; CI, 0.57-0.83; p<0.001) and PCI (aOR, 0.83; CI, 0.72-0.96; p 0.012). Rural hospitals had lesser odds of early diagnostic angiograms (aOR, 0.79; CI, 0.67-0.95; p<0.05) and PCI (aOR, 0.78; CI, 0.66-0.92; p<0.05) within 24 hours. The mortality difference between rural and urban hospitals was not significant (aOR, 1.08; CI, 0.85-1.4; p 0.52).

CONCLUSIONS

Diagnostic coronary angiograms and PCI are performed at a lesser rate in rural hospitals during weekends. This trend did not affect rural AMI mortality.

Closing the Last Mile Gap in Access to Multimodality Imaging in Rural Settings: Design of the Imaging Core of the Risk Underlying Rural Areas Longitudinal Study

Achieving optimal cardiovascular health in rural populations can be challenging for several reasons including decreased access to care with limited availability of imaging modalities, specialist physicians, and other important health care team members. Therefore, innovative solutions are needed to optimize health care and address cardiovascular health disparities in rural areas. Mobile examination units can bring imaging technology to underserved or remote communities with limited access to health care services. Mobile examination units can be equipped with a wide array of assessment tools and multiple imaging modalities such as computed tomography scanning and echocardiography. The detailed structural assessment of cardiovascular and lung pathology, as well as the detection of extracardiac pathology afforded by computed tomography imaging combined with the functional and hemodynamic assessments acquired by echocardiography, yield deep phenotyping of heart and lung disease for populations historically underrepresented in epidemiological studies. Moreover, by bringing the mobile examination unit to local communities, innovative approaches are now possible including engagement with local professionals to perform these imaging assessments, thereby augmenting local expertise and experience. However, several challenges exist before mobile examination unit-based examinations can be effectively integrated into the rural health care setting including standardizing acquisition protocols, maintaining consistent image quality, and addressing ethical and privacy considerations. Herein, we discuss the potential importance of cardiac multimodality imaging to improve cardiovascular health in rural regions, outline the emerging experience in this field, highlight important current challenges, and offer solutions based on our experience in the RURAL (Risk Underlying Rural Areas Longitudinal) cohort study.

Advancing Cardiovascular Risk Assessment with Artificial Intelligence: Opportunities and Implications in North Carolina

Cardiovascular disease mortality is increasing in North Carolina with persistent inequality by race, income, and location. Artificial intelligence (AI) can repurpose the widely available electrocardiogram (ECG) for enhanced assessment of cardiac dysfunction. By identifying accelerated cardiac aging from the ECG, AI offers novel insights into risk assessment and prevention.

Acute poisoning by chlorpyrifos differentially impacts survival and cardiorespiratory function in normotensive and hypertensive rats

Hypertension is the most important and well-known risk factor for cardiovascular disease (CVD). Recently, acute organophosphate (OP) poisoning has also been pointed as a CVD risk factor. Despite this evidence, no studies have contrasted the acute toxicosis and cardiovascular (CV) effects of OP poisoning under conditions of normotension and hypertension. In this work, adult male normotensive Wistar and Spontaneously Hypertensive rats (SHR) were intraperitoneally injected with saline or chlorpyrifos (CPF), an OP compound, monitored for acute toxicosis signs and 24-h survival. After poisoning, blood pressure, heart rate and ventilation were recorded, the Bezold-Jarisch Reflex (BJR), the Chemoreflex (CR) were chemically activated, as well as the cardiac autonomic tone (AUT) was assessed. Erythrocyte and brainstem acetylcholinesterase and plasmatic butyrylcholinesterase (BuChE) activities were measured as well as lipid peroxidation, advanced oxidation protein products (AOPP), nitrite/nitrate levels, expression of catalase, TNFα and angiotensin-I converting enzyme (ACE-1) within the brainstem. CPF induced a much more pronounced acute toxicosis and 33 % lethality in SHR. CPF poisoning impaired ventilation in SHR, the BJR reflex responses in Wistar rats, and the chemoreflex tachypneic response in both strains. CPF inhibited activity of cholinesterases in both strains, increased AOPP and nitrite/nitrate levels and expression of TNFα and ACE-1 in the brainstem of Wistar rats. Interestingly, SHR presented a reduced intrinsic BuChE activity, an important bioscavenger. Our findings show that, CPF at sublethal doses in normotensive rats lead to lethality and much more pronounced acute toxicity signs in the SHR. We also showed that cardiorespiratory reflexes were differentially impacted after CPF poisoning in both strains and that the cardiorespiratory disfunction seems to be associated with interference in cholinergic transmission, oxidative stress and inflammation. These results points to an increased susceptibility to acute toxicosis in hypertension, which may impose a significant risk to vulnerable populations.

Rurality and race in heart failure risk: Insights from the Southern Community Cohort Study

INTRODUCTION

Rural-urban health disparities are apparent in the burden of disease and health outcomes, including cardiovascular disease (CVD), specifically heart failure (HF). However, the factors influencing these disparities are not fully understood. Study and results: Among 27,115 participants in the Southern Community Cohort Study (SCCS) (mean age: 54 years (47-65)), 18,647 (68.8%) were black, 8,468 (32.3%) were white, and 20% resided in rural areas. Over a median 13-year follow-up period, 7,542 HF events occurred (rural = 1,865 vs. urban = 5,677). The age-adjusted HF incidence was 29.6 (95% CI, 28.9-30.5) and 36.5 (95% CI, 34.9-38.3) per 1,000 person-years for urban and rural participants, respectively (P < .001). The risk of HF associated with rurality varied by race and sex. Rural black men had the highest risk across all groups (HR, 1.34; 95% CI, 1.19-1.51) (age-adjusted incidence rate: 40.4/1000 person-years (95% CI, 36.8-44.3)) followed by black women (HR, 1.18; 95% CI, 1.08-1.28) and white women (HR, 1.22; 95% CI, 1.07-1.39). Rurality was not associated with HF risk among white men (HR, 0.97; 95% CI, 0.81-1.16).

LESSONS LEARNED

This large study shows that rural populations have an increased incidence of HF, which is particularly striking among women and black men, independent of individual-level biological, behavioral, and sociocultural risk factors. It also shows the need for further investigation into the rurality-associated risk of HF, the impact of preventive care utilization on the risk of HF and interpersonal, community, or societal factors that could contribute to rural-urban disparities. This will help to guide public health efforts aimed at HF prevention among rural populations.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.