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

Care for Atrial Fibrillation and Outcomes in Rural Versus Urban Communities in the United States: A Systematic and Narrative Review

Atrial fibrillation (AF) is the most common sustained arrhythmia and associated with increased morbidity and mortality. Differences have been identified between medical care delivered in urban and rural settings, and rurality-based disparities may exist in AF care. We performed a systematic review investigating the effect of rurality on AF care and outcomes in the United States. PubMed was queried for entries on AF and rurality: ("atrial fibrillation" OR "atrial flutter") AND ("rural" OR "urban" OR "rurality" OR "metro" OR "metropolitan") AND ("united states" OR "US" OR "U.S.") published up to September 24, 2023. Anticoagulation, rhythm control, settings of care, outcomes, and all-cause mortality were reviewed in relevant studies. The search identified 395 total articles. After screening, 14 relevant articles were included in the review. These studies ranged from 1993 to 2020 and analyzed approximately 41.7 million AF patient encounters. The use of catheter ablation for AF per electrophysiologist was similar across the rural-urban spectrum. Patients with AF and rural residence were less likely to receive a direct oral anticoagulant and more likely to remain on warfarin (relative risk, 0.90 [95% CI, 0.88-0.92]). Patients in rural communities were less likely to receive non-emergent AF care (odds ratio [OR], 0.96 [95% CI, 0.93-0.98]). In-hospital mortality for patients with AF admitted to rural hospitals was higher than urban hospitals (OR, 1.19 [95% CI, 1.01-1.39)]. Measurable differences exist in both treatments and outcomes of patients with AF between rural and urban settings in the United States. These differences should inform future investigations and strategies to improve health in people with AF.

Cardiometabolic Risk in Pediatric Patients with Intellectual and Developmental Disabilities

INTRODUCTION

Intellectual and Developmental Disabilities (IDD) have been associated with high cardiometabolic risk in adults, but there is little data on youth. This study describes the prevalence of cardiometabolic risk factors among pediatric patients with and without IDD receiving care in a large, primarily rural health system.

METHODS

This was a retrospective cohort study of patients aged 6-17 years with an index visit from August 1, 2022, to July 31, 2023, at one of 44 primary care clinics in a Midwestern health system. IDD status was defined by ICD-10 diagnostic codes. Demographic and clinical characteristics were gathered from the electronic health record. The odds of having each cardiometabolic risk factor measured, and the odds of having screened positive for each risk factor, were compared in 2024 using unadjusted ORs and CIs.

RESULTS

The prevalence of any IDD diagnosis among 33,192 eligible patients (mean age 11.6 years, 50% male) was (1,206/33,192) 3.6%, with autism being the most common (749/1,206, 62%). Though the likelihood of cardiometabolic risk factor measurement was similar, the prevalence of positive risk factors was higher in those with IDD. The odds of having obesity (OR=3.8, 95% CI=3.1, 4.8), current smoking or passive smoke exposure (OR=1.4, 95% CI=1.2, 1.6), a hypertension diagnosis (OR=6.4, 95% CI=3.8, 10.7), diabetes diagnosis (OR=2.67, 95% CI=1.2, 5.3), prediabetes diagnosis (OR=6.8, 95% CI=3.6, 12.9) or dyslipidemia (OR=3.5, 95% CI=2.9, 4.2), were all greater in patients with IDD than without IDD.

CONCLUSIONS

This study reports disparities in risk between pediatric patients with and without IDD. Future research and intervention programs should focus on young people with IDD to prevent adverse cardiometabolic outcomes later in life.

Rural-urban disparity in survival and use of PCI in patients who develop STEMI while hospitalized for a non-cardiac condition

BACKGROUND

The development of ST-segment elevation myocardial infarction (STEMI) in patients hospitalized for non-cardiac indications carries a high mortality rate.

OBJECTIVES

Determine the impact of rural vs. urban hospital location and hospital percutaneous coronary intervention (PCI) volumes on clinical outcomes.

METHODS

The New York Statewide Planning and Research Cooperative System database was queried for STEMI claims from 2011 to 2018. The 2010 Rural-Urban Commuting Area classification scheme was used to stratify hospitals as urban or rural.

RESULTS

64960 STEMI patients were identified from 231 hospitals with 2880 (4.4%) being classified as inpatient STEMI (IPS). IPS patients were older (73.5 ± 13.3 years vs 64.6 ± 14.2 years; p < .0001) and more frequently female (49.3% vs 33.1%; p < .0001), had more comorbidities, were less likely to receive PCI (13.1% vs 69.4%; p < .0001), and had higher 1-year mortality (59.6% vs 16.4%; p < .0001) than outpatient STEMI (OPS). IPS that occurred in rural hospitals were less often treated with PCI (3.8% vs 13.8%; p < 0.01) and had higher one-year mortality (68.6% vs 58.9%; p < 0.01) than those occurring in urban hospitals. Similar results were observed when hospitals were divided into rural vs suburban vs urban based on the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties. Patients with IPS admitted to low-volume PCI centers were significantly less likely to receive PCI and had higher one-year mortality, after adjustment for demographics and comorbidities, compared to those admitted to high-volume PCI centers.

CONCLUSIONS

IPS treated at rural hospitals and/or low-volume PCI centers were less likely to be treated with PCI and had higher one-year mortality rates.

UNSTRUCTURED ABSTRACT

The development of ST-Segment Elevation Myocardial Infarction (STEMI) in patients hospitalized for non-cardiac indications carries a high mortality rate. Using a large retrospective cohort study, we investigated the impact of hospital location and PCI volume on outcomes in inpatient STEMI (IPS). Patients with IPS were generally older, more frequently female, and had more comorbidities than those with outpatient STEMI. After adjustment for demographics and comorbidities, those with IPS admitted to rural and/or low-volume PCI centers were less likely to receive PCI and experienced higher one-year mortality rates.

Unraveling trends and disparities in acute myocardial infarction-related mortality among adult cancer patients: A nationwide CDC-WONDER analysis (1999-2020)

Background

Cancer patients are at an increased risk for the incidence and complications of acute myocardial infarction (AMI) due to shared risk factors and treatment-related adverse effects. Mortality trends for AMI-related deaths in adult cancer patients in the U.S. remain unexplored.

Methodology

This study used CDC WONDER data for death certificates from 1999 to 2020, identifying U.S. adults (≥25 years) with cancer (ICD-10: C00-D49) who died of AMI (ICD-10: I21) as the underlying cause. Age-adjusted mortality rates (AAMRs) and annual percent changes (APCs) were calculated and stratified by gender, age, race, and geographic location.

Results

Between 1999 and 2020, there were 109,462 AMI-related deaths in adult cancer patients. The AAMR decreased from 4.3 per 100,000 in 1999 to 1.4 in 2020. A significant decline occurred from 1999 to 2015 (APC: 6.65; 95 % CI: 6.95 to -6.40; p < 0.001), followed by a stable trend from 2015 to 2020 (APC: 1.36; 95 % CI: 2.69 to 0.91; p = 0.152). Men had higher AAMRs than women (3.5 vs. 1.5). AAMRs were highest in older adults (10.5) compared to middle-aged (0.7) and young adults (0.1). Racial disparities showed the highest AAMRs in non-Hispanic (NH) Black patients (2.7), followed by NH Whites (2.4), NH American Indian/Alaska Native (1.6), Hispanic/Latino (1.3), and NH Asian/Pacific Islander (1.1). Non-metropolitan areas had higher AAMRs than metropolitan areas (2.8 vs. 2.2).

Conclusions

This analysis highlights a significant decline in AMI-related mortality among cancer patients in the U.S., with persistent disparities by gender, age, race and geographical location.

Results of Cardiovascular Testing among Pregnant and Postpartum Persons Undergoing Standardized Cardiovascular Risk Assessment

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of maternal mortality in the United States, accounting for one in three pregnancy-related deaths. A standardized CVD Risk Assessment can guide clinicians in identifying patients at risk for CVD.

OBJECTIVE(S)

The objective of this study was to evaluate whether a standardized CVD risk assessment yields more abnormal findings on follow-up CVD testing among pregnant and postpartum patients compared to assessments based on clinician judgment alone.

STUDY DESIGN

A retrospective chart review was performed across three geographically and ethnically diverse hospital networks that had implemented the CVD Risk Assessment algorithm. The analysis included a total of 31,232 pregnant and postpartum patients who had presented for obstetric care visit from September 2020 to August 2024. We calculated the proportion of patients with abnormal composite brain natriuretic peptide (BNP), electrocardiogram (EKG), and/or echocardiogram test results by risk assessment group, and a two Proportion Z-Test was conducted to compare proportions. We then calculated the odds of having abnormal tests for each risk assessment group.

RESULTS

Standardized CVD risk assessment yielded more abnormal composite test results than clinician judgment alone (6.9% vs. 4.2%; p < 0.0001). There was a greater proportion of abnormal test results among the risk-positive than the risk-negative (23.4% vs. 6.6%; p < 0.0001). Patients assessed for CVD had 1.69 times the odds of having an abnormal test than those tested based on clinician judgment alone (p < 0.0001). Risk-positive patients had 4.31 times the odds of having an abnormal test than risk-negative patients (p < 0.0001).

CONCLUSION(S)

Implementing a standardized CVD Risk Assessment algorithm may enhance the detection of cardiovascular disease in pregnant and postpartum patients with previously unknown CVD or at risk of developing CVD, providing a valuable tool that complements clinician judgment for improved perinatal outcomes.

Principles for the Future of Biomedical Research in the United States and Optimizing the National Institutes of Health: A Presidential Advisory From the American Heart Association

Groundbreaking achievements in science and medicine have contributed to reductions in cardiovascular disease and stroke mortality over the past 7 decades. Many of these advances were supported through investments by the National Institutes of Health, the global leader in funding biomedical research. This public investment has produced important economic returns, including supporting >400 000 jobs and roughly $93 billion in economic activity in the United States. Unfortunately, public funding has not kept pace with the burden of disease or rates of inflation. As the nation's oldest and largest volunteer organization dedicated to fighting heart disease and stroke, research is critical to the American Heart Association's mission. Given the American Heart Association's unique position in representation of patients, clinicians, and scientists and as a research funder, we offer the following principles to optimize the future of the US biomedical research enterprise in general and the National Institutes of Health in particular. Specifically, the United States should continue to prioritize innovative and impactful research; to improve efficiency and transparency in its peer review process; to lead in translating evidence into practice; to support the current and future biomedical workforce; and to ensure robust and reliable public investment for the future. The American Heart Association reiterates our strong support for the National Institutes of Health and federal agencies that fund and implement biomedical and population-based research initiatives, which yield important economic returns. These agencies are vital to support today's current and future health challenges, to drive foundational science, to improve patient health, to reduce the global disease burden, to address upstream and preventive strategies, and to improve the value of our public health and health care investments.

Adaptation of a digital health intervention for rural adults: application of the Framework for Reporting Adaptations and Modifications-Enhanced

Introduction

Adaptation is a key aspect of implementation science; interventions frequently need adaptation to better fit their delivery contexts and intended users and recipients. As digital health interventions are rapidly developed and expanded, it is important to understand how such interventions are modified. This paper details the process of engaging end-users in adapting the PREVENT digital health intervention for rural adults and systematically reporting adaptations using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). The secondary objective was to tailor FRAME for digital health interventions and to document potential implications for equity.

Methods

PREVENT's adaptations were informed by two pilot feasibility trials and a planning grant which included advisory boards, direct clinic observations, and qualitative interviews with patients, caregivers, and healthcare team members. Adaptations were catalogued in an Excel tracker, including a brief description of the change. Pilot coding was conducted on a subset of adaptations to revise the FRAME codebook and generate consensus. We used a directed content analysis approach and conducted a secondary data analysis to apply the revised FRAME to all adaptations made to PREVENT (n = 20).

Results

All but one adaptation was planned, most were reactive (versus proactive), and all adaptations preserved fidelity to PREVENT. Adaptations were made to content and features of the PREVENT tool and may have positive implications for equity that will be tested in future trials.

Conclusion

Engaging rural partners to adapt our digital health tool prior to implementation with rural adults was critical to meet the unique needs of rural, low-income adult patients, fit the rural clinical care settings, and increase the likelihood of generating the intended impact among this patient population. The digital health expansion of FRAME can be applied prospectively or retrospectively by researchers and practitioners to plan, understand, and characterize digital health adaptations. This can aid intervention design, scale up, and evaluation in the rapidly expanding area of digital health.

Intersection of Race and Rurality With Health Care-Associated Infections and Subsequent Outcomes

Importance

Health care-associated infections (HAIs) are a major cause of morbidity and mortality, but little is known about whether structural factors impacting race and rurality are associated with HAI and subsequent outcomes.

Objective

To evaluate the association of race and rurality, which are proxies for structural disadvantage, with HAI and subsequent outcomes.

Design, Setting, and Participants

This cohort study was conducted at 3 US urban and suburban hospitals. Participants were adults aged 18 years or older admitted for 48 hours or longer from January 1, 2017, to August 31, 2020. Statistical analysis was performed from November 2022 to April 2024.

Exposure

Patient race and rurality status were defined as the combination of race (Black or White) and residence (urban or rural per patient zip code).

Main Outcomes and Measures

HAI was defined as a positive culture from a urine, blood, or respiratory specimen obtained 48 hours or longer after admission. To determine the association of race and rurality with HAIs, multivariable generalized estimating equations models were used to account for clustering of admissions by patient. Among patients with HAI admissions, similar models examined post-HAI intensive care unit admission and in-hospital death.

Results

Among 214 955 patients admitted to the hospital (median [IQR] age, 63 [51-73] years; 108 679 female patients [50.6%]; 72 490 Black patients [33.7%]; 142 465 White patients [66.3%]), recognized HAIs occurred during 6699 (3.1%). Compared with White urban patients, Black urban patients had a decreased risk of HAI (adjusted relative risk [aRR], 0.81; 95% CI, 0.75-0.87), White rural patients had an increased risk of HAI (aRR, 1.12; 95% CI, 1.05-1.20), and Black rural patients (aRR, 1.08; 95% CI, 0.81-1.44) had a similar risk of HAI. Among patients with HAI admissions, Black rural patients had an increased risk of intensive care unit admission (aRR, 1.92; 95% CI, 1.16-3.17) and in-hospital death (aRR, 1.78; 95% CI, 1.26-2.50). White rural and Black urban patients had outcomes similar to those of White urban patients.

Conclusions and Relevance

This cohort study of hospitalized adults identified inequities related to race and rurality in HAIs and adverse outcomes from HAIs. These findings suggest that factors such as structural racism and disinvestment in rural communities may be associated with individual HAI risk and post-HAI outcomes. Future work to further understand the reasons underpinning these disparities and methods to address structural factors through policy and process changes are critical to eliminate health inequities.

Shared Use to Promote Physical Activity and Healthy Eating in Rural South Carolina United Methodist Churches: Opportunities and Pastor Beliefs

Access to facilities that could promote physical activity (PA) and healthy eating (HE) is limited in rural areas. Shared use agreements with churches may be a promising strategy for enhancing rural community access to facilities. The goals of this qualitative study were to (a) examine rural pastors' views on the role of faith-based organizations in improving PA and HE in rural communities; (b) describe the availability of church facilities that could be used for PA and HE; (c) understand pastors' opinions on shared use of church facilities for community health promotion. A purposeful sampling strategy was used to recruit pastors in rural South Carolina. Thirteen United Methodist Church (UMC) pastors (46% female; 54% predominantly African American congregations) participated in phone interviews. Interviews were transcribed and coded using grounded theory and analyzed with NVIVO. Most pastors reported that their churches had a kitchen (88%), classrooms (82%), and open field space (71%). Nine churches (53%) said they had shared use agreements in place although only two agreements (12%) were related to PA promotion and none related to HE activities. Most pastors did not have concerns about shared use, and many believed that sharing the church's space with the community was an important aspect of outreach. These results demonstrate that rural churches have facilities to support shared use agreements for PA and HE activities and that pastors are open to sharing church space. Future studies should engage rural churches in establishing shared use agreements for health promotion.

Screening and Referral for Social Needs Among Veterans: A Randomized Controlled Trial

BACKGROUND

Healthcare-based social need screening and referral (S&R) among adult populations has produced equivocal results regarding social need resource connection.

OBJECTIVE

Assess the efficacy of S&R on resource connection (primary outcome) and unmet need reduction (secondary outcome).

DESIGN

Intention-to-treat randomized controlled trial. Analyses adjusted for demographics (e.g., age, race), comorbidity (Elixhauser), and VA priority group (PG).

PARTICIPANTS

Veterans with and at-risk for cardiovascular disease and one of more (hereafter " ≥ 1") social needs receiving healthcare at one of three Veterans Healthcare Administration (VHA) medical facilities.

INTERVENTION

Study arms represented referral strategies of varying intensity. Arm 1 (control) received generic resource information; Arm 2 (low intensity) received generic and tailored resource information; Arm 3 (high intensity) received all the above plus social work navigation assistance.

MAIN MEASURES

Post index surveys at 2-months assessed resource connection (connection to ≥ 1 new resources) and 6-months assessed need reduction (≥ 1 needs at the index screen no longer identified).

KEY RESULTS

A total of 479 Veterans were randomized: 50% were minoritized Veterans, mean age was 64, and 91% were male. Arm 3 was associated with greater resource connection but differences across study arms were not statistically significant. For example, compared to the control arm, participants in Arm 3 had higher but non-statistically significant odds of connecting to ≥ 1 resources (OR = 1.60, CI [.96, 2.67]).

CONCLUSIONS

Among VHA-enrolled Veterans, a high-intensity S&R intervention was associated with a non-statistically significant increase in connection to social need resources. Further study needed to establish S&R efficacy.

TRIAL REGISTRATION

NCT04977583.

Urban versus rural older adults: occupational balance and quality of life comparison

BACKGROUND

Occupational balance is a crucial concept in occupational therapy and is recognized as a vital component of health and well-being. The residential status may have a significant impact on the occupational balance (OB) and quality of life (QoL) of older adults.

METHODS

A group of 107 older adults from the urban area (mean age: 69.80 ± 4.78 years), and 93 older adults from the rural area (mean age: 71.24 ± 6.79 years) were examined. OB of the participants was evaluated with the Occupational Balance Questionnaire 11-T (OBQ 11-T) The QoL of older adults assessed by the World Health Organization Quality of Life - OLD module (WHOQOL-OLD).

RESULTS

The median OBQ11-T total score was 21.00 (7.00) in the urban area group and 20.00 (5.00) in the rural area group. Older adults residing in urban areas had higher scores in the OBQ 11-T total score, Item 1 = "Having enough things to do during a regular week", Item 5 = "Have sufficient time for doing mandatory occupations", and Item 11 = "Satisfaction with time spent in rest, recovery, and sleep" (p < .05). This suggests that older adults in urban areas may perceive a better balance in their activities. In contrast, rural residents had lower scores on these items, potentially reflecting fewer perceived opportunities for engaging in activities in a balanced manner. Older adults daily residing in urban areas had higher scores in the WHOQOL-OLD total score, WHOQOL-OLD Sensory Abilities Subtest, and WHOQOL-OLD Autonomy Subtest (p < .05). These findings indicate a higher QoL, particularly in sensory and autonomy-related aspects, for older adults in urban areas. Conversely, rural residents reported lower scores on these QoL subscales, which may be attributed to different environmental and lifestyle factors associated with rural living.

CONCLUSIONS

These findings indicated that residency status is an important variable for both OB and QoL of older adults. Occupational therapy interventions should consider special needs of older adults who live in rural areas.

TRIAL REGISTRATION

The clinical trial number is not applicable.

An Asset-Based Examination of Contextual Factors Influencing Nutrition Security: The Case of Rural Northern New England

BACKGROUND/OBJECTIVES

Rural communities face a disproportionate burden in terms of diet-related health challenges and have been identified as a target for the U.S. Department of Agriculture's nutrition security initiatives. In this paper, we adopt an asset-based approach and use the Community Capitals Framework to examine the characteristics that support nutrition security in rural communities, using rural northern New England as a case study.

METHODS

We conducted focus groups and interviews with 32 food and nutrition professionals in Maine, New Hampshire, and Vermont in 2023 and 2024 to explore the contextual factors that influence nutrition security in rural communities. We coded the data for community assets and mapped the identified assets into the seven dimensions of the Community Capitals Framework: built capital, cultural capital, financial capital, human capital, natural capital, political capital, and social capital.

RESULTS

The participants described assets in all dimensions of the Community Capitals Framework except built capital. The specific assets discussed were related to local food production (natural and cultural capital), coordination between food system stakeholders and strong social networks (human and social capital), regional political commitments to food security and nutrition (political capital), and the strong seasonal tourist economy present in some communities (financial capital).

CONCLUSIONS

Rural communities remain under-studied in the literature regarding nutrition, and little is known about how to advance healthful eating in rural contexts. An asset-based approach was helpful for identifying existing resources that enhance rural nutrition security and may provide an opportunity to characterize and disseminate strategies to advance rural health equity.

Digital Solutions for the Optimization of Pharmacologic Therapy for Heart Failure

Data from large-scale, randomized, controlled trials demonstrate that contemporary treatments for heart failure (HF) can substantially improve morbidity and mortality. Despite this, observed outcomes for patients living with HF are poor, and they have not improved over time. The are many potential reasons for this important problem, but inadequate use of optimal medical therapy for patients with HF, an important component of guideline-directed medical therapy, in routine practice is a principal and modifiable contributor. In this state-of-the-art review, we focus on digital interventions that specifically target the rapid initiation and titration of medical therapy for HF, typically not involving face-to-face encounters. Early data suggest that digital interventions that use data collected outside of structured episodes of care can facilitate initiation and titration of guideline-directed medical therapy for patients with HF. More data are necessary, however, to understand the safety and efficacy of these interventions compared with current care models. In addition, specific efforts by key constituents are necessary to generate sufficient data on the effectiveness and sustainability of digital interventions in routine practice and to ensure that they do not exacerbate existing disparities in care.

Health differences between rural and non-rural Texas counties based on 2023 County Health Rankings

BACKGROUND

Place matters for health. In Texas, growing rural populations face a variety of structural, social, and economic disparities that position them for potentially worse health outcomes. The current study contributes to understanding rural health disparities in a state-specific context.

METHODS

Using 2023 County Health Rankings data from the University of Wisconsin Population Health Institute, the study analyzes rural/non-rural county differences in Texas across six composite indexed domains of health outcomes (length of life, quality of life) and health factors (health behavior, clinical care, socioeconomic factors, physical environment) with a chi-square test of significance and logistic regression.

RESULTS

Quartile ranking distributions of the six domains differed between rural and non-rural counties. Rural Texas counties were significantly more likely to fall into the bottom quartile(s) in the domains of length of life and clinical care and less likely to fall into the bottom quartile(s) in the domains of quality of life and physical environment. No differences were found in the domains of health behavior and socioeconomic factors. Findings regarding disparities in length of life and clinical care align with other studies examining disease prevalence and the unavailability of many health services in rural Texas. The lack of significant differences in other domains may relate to indicators that are not present in the dataset, given studies that find disparities relating to other underlying factors.

CONCLUSIONS

Texas County Health Rankings data show differences in health outcomes and factors between rural and non-rural counties. Limitations of findings relate to the study's cross-sectional design and parameters of the secondary data source. Ultimately, results can help state health stakeholders, especially those in community or operational contexts with limited resources or access to more detailed health statistics, to use the CHR dataset to consider more relevant local interventions to address rural health disparities.

Racial, Socioeconomic, and Geographic Disparities in Preamputation Vascular Care for Patients With Chronic Limb-Threatening Ischemia

BACKGROUND

Black patients, those with low socioeconomic status (SES), and those living in rural areas have elevated rates of major lower extremity amputation, which may be related to a lack of subspecialty chronic limb-threatening ischemia care. We evaluated the association between race, rurality, SES, and preamputation vascular care.

METHODS

Among patients aged 66 to 86 years with fee-for-service Medicare who underwent major lower extremity amputation for chronic limb-threatening ischemia from July 2010 to December 2019, we compared the proportion who received vascular care in the 12 months before amputation by race (Black versus White), rurality, and SES (dual eligibility for Medicaid versus no dual eligibility) using multivariable logistic regression adjusting for clinical and demographic covariates.

RESULTS

Among 73 237 patients who underwent major lower extremity amputation, 40 320 (55.1%) had an outpatient vascular subspecialist visit, 60 109 (82.1%) had lower extremity arterial testing, and 28 345 (38.7%) underwent lower extremity revascularization in the year before amputation. Black patients were less likely to have an outpatient vascular specialist visit (adjusted odds ratio [adjOR], 0.87 [95% CI, 0.84-0.90]) or revascularization (adjOR, 0.90 [95% CI, 0.86-0.93]) than White patients. Compared with patients without low SES or residing in urban areas, patients with low SES or residing in rural areas were less likely to have an outpatient vascular specialist visit (adjOR, 0.62 [95% CI, 0.60-0.64]; low SES versus nonlow SES; adjOR, 0.82 [95% CI, 0.79-0.85]; rural versus urban), lower extremity arterial testing (adjOR, 0.78 [95% CI, 0.75-0.81]; low SES versus nonlow SES; adjOR, 0.90 [95% CI, 0.0.86-0.94]; rural versus urban), or revascularization (adjOR, 0.65 [95% CI, 0.63-0.67]; low SES versus nonlow SES; adjOR, 0.89 [95% CI, 0.86-0.93]; rural versus urban).

CONCLUSIONS

Black race, rural residence, and low SES are associated with failure to receive subspecialty chronic limb-threatening ischemia care before amputation. To reduce disparities in amputation, multilevel interventions to facilitate equitable chronic limb-threatening ischemia care are needed.

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.

Discordance Between Clinician and Person-With-Diabetes Perceptions Regarding Technology Barriers and Benefits

The quality of clinician-patient relationship is integral to patient health and well-being. This article is a narrative review of published literature on concordance between clinician and patient perspectives on barriers to diabetes technology use. The goals of this manuscript were to review published literature on concordance and to provide practical recommendations for clinicians and researchers. In this review, we discuss the qualitative and quantitative methods that can be applied to measure clinician and patient concordance. There is variability in how concordance is defined, with some studies using questionnaires related to working alliance, while others use a dichotomous variable. We also explore the impact of concordance and discordance on diabetes care, barriers to technology adoption, and disparities in technology use. Published literature has emphasized that physicians may not be aware of their patients' perspectives and values. Discordance between clinicians and patients can be a barrier to diabetes management and technology use. Future directions for research in diabetes technology including strategies for recruiting and retaining representative samples, are discussed. Recommendations are given for clinical care, including shared decision-making frameworks, establishing social support groups optimizing clinician-patient communication, and using patient-reported outcomes to measure patient perspectives on outcomes of interest.

Socioeconomic Disparities in Rate of Poststroke Dementia: A Nationwide Cohort Study

BACKGROUND

Socioeconomic disparities exist in acute stroke care as well as in long-term stroke outcomes. We aimed to investigate whether socioeconomic status was associated with the rate of poststroke dementia (PSD).

METHODS

This was a nationwide register-based cohort study including all patients with incident ischemic or hemorrhagic stroke in Denmark from 2010 to 2020. Socioeconomic status was defined by prestroke income, education, and employment. PSD was defined as a dementia diagnosis in the National Patient Registry or a dispensed prescription of dementia medication after a stroke. PSD incidence rates were compared between socioeconomic status groups using Poisson regression.

RESULTS

A total of 98 489 patients with incident stroke without a diagnosis of prestroke dementia were identified and followed for a median (IQR) of 4.2 (IQR, 2.1-7.3) years. Median age was 72 (62-80) years, 56% were male, 5.1% were immigrants, and 86% had ischemic stroke. Dementia was diagnosed in 5680 patients at a median of 2.4 (IQR, 0.9-4.8) years after stroke (incidence rate=12.1/1000 person-years). After adjusting for age, sex, and immigrant status, PSD rates were 1.24 (1.15-1.34) times higher for low income compared with high income, 1.11 (1.03-1.20) times higher for low education compared with high education, and 1.57 (1.38-1.77) times higher for patients without employment compared with patients with employment. Further adjustments for stroke severity, cohabitation, and comorbidities showed similar results. Stratified analyses showed that the socioeconomic disparities in PSD rates were more pronounced among women, immigrants, and patients <70 years of age.

CONCLUSIONS

Low socioeconomic status measured by prestroke income, education, and employment status was associated with higher rates of PSD. These socioeconomic disparities extended beyond what could be explained by common PSD risk factors.

The relationship between food and housing insecurity and healthcare use among Virginia Medicaid expansion members: Considering the neighborhood context

OBJECTIVE

To understand relationships between healthcare use and food and housing insecurity in Medicaid expansion members, as well as whether these relationships differ by rurality or residential segregation.

DATA SOURCES AND STUDY SETTING

Database of Virginia Medicaid expansion members from the Department of Medical Assistance Services. Sample included individuals who enrolled January-June 2019, were aged 19-64 years, remained continuously enrolled for 12 months, and completed a Medicaid Member Health Screening (MMHS) conducted within the first 3 months of enrollment (n = 14,735).

STUDY DESIGN

Retrospective cohort study. Outcomes included any primary care visits (PC) and any emergency department (ED) visits in the first 12 months of enrollment. The MMHS sample was weighted to represent all Medicaid expansion members (n = 234,296). Separate multivariable linear probability models regressed having any PC or ED visits on food and housing insecurity controlling for individual and neighborhood characteristics. Models were then stratified by rurality and racial residential segregation.

DATA COLLECTION

None.

PRINCIPAL FINDINGS

Food insecurity was negatively associated with having any PC visit (-2.9 percentage points (PP); p-value <0.01) and positively associated with having any ED visit (7.0 PP; p-value <0.001). No significant relationships between PC or ED visits and housing insecurity were found. Suburban and urban individuals with food insecurity were significantly less likely to have any PC visit (p < 0.05 each). Medicaid expansion members living in disproportionately low-income or mixed-income neighborhoods experiencing food insecurity were also less likely to have any PC visits (p < 0.05), and the same was not true for those living in disproportionately high-income neighborhoods.

CONCLUSIONS

Food insecurity among Medicaid expansion members is associated with less primary care and more emergency department use, but these relationships differ by the neighborhoods in which members live. Medicaid agency efforts that coordinate medical and social service benefits and also consider local context may further increase access to necessary and appropriate care.

Comparing models that integrate obstetric care and WIC on improved program enrollment during pregnancy: a protocol for a randomized controlled trial

BACKGROUND

Low-income, rural pregnant women are at disproportionate risk for adverse pregnancy outcomes as well as future cardiovascular risk. Currently, less than half of eligible women enroll in the Women, Infants, and Children's (WIC) Program. This study aims to evaluate whether integrating clinical care and social care may advance health equity and reduce health disparities by directly linking women receiving obstetric care to the Special Supplemental Nutrition Program for WIC and/or a Registered Dietitian/Nutritionist (RDN).

METHODS

This pragmatic study is situated in real-world care and utilizes a randomized controlled trial design. A total of 240 low-income, rural, pregnant patients will be recruited from Geisinger (Pennsylvania, USA) obstetric clinics and randomized to receive one of four models: (1) Clinic; (2) Clinic-WIC; (3) Clinic-RDN, or (4) Clinic-WIC-RDN. Participants provide consent for electronic referrals that directly link their contact information from the electronic health record to WIC and/or RDN. Patients in the Clinic model receive standard prenatal care, which includes provision of basic information about WIC. The Clinic-WIC model includes a clinical decision alert to queue clinical staff to ask about WIC interest and place a referral to WIC using a social health access referral platform. In turn, WIC staff contact the pregnant woman about enrollment. The Clinic-RDN model includes a referral to an RDN for telehealth counseling to promote heart healthy eating and food resource management. The Clinic-WIC-RDN model includes referrals to both WIC and RDN. The primary outcome is difference in WIC enrollment between the Clinic and Clinic-RDN models versus the Clinic-WIC and Clinic-WIC-RDN arms at 6-months post-baseline. Secondary endpoints include WIC retention and adherence, change in participant behavior, skills, and food security, preterm delivery, birthweight, and maternal and child health outcomes. Implementation outcome measures include acceptability, appropriateness, and feasibility from the perspective of clinic and WIC staff.

DISCUSSION

Study findings will inform system models that integrate clinic care and social care to improve health equity among a high-risk population. Specifically, these findings will advance implementation of strategies to increase enrollment in a widely available but underutilized food provision program during pregnancy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier (NCT06311799). Registered 3/13/2024.

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-based simulation: a scoping review of charting medical education over the last two decades in the lens of the 'marvelous medical education machine'

BACKGROUND

Over the past two decades, the use of Metaverse-enhanced simulations in medical education has witnessed significant advancement. These simulations offer immersive environments and technologies, such as augmented reality, virtual reality, and artificial intelligence that have the potential to revolutionize medical training by providing realistic, hands-on experiences in diagnosing and treating patients, practicing surgical procedures, and enhancing clinical decision-making skills. This scoping review aimed to examine the evolution of simulation technology and the emergence of metaverse applications in medical professionals' training, guided by Friedman's three dimensions in medical education: physical space, time, and content, along with an additional dimension of assessment.

METHODS

In this scoping review, we examined the related literature in six major databases including PubMed, EMBASE, CINAHL, Scopus, Web of Science, and ERIC. A total of 173 publications were selected for the final review and analysis. We thematically analyzed these studies by combining Friedman's three-dimensional framework with assessment.

RESULTS

Our scoping review showed that Metaverse technologies, such as virtual reality simulation and online learning modules have enabled medical education to extend beyond physical classrooms and clinical sites by facilitating remote training. In terms of the Time dimension, simulation technologies have made partial but meaningful progress in supplementing traditional time-dependent curricula, helping to shorten learning curves, and improve knowledge retention. As for the Content dimension, high-quality simulation and metaverse content require alignment with learning objectives, interactivity, and deliberate practice that should be developmentally integrated from basic to advanced skills. With respect to the Assessment dimension, learning analytics and automated metrics from metaverse-enabled simulation systems have enhanced competency evaluation and formative feedback mechanisms. However, their integration into high-stakes testing is limited, and qualitative feedback and human observation remain crucial.

CONCLUSION

Our study provides an updated perspective on the achievements and limitations of using simulation to transform medical education, offering insights that can inform development priorities and research directions for human-centered, ethical metaverse applications that enhance healthcare professional training.

The Role of Primary Care in Achieving Life's Essential 8: A Scientific Statement From the American Heart Association

To reduce morbidity and mortality rates of cardiovascular disease, an urgent need exists to improve cardiovascular health among US adults. In 2022, the American Heart Association issued Life's Essential 8, which identifies and defines 8 health behaviors and factors that, when optimized through a combination of primary prevention, risk factor management, and effective treatments, can promote ideal cardiovascular health. Because of its central role in patient care across the life span, primary care is in a strategic position to promote Life's Essential 8 and improve cardiovascular health in the United States. High-quality primary care is person-centered, team-based, community-aligned, and designed to provide affordable optimized health care. The purpose of this scientific statement from the American Heart Association is to provide evidence-based guidance on how primary care, as a field and practice, can support patients in implementing Life's Essential 8. The scientific statement aims to describe the role and functions of primary care, provide evidence for how primary care can be leveraged to promote Life's Essential 8, examine the role of primary care in providing access to care and mitigating disparities in cardiovascular health, review challenges in primary care, and propose solutions to address challenges in achieving Life's Essential 8.

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.

The Benefits of Using Active Remote Patient Management for Enhanced Heart Failure Outcomes in Rural Cardiology Practice: Single-Site Retrospective Cohort Study

BACKGROUND

Rural populations have a disproportionate burden of heart failure (HF) morbidity and mortality, associated with socioeconomic and racial inequities. Multiple randomized controlled trials of remote patient monitoring (RPM) using both direct patient contact and device-based monitoring have been conducted to assess improvement in HF outcomes, with mixed results.

OBJECTIVE

We aimed to assess whether a novel digital health care platform designed to proactively assess and manage patients with HF improved patient outcomes by preventing HF re-exacerbations, thus reducing emergency room visits and HF hospitalizations.

METHODS

This was a single-site, retrospective cohort study using electronic medical record (EMR) data gathered from 2 years prior to RPM initiation and 2 years afterward. In January 2017, this single center began enrolling New York Heart Association (NYHA) class II and class III patients with HF prone to HF exacerbation into an RPM program using the Cordella HF system. By July 2022, 93 total patients had been enrolled in RPM. Of these patients, 87% lived in rural areas. This retrospective review included 40 of the 93 patients enrolled in RPM. These 40 were selected because they had 2 years of established EMR data prior to initiation of RPM and 2 years of post-RPM data; each consented to this Sterling IRB-approved study.

RESULTS

We included 40 patients with at least 4 years of follow-up, including 2 years prior to RPM initiation and 2 years after RPM initiation. In the 2 years after RPM initiation, check-up calls increased 519%, medication change calls increased 519%, and total calls increased by 519%. Emergency room visits for HF fell 93%, heart failure hospitalizations fell 83%, and all other cardiovascular hospitalizations fell 50%. Additionally, the total number of office visits declined by 15% after RPM, and unscheduled or urgent office visits declined by 73%.

CONCLUSIONS

Daily monitoring of trends in vital sign data between engaged patients and a collaborative team of clinicians, incorporated into daily clinical workflow, enhanced patient interactions and allowed timely response or intervention when HF decompensation occurred, resulting in a reduction of outpatient and inpatient clinical use over more than 2 years of follow-up.

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.

Cardiovascular Disease and Diabetes Are Among the Main Underlying Causes of Death in Twenty Healthcare Facilities Across Two Cities in the Democratic Republic of Congo

INTRODUCTION

The mortality rates associated with cardiovascular disease (CVD) and diabetes exhibit disparities by region, with Central Africa ranking fourth globally in terms of mortality rate. The Democratic Republic of Congo (DRC) does not possess mortality data pertaining to these specific underlying causes of death. This study aimed to determine the death rate attributable to CVD and diabetes in two cities in the DRC.

METHODOLOGY

The data on CVD and diabetes utilized in this study were obtained from a pilot project and were registered in the National Health Information System (NHIS). Data quality was initially evaluated using an automated Digital Open Rule Integrated Selection (DORIS), followed by an assessment conducted manually by three assessors. Descriptive and comparative analyses were carried out to determine the proportion of mortality related to CVD and diabetes.

RESULTS

CVD accounted for 20.4% (95%CI: 17.7-23.4%) of deaths in the two cities (Kinshasa and Matadi), whereas diabetes accounted for 5.4% (95%CI: 3.9-7.2%). After adjusting for age and city, the proportional mortality from CVD and diabetes was higher for women than men and increased with age. This study recorded 4.4% of deaths among men and 7.0% among women as the proportional mortality from diabetes.

CONCLUSIONS

Non-communicable diseases (NCDs) continue to be a major cause of death, and CVD and diabetes are among the leading causes of early mortality in adults in urban areas. The proportional mortality related to CVD and diabetes appears to be higher in women than in men. Special emphasis should be placed on women, particularly during adulthood, to ensure the prompt detection of diabetes and cardiovascular conditions.

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.

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.