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

Creating 'good' hospital to home transfers in the rural north of Sweden: informal workarounds and opportunities for improvement

Hospital to home transfers for older people require effective communication, coordination and collaboration across multiple service settings. Rural Nursing Theory and the Beyond Periphery model explain why this is particularly difficult in rural areas, but there are few examples of how rural services respond. This paper presents a case study of the district of Tärnaby in the inland north of Sweden. Data are drawn from interviews with health and care staff in Tärnaby, observations, and experiences of the researchers. Data were analyzed thematically, with four main themes emerging - role clarity, communication, geography, and understanding of the rural context. Responses to challenges included increasing opportunities for communication between service providers and improving documentation. The paper concludes that informal "workarounds" run the risk of further disconnecting rural service settings from "the city". Rather, the aim needs to be to improve contextual understanding through formally incorporating "the rural" in service design.

A Christian Faith-Based Facebook Intervention for Smoking Cessation in Rural Communities (FAITH-CORE): Protocol for a Community Participatory Development Study

BACKGROUND

Tobacco smoking remains the leading cause of preventable morbidity and mortality in the United States, with significant rural-urban disparities. Adults who live in rural areas of the United States have among the highest tobacco smoking rates in the nation and experience a higher prevalence of smoking-related deaths and deaths due to chronic diseases for which smoking is a causal risk factor. Barriers to accessing tobacco use cessation treatments are a major contributing factor to these disparities. Adults living in rural areas experience difficulty accessing tobacco cessation services due to geographical challenges, lack of insurance coverage, and lack of health care providers who treat tobacco use disorders. The use of digital technology could be a practical answer to these barriers.

OBJECTIVE

This report describes a protocol for a study whose main objectives are to develop and beta test an innovative intervention that uses a private, moderated Facebook group platform to deliver peer support and faith-based cessation messaging to enhance the reach and uptake of existing evidence-based smoking cessation treatment (EBCT) resources (eg, state quitline coaching programs) for rural adults who smoke.

METHODS

We will use the Integrated Theory of Health Behavior Change, surface or deep structure frameworks to guide intervention development, and the community-based participatory research (CBPR) approach to identify and engage with community stakeholders. The initial content library of moderator postings (videos and text or image postings) will be developed using existing EBCT material from the Centers for Disease Control and Prevention Tips from Former Smokers Campaign. The content library will feature topics related to quitting smoking, such as coping with cravings and withdrawal and using EBCTs with faith-based message integration (eg, Bible quotes). A community advisory board and a community engagement studio will provide feedback to refine the content library. We will also conduct a beta test of the intervention with 15 rural adults who smoke to assess the recruitment feasibility and preliminary intervention uptake such as engagement, ease of use, usefulness, and satisfaction to further refine the intervention based on participant feedback.

RESULTS

The result of this study will create an intervention prototype that will be used for a future randomized controlled trial.

CONCLUSIONS

Our CBPR project will create a prototype of a Facebook-delivered faith-based messaging and peer support intervention that may assist rural adults who smoke to use EBCT. This study is crucial in establishing a self-sufficient smoking cessation program for the rural community. The project is unique in using a moderated social media platform providing peer support and culturally relevant faith-based content to encourage adult people who smoke to seek treatment and quit smoking.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52398.

Differences in health characteristics and health behaviors between rural and non-rural community-dwelling stroke survivors aged ≥65 years in the USA

OBJECTIVES

To examine differences in health characteristics and health behaviors between rural and non-rural stroke survivors in the USA.

METHODS

Data were extracted from the 2017 and 2019 Behavioral Risk Factor Surveillance System (BRFSS) to compare prevalences of health characteristics (i.e., diabetes, disability, poor health, high cholesterol, hypertension, no health care coverage, weight status) and health behaviors (i.e., fruit consumption, vegetable consumption, physical inactivity, high alcohol consumption, smoking) among community-dwelling stroke survivors, stratified by rural status (i.e., rural vs. non-rural). Logistic regression was used to calculate odds ratios (ORs) for health characteristics and health behaviors to examine the association of rural status with each variable of interest (reference group=non-rural).

RESULTS

Data from 14,599 respondents (rural: n = 5,039; non-rural: n = 9,560) were available for analysis. The majority of respondents were female (61.4%), non-Hispanic white (83.2%), previously married (56.1%), had at least some college education (55.2%), and had an annual household income ≥USD $25,000 (56.9%). Prevalences of disability, poor health, weekly aerobic exercise, and smoking were higher among rural respondents compared to non-rural respondents. Logistic regression showed increased odds (odds ratio range: 1.1-1.2) for these variables among rural respondents; however, odds ratios were attenuated after controlling for sociodemographic and health characteristics.

CONCLUSIONS

We did not find evidence of differences in the investigated health characteristics and health behaviors between rural and non-rural community-dwelling stroke survivors in the USA. Additional research is needed to confirm these findings and to identify alternative sociodemographic and health factors that may differ between rural and non-rural community-dwelling stroke survivors.

Urban-rural differences in hypertension prevalence, blood pressure control, and systolic blood pressure levels

Higher rates of cardiovascular events have been observed among rural residents compared with urban. Hypertension and lack of blood pressure (BP) control are risk factors for cardiovascular events. We compared the prevalence of hypertension and controlled BP, and the distribution of systolic blood pressure (SBP), by urban-rural residence. Participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study, a prospective cohort of Black and White adults aged ≥45 years, were categorized as either urban, large rural, or small-isolated rural, by using the Rural-Urban Commuting Area (RUCA) categorization B system. Oucomes were hypertension prevalence (BP ≥ 140/90 mmHg or antihypertensive use), BP control (BP < 140/90 among participants on antihypertensive medication), and the distribution of SBP. Counfounders were age, race, sex, antihypertensive medication use, and US Census Bureau division. The analysis included 26,133 participants (80.3% urban, 11.6% large-rural, 8.2% small-isolated rural). The unadjusted prevalence of hypertension was not different between groups. However, after adjustment, the odds of hypertension was higher among participants in the large rural group (odds ratio [OR] 1.17; 95% confidence interval [CI], 1.08-1.27) and small-isolated rural group (OR 1.19; 95% CI, 1.08-1.30), compared with the urban group. There was no evidence of an adjusted difference in BP control for those taking antihypertensive medications. Adjusted differences in SBP were greater for both rural groups, compared with urban, at the higher percentiles of SBP. Rural residence was associated with a higher adjusted odds of hypertension and higher SBP.

Rurality and Atrial Fibrillation: Patient Perceptions of Barriers and Facilitators to Care

Background Patients experience atrial fibrillation (AF) as a complex disease given its adversity, chronicity, and necessity for long-term treatments. Few studies have examined the experience of rural individuals with AF. We conducted qualitative assessments of patients with AF residing in rural, western Pennsylvania to identify barriers and facilitators to care. Methods and Results We conducted 8 semistructured virtual focus groups with 42 individuals living in rural western Pennsylvania using contextually tailored questions to assess participant perspectives. We inductively analyzed focus group transcripts using paragraph-by-paragraph and focused coding to identify themes with the qualitative description approach. We used Krippendorff α scoring to determine interreviewer reliability. We harnessed investigator triangulation to augment the reliability of our findings. We reached thematic saturation after coding 8 focus groups. Participants were 52.4% women, with a median age of 70.9 years (range, 54.5-82.0 years), and most were White race (92.9%). Participants identified medication costliness, invisibility of AF to others, and lack of emergent transportation as barriers to care. Participants described interpersonal support and use of technology as important for AF self-care, and expressed ambivalence about how relationships with health care providers affected AF care. Conclusions Focus group participants described multiple social and structural barriers to care for AF. Our findings highlight the complexity of the experience of individuals with AF residing in rural western Pennsylvania. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04076020.

Cardiac catheterization, coronary intervention, and wait times for transcatheter aortic valve replacement

OBJECTIVES

Prolonged wait times for transcatheter aortic valve replacement (TAVR) are associated with increased morbidity and mortality. The incidence and predictors of short TAVR wait times (STWT: defined as ≤ 30 days from referral to TAVR procedure) have not been defined. This study examined the impact of clinical characteristics, demographics, and pre-TAVR cardiac catheterization on wait times for TAVR.

METHODS

This was a retrospective observational analysis of 831 patients with severe aortic stenosis undergoing TAVR from 2019 to mid-2022 at the University of Vermont Medical Center. Demographics, timing of treatment [stratified by COVID-19 onset (1 March 2020)], TAVR center travel distance, baseline clinical factors, and process-related variables were analyzed to determine univariate STWT predictors (P < 0.10). Multivariable analysis was performed to determine independent STWT predictors.

RESULTS

Approximately 50% of TAVR patients in this study achieved a STWT. The proportion of patients with STWT was higher (54.7% vs. 45.2%; P = 0.008) after the onset of COVID-19 pandemic. STWT was not related to travel distance (P = 0.61). Patients with left ventricular ejection fraction (LVEF) > 60% were less likely to achieve STWT compared to patients with LVEF < 40% (OR 0.45, P = 0.003). Patients who required catheterization or percutaneous coronary intervention (PCI) before TAVR were significantly less likely to achieve STWT (OR 0.65, P = 0.01).

CONCLUSION

TAVR wait times were not affected by the COVID-19 pandemic or single rural TAVR center travel distance. Sicker patients were more likely to achieve STWT while catheterization/PCI before TAVR was associated with longer wait times.

Trends in CV mortality among patients with known mental and behavioral disorders in the US between 1999 and 2020

Introduction

Patients with mental disorders are at increased risk of cardiovascular events. We aimed to assess the cardiovascular mortality trends over the last two decades among patients with mental and behavioral co-morbidities in the US.

Methods

We performed a retrospective, observational study using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) Multiple Cause of Death dataset. We determined national trends in age-standardized mortality rates attributed to cardiovascular diseases in patients with and without mental and behavioral disorders, from 1999 to 2020, stratified by mental and behavioral disorders subtype [ICD10 codes F], age, gender, race, and place of residence.

Results

Among more than 18.7 million cardiovascular deaths in the United States (US), 13.5% [2.53 million] were patients with a concomitant mental and behavioral disorder. During the study period, among patients with mental and behavioral disorders, the age-adjusted mortality rate increased by 113.9% Vs a 44.8% decline in patients with no mental disorder (both p<0.05). In patients with mental and behavioral disorders, the age-adjusted mortality rate increased more significantly among patients whose mental and behavioral disorder was secondary to substance abuse (+532.6%, p<0.05) than among those with organic mental disorders, such as dementia or delirium (+6.2%, P- nonsignificant). Male patients (+163.6%) and residents of more rural areas (+128-162%) experienced a more prominent increase in age-adjusted cardiovascular mortality.

Discussion

While there was an overall reduction in cardiovascular mortality in the US in the past two decades, we demonstrated an overall increase in cardiovascular mortality among patients with mental disorders.

A cross-sectional examination of post-myocardial infarction physical activity levels among US rural and urban residents: Findings from the 2017-2019 Behavioral Risk Factor Surveillance System

BACKGROUND

This study sought to examine the relationship between rural residence and physical activity levels among US myocardial infarction (MI) survivors.

METHODS

We conducted a cross-sectional study using nationally representative Behavioral Risk Factor Surveillance System surveys from 2017 and 2019. We determined the survey-weighted percentage of rural and urban MI survivors meeting US physical activity guidelines. Logistic regression models were used to examine the relationship between rural/urban residence and meeting physical activity guidelines, accounting for sociodemographic factors.

RESULTS

Our study included 22,732 MI survivors (37.3% rural residents). The percentage of rural MI survivors meeting physical activity guidelines (37.4%, 95% CI: 35.1%-39.7%) was significantly less than their urban counterparts (45.6%, 95% CI: 44.0%-47.2%). Rural residence was associated with a 28.8% (95% CI: 20.0%-36.7%) lower odds of meeting physical activity guidelines, with this changing to a 19.3% (95% CI: 9.3%-28.3%) lower odds after adjustment for sociodemographic factors.

CONCLUSIONS

A significant rural/urban disparity in physical activity levels exists among US MI survivors. Our findings support the need for further efforts to improve physical activity levels among rural MI survivors as part of successful secondary prevention in US high-MI burden rural areas.

Uncovering the Work-Family Interface: The Impact of Facilitators and Stressors on the Health of Farm Women

Work-family interface (WFI) theory has identified many stressors that influence work-family dynamics from the standpoint of employees. However, work-family facilitators, as well as the effects of gender differences and the impact of sociocultural environments that differ from a formal employment situation, have received much less attention. Our research aimed to fill these theoretical gaps by analyzing the facilitators and stressors involved in work-family dynamics and determining their consequences for farm women's physical, psychological, and social health. We used a qualitative method with a grounded theory design to collect data via semi-structured interviews with 46 farm women from the region of Araucanía in Chile. Our results explain how facilitators, stressors, and outcomes take place in a process of work-family balance that, paradoxically, implies exhausting journeys, a gender-based overload, a risk of diffuse body pain and distress, and a lack of time for personal healthcare and productive autonomy. Addressing these issues requires a comprehensive approach involving improved healthcare infrastructure and services focused on changing the pressures that the farming WFI exerts on rural women.

Implementation of Prevention Science to Eliminate Health Care Inequities in Achieving Cardiovascular Health: A Scientific Statement From the American Heart Association

Prevention of cardiovascular and related diseases is foundational to attaining ideal cardiovascular health to improve the overall health and well-being of individuals and communities. Social determinants of health and health care inequities adversely affect ideal cardiovascular health and prevention of disease. Achieving optimal cardiovascular health in an effective and equitable manner requires a coordinated multidisciplinary and multilayered approach. In this scientific statement, we examine barriers to ideal cardiovascular health and its related conditions in the context of leveraging existing resources to reduce health care inequities and to optimize the delivery of preventive cardiovascular care. We systematically discuss (1) interventions across health care environments involving direct patient care, (2) leveraging health care technology, (3) optimizing multispecialty/multiprofession collaborations and interventions, (4) engaging local communities, and (5) improving the community environment through health-related government policies, all with a focus on making ideal cardiovascular health equitable for all individuals.

A Community-Based Educational Intervention: Increasing Medication Adherence in Rural Older Adults

PURPOSE

This study evaluated the effectiveness of a community-based, interdisciplinary, medication education intervention for rural older adults.

METHODS

The research design was a quasi-experimental pretest/posttest design. Self-efficacy, adherence to refills and medication, and knowledge were examined. An educational intervention was conducted with each participant on their prescribed medications.

FINDINGS

Mean scores for the adherence to refills and medication subscale decreased from 9.9 to 8.5 (p = .003) indicating improved adherence. Mean scores for the knowledge subscale increased from 21.8 to 22.4 (p = .192).

CONCLUSIONS

Results suggest a community-based, interdisciplinary, individualized medication education intervention could increase medication adherence in rural older adults.

Rural-Urban Disparities in Hospital Admissions and Mortality Among Patients with COVID-19: Evidence from South Carolina from 2021 to 2022

Although rural communities have been hard-hit by the COVID-19 pandemic, there is limited evidence on COVID-19 outcomes in rural America using up-to-date data. This study aimed to estimate the associations between hospital admissions and mortality and rurality among COVID-19 positive patients who sought hospital care in South Carolina. We used all-payer hospital claims, COVID-19 testing, and vaccination history data from January 2021 to January 2022 in South Carolina. We included 75,545 hospital encounters within 14 days after positive and confirmatory COVID-19 testing. Associations between hospital admissions and mortality and rurality were estimated using multivariable logistic regressions. About 42% of all encounters resulted in an inpatient hospital admission, while hospital-level mortality was 6.3%. Rural residents accounted for 31.0% of all encounters for COVID-19. After controlling for patient-level, hospital, and regional characteristics, rural residents had higher odds of overall hospital mortality (Adjusted Odds Ratio - AOR = 1.19, 95% Confidence Intervals - CI = 1.04-1.37), both as inpatients (AOR = 1.18, 95% CI = 1.05-1.34) and as outpatients (AOR = 1.63, 95% CI = 1.03-2.59). Sensitivity analyses using encounters with COVID-like illness as the primary diagnosis only and encounters from September 2021 and beyond - a period when the Delta variant was dominant and booster vaccination was available - yielded similar estimates. No significant differences were observed in inpatient hospitalizations (AOR = 1.00, 95% CI = 0.75-1.33) between rural and urban residents. Policymakers should consider community-based public health approaches to mitigate geographic disparities in health outcomes among disadvantaged population subgroups.

Recruiting historically under-represented individuals into Project ECHO Diabetes: using barrier analysis to understand disparities in clinical research in the USA

OBJECTIVES

Individuals under-recruited in diabetes research studies include those not seen at endocrinology centres and those from rural, low socioeconomic and/or under-represented racial/ethnic groups. The purpose of this descriptive analysis is to detail recruitment and retention efforts of Project ECHO Diabetes clinical sites affiliated with Stanford University and University of Florida.

DESIGN

Prospective collection of participant engagement and qualitative analysis of barriers and facilitators of research engagement within Project ECHO Diabetes, a virtual tele-education programme for healthcare providers in the management of individuals with insulin-requiring diabetes.

SETTING

Data were collected at the patient level, provider level and clinic level between 1 May 2021 and 31 July 2022.

PARTICIPANTS

Participants and study personnel were recruited from 33 Project ECHO Diabetes sites in California and Florida.

OUTCOMES

We report study completion rates for participants recruited into 33 Project ECHO Diabetes sites. Using barrier analysis, a methodology designed for the real-time assessment of interventions and system processes to identify barriers and facilitators, study personnel identified significant barriers to recruitment and retention and mapped them to actionable solutions.

RESULTS

In total, 872 participants (California n=495, Florida n=377) were recruited with differing recruitment rates by site (California=52.7%, Florida=21.5%). Barrier analysis identified lack of trust, unreliable contact information, communication issues and institutional review board (IRB) requirements as key recruitment barriers. Culturally congruent staff, community health centre (CHC) support, adequate funding and consent process flexibility were solutions to address recruitment challenges. Barriers to retention were inconsistent postal access, haemoglobin A1c kit collection challenges, COVID-19 pandemic and broadband/connectivity issues. Additional funding supporting research staff and analogue communication methods were identified as solutions address barriers to retention.

CONCLUSIONS

Funded partnerships with CHCs, trusted by their local communities, were key in our recruitment and retention strategies. IRB consent process flexibility reduced barriers to recruitment. Recruiting historically under-represented populations is feasible with funding aimed to address structural barriers to research participation.

The ACTIVATE Digital Health Pilot Program for Diabetes and Hypertension in an Underserved and Rural Community

BACKGROUND

Community health centers and patients in rural and agricultural communities struggle to address diabetes and hypertension in the face of health disparities and technology barriers. The stark reality of these digital health disparities were highlighted during the coronavirus disease 2019 pandemic.

OBJECTIVES

The objective of the ACTIVATE (Accountability, Coordination, and Telehealth in the Valley to Achieve Transformation and Equity) project was to codesign a platform for remote patient monitoring and program for chronic illness management that would address these disparities and offer a solution that fit the needs and context of the community.

METHODS

ACTIVATE was a digital health intervention implemented in three phases: community codesign, feasibility assessment, and a pilot phase. Pre- and postintervention outcomes included regularly collected hemoglobin A1c (A1c) for participants with diabetes and blood pressure for those with hypertension.

RESULTS

Participants were adult patients with uncontrolled diabetes and/or hypertension (n = 50). Most were White and Hispanic or Latino (84%) with Spanish as a primary language (69%), and the mean age was 55. There was substantial adoption and use of the technology: over 10,000 glucose and blood pressure measures were transmitted using connected remote monitoring devices over a 6-month period. Participants with diabetes achieved a mean reduction in A1c of 3.28 percentage points (standard deviation [SD]: 2.81) at 3 months and 4.19 percentage points (SD: 2.69) at 6 months. The vast majority of patients achieved an A1c in the target range for control (7.0-8.0%). Participants with hypertension achieved reductions in systolic blood pressure of 14.81 mm Hg (SD: 21.40) at 3 months and 13.55 mm Hg (SD: 23.31) at 6 months, with smaller reductions in diastolic blood pressure. The majority of participants also reached target blood pressure (less than 130/80).

CONCLUSION

The ACTIVATE pilot demonstrated that a codesigned solution for remote patient monitoring and chronic illness management delivered by community health centers can overcome digital divide barriers and show positive health outcomes for rural and agricultural residents.

Contextualizing physical activity in rural adults: Do relationships between income inequality, neighborhood environments, and physical activity exist?

OBJECTIVE

To examine if income inequality, social cohesion, and neighborhood walkability are associated with physical activity among rural adults.

DATA SOURCE

Cross-sectional data came from a telephone survey (August 2020-March 2021) that examined food access, physical activity, and neighborhood environments across rural counties in a southeastern state.

STUDY DESIGN

Multinomial logistic regression models assessed the likelihood of being active versus inactive and insufficiently active versus inactive in this rural population. Coefficients are presented as relative risk ratios (RRRs). Statistical significance was determined using 95% confidence intervals (CIs). All analyses were performed in STATA 16.1.

DATA COLLECTION/EXTRACTION METHODS

Trained university students administered the survey. Students verbally obtained consent, read survey items, and recorded responses into Qualtrics software. Upon survey completion, respondents were mailed a $10 incentive card and printed informed consent form. Eligible participants were ≥18 years old and current residents of included counties.

PRINCIPAL FINDINGS

Respondents in neighborhoods with relatively high social cohesion versus low social cohesion were more likely to be active than inactive (RRR = 2.50, 95% CI: 1.27-4.90, p < 0.01), after accounting for all other variables in the model. Income inequality and neighborhood walkability were not associated with different levels of physical activity in the rural sample.

CONCLUSIONS

Study findings contribute to limited knowledge on the relationship between neighborhood environmental contexts and physical activity among rural populations. The health effects of neighborhood social cohesion warrant more attention in health equity research and consideration when developing multilevel interventions to improve the health of rural populations.

Opportunities and Achievement of Medication Initiation Among Inpatients With Heart Failure With Reduced Ejection Fraction

BACKGROUND

Initiation of evidence-based medications for patients with heart failure with reduced ejection fraction (HFrEF) during hospitalization in contemporary practice is unknown.

OBJECTIVES

This study characterized opportunities for and achievement of heart failure (HF) medication initiation.

METHODS

Using the GWTG-HF (Get With The Guidelines-Heart Failure) Registry 2017-2020, which collected data on contraindications and prescribing for 7 evidence-based HF-related medications, we assessed the number of medications for which each patient with HFrEF was eligible, use before admission, and prescribed at discharge. Multivariable logistic regression identified factors associated with medication initiation.

RESULTS

Among 50,170 patients from 160 sites, patients were eligible for mean number of 3.9 ± 1.1 evidence-based medications with 2.1 ± 1.3 used before admission and 3.0 ± 1.0 prescribed on discharge. The number of patients receiving all indicated medications increased from admission (14.9%) to discharge (32.8%), a mean net gain of 0.9 ± 1.3 medications over a mean of 5.6 ± 5.3 days. In multivariable analysis, factors associated with lower odds of HF medication initiation included older age, female sex, medical pre-existing conditions (stroke, peripheral arterial disease, pulmonary disease, and renal insufficiency), and rural location. Odds of medication initiation increased during the study period (adjusted OR: 1.08; 95% CI: 1.06-1.10).

CONCLUSIONS

Nearly 1 in 6 patients received all indicated HF-related medications on admission, increasing to 1 in 3 on discharge with an average of 1 new medication initiation. Opportunities to initiate evidence-based medications persist, particularly among women, those with comorbidities, and those receiving care at rural hospitals.

Hoosier Sport: a research protocol for a multilevel physical activity-based intervention in rural Indiana

Introduction

Currently, only 1 in 4 children in the U.S. engage in the recommended amount of physical activity (PA) and disparities in PA participation increase as income inequities increase. Moreover, leading health organizations have identified rural health as a critical area of need for programming, research, and policy. Thus, there is a critical need for the development and testing of evidence-based PA interventions that have the potential to be scalable to improve health disparities in children from under-resourced rural backgrounds. As such, the present study utilizes human-centered design, a technique that puts community stakeholders at the center of the intervention development process, to increase our specific understanding about how the PA-based needs of children from rural communities manifest themselves in context, at the level of detail needed to make intervention design decisions. The present study connects the first two stages of the NIH Stage Model for Behavioral Intervention Development with a promising conceptual foundation and potentially sustainable college student mentor implementation strategy.

Methods

We will conduct a three-phase study utilizing human-centered community-based participatory research (CBPR) in three aims: (Aim 1) conduct a CBPR needs assessment with middle school students, parents, and teachers/administrators to identify perceptions, attributes, barriers, and facilitators of PA that are responsive to the community context and preferences; (Aim 2) co-design with children and adults to develop a prototype multi-level PA intervention protocol called Hoosier Sport; (Aim 3) assess Hoosier Sport's trial- and intervention-related feasibility indicators. The conceptual foundation of this study is built on three complementary theoretical elements: (1) Basic Psychological Needs mini-theory within Self-Determination Theory; (2) the Biopsychosocial Model; and (3) the multilevel Research Framework from the National Institute on Minority Health and Health Disparities.

Discussion

Our CBPR protocol takes a human-centered approach to integrating the first two stages of the NIH Stage Model with a potentially sustainable college student mentor implementation strategy. This multidisciplinary approach can be used by researchers pursuing multilevel PA-based intervention development for children.

Guidelines, position statements, and advisories for the primary prevention of type 2 diabetes, hypertension, and cardiovascular disease in rural populations: A systematic review protocol

INTRODUCTION

Globally, noncommunicable diseases (NCDs), which include type 2 diabetes (T2D), hypertension, and cardiovascular disease (CVD), are associated with a high burden of morbidity and mortality. Health disparities exacerbate the burden of NCDs. Notably, rural, compared with urban, populations face greater disparities in access to preventive care, management, and treatment of NCDs. However, there is sparse information and no known literature synthesis on the inclusion of rural populations in documents (i.e., guidelines, position statements, and advisories) pertaining to the prevention of T2D, hypertension, and CVD. To address this gap, we are conducting a systematic review to assess the inclusion of rural populations in documents on the primary prevention of T2D, hypertension, and CVD.

METHODS AND ANALYSIS

This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched 19 databases including EMBASE, MEDLINE, and Scopus, from January 2017 through October 2022, on the primary prevention of T2D, hypertension, and CVD. We conducted separate Google® searches for each of the 216 World Bank economies. For primary screening, titles and/or abstracts were screened independently by two authors (databases) or one author (Google®). Documents meeting selection criteria will undergo full-text review (secondary screening) using predetermined criteria, and data extraction using a standardized form. The definition of rurality varies, and we will report the description provided in each document. We will also describe the social determinants of health (based on the World Health Organization) that may be associated with rurality.

ETHICS AND DISSEMINATION

To our knowledge, this will be the first systematic review on the inclusion of rurality in documents on the primary prevention of T2D, hypertension, and CVD. Ethics approval is not required since we are not using patient-level data. Patients are not involved in the study design or analysis. We will present the results at conferences and in peer-reviewed publication(s).

TRIAL REGISTRATION

PROSPERO Registration Number: CRD42022369815.

Demographic and regional trends of peripheral artery disease-related mortality in the United States, 2000 to 2019

INTRODUCTION

Peripheral artery disease (PAD) is a common progressive atherosclerotic disease associated with significant morbidity and mortality in the US; however, data regarding PAD-related mortality trends are limited. This study aims to characterize contemporary trends in mortality across sociodemographic and regional groups.

METHODS

The Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research (CDC WONDER) was queried for data regarding PAD-related deaths from 2000 to 2019 in the overall sample and different demographic (age, sex, race/ethnicity) and regional (state, urban-rural) subgroups. Crude and age-adjusted mortality rates (CMR and AAMR, respectively) per 100,000 people were calculated. Associated annual percentage changes (APC) were computed using Joinpoint Regression Program Version 4.9.0.0 trend analysis software.

RESULTS

Between 2000 and 2019, a total of 1,959,050 PAD-related deaths occurred in the study population. Overall, AAMR decreased from 72.8 per 100,000 in 2000 to 32.35 per 100,000 in 2019 with initially decreasing APCs followed by no significant decline from 2016 to 2019. Most demographic and regional subgroups showed initial declines in AAMRs during the study period, with many groups exhibiting no change in mortality in recent years. However, men, non-Hispanic (NH) Black or African American individuals, people aged ⩾ 85 years, and rural counties were associated with the highest AAMRs of their respective subgroups. Notably, there was an increase in crude mortality rate among individuals 25-39 years of age from 2009 to 2019.

CONCLUSION

Despite initial improvement, PAD-related mortality has remained stagnant in recent years. Disparities have persisted across several demographic and regional groups, requiring further investigation.

Culturally Relevant Physical Activity in the Behavioral Risk Factor Surveillance System in Hawai'i

INTRODUCTION

Culturally relevant physical activity is a promising field for chronic disease prevention and management. Native Hawaiians and Other Pacific Islanders have higher rates of physical inactivity than other racial or ethnic groups and increased risk of chronic disease. The study objective was to provide population-level data from Hawai'i on lifetime experiences in the Native Hawaiian Indigenous practices of hula and outrigger canoe paddling across demographic and health factors to identify opportunities for public health intervention, engagement, and surveillance.

METHODS

Questions about hula and paddling were added to the Hawai'i 2018 and 2019 Behavioral Risk Factor Surveillance System (N = 13,548). We considered level of engagement by demographic categories and health status indicators, accounting for the complex survey design.

RESULTS

Overall, 24.5% of adults engaged in hula and 19.8% in paddling in their lifetime. Prevalence of engagement was higher among Native Hawaiians (48.8% hula, 41.5% paddling) and Other Pacific Islanders (35.3% hula, 31.1% paddling) than among other racial and ethnic groups. In adjusted rate ratios, experience in these activities was strong across age groups, education, sex, and income levels, particularly among Native Hawaiians and Other Pacific Islanders.

CONCLUSION

Throughout Hawai'i, hula and outrigger canoe paddling are important and popular cultural practices with high physical activity demands. Participation was notably high for Native Hawaiians and Other Pacific Islanders. Surveillance information around culturally relevant physical activities can benefit public health programming and research from a strength-based community perspective.

Outpatient intravenous diuresis in a rural setting: safety, efficacy, and outcomes

Purpose

To evaluate the safety, efficacy, and outcomes of outpatient intravenous diuresis in a rural setting and compare it to urban outcomes.

Methods

A single-center study was conducted on 60 patients (131 visits) at the Dartmouth-Hitchcock Medical Center (DHMC) from 1/2021-12/2022. Demographics, visit data, and outcomes were collected and compared to urban outpatient IV centers, and inpatient HF hospitalizations from DHMC FY21 and national means. Descriptive statistics, T-tests and chi-squares were used.

Results

The mean age was 70 ± 13 years, 58% were male, and 83% were NYHA III-IV. Post-diuresis, 5% had mild-moderate hypokalemia, 16% had mild worsening of renal function, and 3% had severe worsening of renal function. No hospitalizations occurred due to adverse events. The mean infusion-visit urine output was 761 ± 521 ml, and post-visit weight loss was -3.9 ± 5.0 kg. No significant differences were observed between HFpEF and HFrEF groups. 30-day readmissions were similar to urban outpatient IV centers, DHMC FY21, and the national mean (23.3% vs. 23.5% vs. 22.2% vs. 22.6%, respectively; p = 0.949). 30-day mortality was similar to urban outpatient IV centers but lower than DHMC FY21 and the national means (1.7% vs. 2.5% vs. 12.3% vs. 10.7%, respectively; p < 0.001). At 60 days, 42% of patients had ≥1 clinic revisit, 41% had ≥1 infusion revisit, 33% were readmitted to the hospital, and two deaths occurred. The clinic avoided 21 hospitalizations, resulting in estimated cost savings of $426,111.

Conclusion

OP IV diuresis appears safe and effective for rural HF patients, potentially decreasing mortality rates and healthcare expenses while mitigating rural-urban disparities.

Disparity of Performance Measure by Door-to-Balloon Time Between a Rural and Urban Area for Management of Patients With ST-Segment Elevation Myocardial Infarction - Insights From the Nationwide Japan Acute Myocardial Infarction Registry

BACKGROUND

Although a door-to-balloon (D2B) time ≤90 min is recognized as a key indicator of timely reperfusion for patients with ST-segment elevation myocardial infarction (STEMI), it is unclear whether regional disparities in the prognostic value of D2B remain in contemporary Japan.

METHODS AND RESULTS

We retrospectively analyzed 17,167 STEMI patients (mean [±SD] age 68±13 years, 77.6% male) undergoing primary percutaneous coronary intervention. With reference to the Japanese median population density of 1,147 people/km2, patients were divided into 2 groups: rural (n=6,908) and urban (n=10,259). Compared with the urban group, median D2B time was longer (70 vs. 62 min; P<0.001) and the rate of achieving a D2B time ≤90 min was lower (70.7% vs. 75.4%; P<0.001) in the rural group. In-hospital mortality was lower for patients with a D2B time ≤90 min than >90 min, regardless of residential area, whereas multivariable analysis identified prolonged D2B time as a predictor of in-hospital death only in the rural group (adjusted odds ratio 1.57; 95% confidence interval 1.18-2.09; P=0.002). Importantly, the rural-urban disparity in in-hospital mortality emerged most distinctively among patients with Killip Class IV and a D2B time >90 min.

CONCLUSIONS

These data suggest that there is a substantial rural-urban gap in the prognostic significance of D2B time among STEMI patients, especially those with cardiogenic shock and a prolonged D2B time.

Demographic and Regional Trends of Cardiovascular Diseases and Diabetes Mellitus-Related Mortality in the United States From 1999 to 2019

OBJECTIVE

The purpose of this research was to study the contemporary trends in cardiovascular disease (CVD) and diabetes mellitus (DM)-related mortality.

METHODS

We used the Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research (CDC WONDER) database to identify adults ≥25 years old where both CVD and DM were listed as an underlying or contributing cause of death between 1999 and 2019. Crude and age-adjusted mortality rates per 100,000 population were determined.

RESULTS

The overall age-adjusted mortality rate was 99.18 in 1999 and 91.43 in 2019, with a recent increase from 2014-2019 (annual percent change 1.0; 95% confidence interval [CI], 0.3-1.6). Age-adjusted mortality rate was higher for males compared with females, with increasing mortality in males between 2014 and 2019 (annual percent change 1.5; 95% CI, 0.9-2.0). Age-adjusted mortality rate was highest for non-Hispanic Black adults and was ∼2-fold higher compared with non-Hispanic White adults. Young and middle-aged adults (25-69 years) had increasing age-adjusted mortality rates in recent years. There were significant urban-rural disparities, and age-adjusted mortality rates in rural counties increased from 2014 to 2019 (annual percent change 2.2; 95% CI, 1.5-2.9); states in the 90^th percentile of mortality had age-adjusted mortality rates that were ∼2-fold higher than those in the bottom 10^th percentile of mortality.

CONCLUSION

After an initial decrease in DM + CVD-related mortality for a decade, this trend has reversed, with increasing mortality from 2014 to 2019. Significant geographic and demographic disparities persist, requiring targeted health policy interventions to prevent the loss of years of progress.

Quality of Care and Outcomes Among Patients Hospitalized for Heart Failure in Rural vs Urban US Hospitals: The Get With The Guidelines-Heart Failure Registry

Importance

Prior studies have suggested patients with heart failure (HF) from rural areas have worse clinical outcomes. Contemporary differences between rural and urban hospitals in quality of care and clinical outcomes for patients hospitalized for HF remain poorly understood.

Objective

To assess quality of care and clinical outcomes for US patients hospitalized for HF at rural vs urban hospitals.

Design, Setting, and Participants

This retrospective cohort study analyzed 774 419 patients hospitalized for HF across 569 sites in the Get With The Guidelines-Heart Failure (GWTG-HF) registry between January 1, 2014, and September 30, 2021. Postdischarge outcomes were assessed in a subset of 161 996 patients linked to Medicare claims. Data were analyzed from August 2022 to January 2023.

Main Outcomes and Measures

GWTG-HF quality measures, in-hospital mortality, length of stay, and 30-day mortality and readmission outcomes.

Results

This study included 19 832 patients (2.6%) and 754 587 patients (97.4%) hospitalized at 49 rural hospitals (8.6%) and 520 urban hospitals (91.4%), respectively. Of 774 419 included patients, 366 161 (47.3%) were female, and the median (IQR) age was 73 (62-83) years. Compared with patients at urban hospitals, patients at rural hospitals were older (median [IQR] age, 74 [64-84] years vs 73 [61-83] years; standardized difference, 10.63) and more likely to be non-Hispanic White (14 572 [73.5%] vs 498 950 [66.1%]; standardized difference, 34.47). In adjusted models, patients at rural hospitals were less likely to be prescribed cardiac resynchronization therapy (adjusted risk difference [aRD], -13.5%; adjusted odds ratio [aOR], 0.44; 95% CI, 0.22-0.92), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (aRD, -3.7%; aOR, 0.71; 95% CI, 0.53-0.96), and an angiotensin receptor-neprilysin inhibitor (aRD, -5.0%; aOR, 0.68; 95% CI, 0.47-0.98) at discharge. In-hospital mortality was similar between rural and urban hospitals (460 of 19 832 [2.3%] vs 20 529 of 754 587 [2.7%]; aOR, 0.86; 95% CI, 0.70-1.07). Patients at rural hospitals were less likely to have a length of stay of 4 or more days (aOR, 0.75; 95% CI, 0.67-0.85). Among Medicare beneficiaries, there were no significant differences between rural and urban hospitals in 30-day HF readmission (adjusted hazard ratio [aHR], 1.03; 95% CI, 0.90-1.19), all-cause readmission (aHR, 0.97; 95% CI, 0.91-1.04), and all-cause mortality (aHR, 1.05; 95% CI, 0.91-1.21).

Conclusions and Relevance

In this large contemporary cohort of US patients hospitalized for HF, care at rural hospitals was independently associated with lower use of some guideline-recommended therapies at discharge and shorter length of stay. In-hospital mortality and 30-day postdischarge outcomes were similar at rural and urban hospitals.

Planned adaptation and implementation of the Community Guide recommendations for increasing physical activity in rural community settings: A qualitative study

Background

The purpose of this paper is to report on the implementation of an evidence-based model, VIVA, which was developed to translate physical activity (PA) recommendations to rural environments and was scaled-up to 12 rural communities across New Mexico. Our longitudinal qualitative research describes processes of planned adaptation in the rural context with an exploration of inner and outer context adaptations that consider important implementation constructs including leadership, partnership and collaboration.

Materials & methods

An enhanced version of the RE-AIM framework was used to formulate community-level engagement and process questions essential to implementation science. Qualitative methods, using a thematic approach that included both inductive and deductive coding with attention to processes, was used to explore adaptation at the community level. Data included semi-structured interviews with 17 community leaders at baseline and 10 at follow-up, fieldnotes, and technical assistance tracking forms. Analysis was conducted with NVivo qualitative data analysis software.

Results

Analysis demonstrated how planned adaptation of the implementation model was critical to dissemination in rural communities. Understanding and adapting to local context-including geography, culture, economics-is essential for implementation. Inner context constructs, recognized as important across implementation models, including leadership, partnerships and political engagement were found to be key to implementation success. Moreover, we provide concrete examples of the range and complexity of these issues in rural communities, and how these shaped implementation uptake and success.

Discussion

Studying processes of planned adaptation in rural contexts will further implementation science efforts to move evidence into practice. It is essential to incorporate planned adaptation to local, community contexts to create models which are simple to encourage adoption, are evidence-based, and are adaptable to local conditions without compromising the integrity of the evidence-based model.

Association of Rurality With Risk of Heart Failure

Importance

Rural populations experience an increased burden of heart failure (HF) mortality compared with urban populations. Whether HF incidence is greater among rural individuals is less known. Additionally, the intersection between racial and rural health inequities is understudied.

Objective

To determine whether rurality is associated with increased risk of HF, independent of cardiovascular (CV) disease and socioeconomic status (SES), and whether rurality-associated HF risk varies by race and sex.

Design, Setting, and Participants

This prospective cohort study analyzed data for Black and White participants of the Southern Community Cohort Study (SCCS) without HF at enrollment who receive care via Centers for Medicare & Medicaid Services (CMS). The SCCS is a population-based cohort of low-income, underserved participants from 12 states across the southeastern United States. Participants were enrolled between 2002 and 2009 and followed up until December 31, 2016. Data were analyzed from October 2021 to November 2022.

Exposures

Rurality as defined by Rural-Urban Commuting Area codes at the census-tract level.

Main Outcomes and Measures

Heart failure was defined using diagnosis codes via CMS linkage through 2016. Incidence of HF was calculated by person-years of follow-up and age-standardized. Sequentially adjusted Cox proportional hazards regression models tested the association between rurality and incident HF.

Results

Among 27 115 participants, the median (IQR) age was 54 years (47-65), 18 647 (68.8%) were Black, and 8468 (32.3%) were White; 5556 participants (20%) resided in rural areas. Over a median 13-year follow-up, age-adjusted HF incidence was 29.6 (95% CI, 28.9-30.5) per 1000 person-years for urban participants and 36.5 (95% CI, 34.9-38.3) per 1000 person-years for rural participants (P < .001). After adjustment for demographic information, CV risk factors, health behaviors, and SES, rural participants had a 19% greater risk of incident HF (hazard ratio [HR], 1.19; 95% CI, 1.13-1.26) compared with their urban counterparts. The rurality-associated risk of HF varied across race and sex and was greatest among Black men (HR, 1.34; 95% CI, 1.19-1.51), followed by White women (HR, 1.22; 95% CI, 1.07-1.39) and Black women (HR, 1.18; 95% CI, 1.08-1.28). Among White men, rurality was not associated with greater risk of incident HF (HR, 0.97; 95% CI, 0.81-1.16).

Conclusions and Relevance

Among predominantly low-income individuals in the southeastern United States, rurality was associated with an increased risk of HF among women and Black men, which persisted after adjustment for CV risk factors and SES. This inequity points to a need for additional emphasis on primary prevention of HF among rural populations.

Investigation on Gender Differences in Leadership of Stroke-Related Clinical Trials

BACKGROUND

Gender disparities among principal investigators of clinical trials (CT) can have implications regarding the areas of investigation, methods, conduct, trial enrollment, and interpretation of results. An estimation of the gender gap in the leadership of stroke-related CTs from North America has to date not been undertaken.

METHODS

We extracted information about stroke-related CTs between 2011 and 2020 from www.

CLINICALTRIALS

gov and PubMed. We examined the gender distribution according to the academic credentials and the trial type. The gender of PIs and authors was determined using gender package in R, which identifies gender using historical data from the United States. Additionally, we obtained information from Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education data resource books on the gender composition of full-time neurology faculty, neurology residents and vascular neurology fellows.

RESULTS

In these analyses of 821 CTs registered on Clinicaltrials.gov and 110 trials published on PubMed, we found that gender disparity among the PIs, first and last authors have persisted over the last decade without any significant trend toward parity (P>0.05). On examining the gender distribution according to academic credentials and trial type, we found that men were over-represented in the sub-group of PIs with an MD degree (78.11% versus 21.87%; P<0.01) and those leading acute stroke trials (86.04% versus 13.89%; P<0.01). We also found that a lower proportion of women neurology residents pursued a vascular neurology fellowship during this period (33.5% versus 42.5%; P<0.05).

CONCLUSIONS

Our results show that the favorable trend toward gender parity seen in Neurology faculty over the last decade has not translated to the same in the leadership of CTs. Our findings merit further investigation and a re-examination of efforts toward inclusion of women as leaders of stroke-related CTs.

Perception of recurrent risk versus objective measured risk of ischemic stroke in first-ever stroke patients from a rural area in China: A cross-sectional study

OBJECTIVE

Risk perception is critical to the formation of individual health prevention behaviors. A long-term accurate perception of stroke recurrent risks is imperative for stroke secondary prevention. This study aims to explore the level of recurrence risk perceptions and the influential factors of inaccuracy between perceived and objective risk in first-ever ischemic stroke patients from a rural area.

METHODS

From May to November 2020, 284 first-ever ischemic stroke patients were conveniently recruited in a rural area of Henan Province, China. Perceived risk was measured based on self-reported using a numerical rating scale, whereas the objective risk was measured by the Essen Stroke Risk Score. Patients' perceived risk was compared with their objective risk and categorized as "Accurate," "Underestimated," and "Overestimated." The influencing factors of inaccuracy were further evaluated using multivariate regression analyses.

RESULTS

46% of the participants underestimated their stroke risk, while 15.9% overestimated their risks. Patients who were younger (≤65 years), didn't worry about recurrent stroke, and had a low actual recurrent risk were more likely to underestimate their recurrent risk. Patients who were employed, had lower independence, and had greater anxiety were more likely to overestimate their recurrent risk.

CONCLUSIONS

The majority of participants were unable to accurately perceive their own risk of stroke recurrence. Patients' age, working status, worry about recurrent stroke, actual recurrent risk, level of dependence, and anxiety played a role in perception inaccuracy.

PRACTICE IMPLICATIONS

The findings could help healthcare providers gain a better understanding of the level and accuracy of recurrence risk perceptions among first-ever stroke patients in the rural area. Future counseling on the perceived risk of stroke recurrence and individual objective risk assessment could be conducted to help patients better understand their risk of recurrence. Individualized risk communication and multidisciplinary teamwork can be developed to improve the accuracy of recurrence risk perceptions and health behaviors.

Kenton Award Lecture-Stroke Disparities Research: Learning From the Past, Planning for the Future

Inequities in stroke care and outcomes have been documented both within and among countries based on factors, such as race, geography, and socioeconomic status. Research can help us to identify, understand, and address inequities, and this article offers considerations for scientists working in this area. These include designing research aimed at identifying the underlying causes of inequities, recognizing the importance of the social determinants of health, considering interventions that go beyond the individual patient and provider to include policies and systems, acknowledging the role of structural racism, performing community-engaged participatory research, considering intersecting social identities, learning from cross-national comparisons, maintaining the data sources needed for inequities research, using terminology that advances health equity, and improving diversity across the research enterprise.

Rural and socioeconomic differences in the effectiveness of the HEART Pathway accelerated diagnostic protocol

BACKGROUND

The HEART Pathway is a validated accelerated diagnostic protocol (ADP) for patients with possible acute coronary syndrome (ACS). This study aimed to compare the safety and effectiveness of the HEART Pathway based on patient rurality (rural vs. urban) or socioeconomic status (SES).

METHODS

We performed a preplanned subgroup analysis of the HEART Pathway Implementation Study. The primary outcomes were death or myocardial infarction (MI) and hospitalization at 30 days. Proportions were compared by SES and rurality with Fisher's exact tests. Logistic regression evaluated for interactions of ADP implementation with SES or rurality and changes in outcomes within subgroups.

RESULTS

Among 7245 patients with rurality and SES data, 39.9% (2887/7245) were rural and 22.2% were low SES (1607/7245). The HEART Pathway identified patients as low risk in 32.2% (818/2540) of urban versus 28.1% (425/1512) of rural patients (p = 0.007) and 34.0% (311/915) of low SES versus 29.7% (932/3137) high SES patients (p = 0.02). Among low-risk patients, 30-day death or MI occurred in 0.6% (5/818) of urban versus 0.2% (1/425) rural (p = 0.67) and 0.6% (2/311) with low SES versus 0.4% (4/932) high SES (p = 0.64). Following implementation, 30-day hospitalization was reduced by 7.7% in urban patients (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.66-0.87), 10.6% in low SES patients (aOR 0.68, 95% CI 0.54-0.86), and 4.5% in high SES patients (aOR 0.83, 95% CI 0.73-0.94). However, rural patients had a nonsignificant 3.3% reduction in hospitalizations.

CONCLUSIONS

HEART Pathway implementation decreased 30-day hospitalizations regardless of SES and for urban patients but not rural patients. The 30-day death or MI rate was similar among low-risk patients.

Transforming Atrial Fibrillation Research to Integrate Social Determinants of Health: A National Heart, Lung, and Blood Institute Workshop Report

Importance

Only modest attention has been paid to the contributions of social determinants of health to atrial fibrillation (AF) risk factors, diagnosis, symptoms, management, and outcomes. The diagnosis of AF provides unique challenges exacerbated by the arrhythmia's often paroxysmal nature and individuals' disparate access to health care and technologies that facilitate detection. Social determinants of health affect access to care and management decisions for AF, increasing the likelihood of adverse outcomes among individuals who experience systemic disadvantages. Developing effective approaches to address modifiable social determinants of health requires research to eliminate the substantive inequities in health care delivery and outcomes in AF.

Observations

The National Heart, Lung, and Blood Institute convened an expert panel to identify major knowledge gaps and research opportunities in the field of social determinants of AF. The workshop addressed the following social determinants: (1) socioeconomic status and access to care; (2) health literacy; (3) race, ethnicity, and racism; (4) sex and gender; (5) shared decision-making in systemically disadvantaged populations; and (6) place, including rurality, neighborhood, and community. Many individuals with AF have multiple adverse social determinants, which may cluster in the individual and in systemically disadvantaged places (eg, rural locations, urban neighborhoods). Cumulative disadvantages may accumulate over the life course and contribute to inequities in the diagnosis, management, and outcomes in AF.

Conclusions and Relevance

Workshop participants identified multiple critical research questions and approaches to catalyze social determinants of health research that address the distinctive aspects of AF. The long-term aspiration of this work is to eradicate the substantive inequities in AF diagnosis, management, and outcomes across populations.

Cost-effectiveness Analysis of a Personalized, Teleretinal-Inclusive Screening Policy for Diabetic Retinopathy via Markov Modeling

PURPOSE

Although teleretinal imaging has proved effective in increasing population-level screening for diabetic retinopathy (DR), there is a lack of quantitative understanding of how to incorporate teleretinal imaging into existing screening guidelines. We develop a mathematical model to determine personalized DR screening recommendations that utilize teleretinal imaging and evaluate the cost-effectiveness of the personalized screening policy.

DESIGN

A partially observable Markov decision process is employed to determine personalized screening recommendations based on patient compliance, willingness to pay, and A1C level. Deterministic sensitivity analysis was conducted to evaluate the impact of patient-specific factors on personalized screening policy. The cost-effectiveness of identified screening policies was evaluated via hidden-Markov chain Monte Carlo simulation on a data-based hypothetical cohort.

PARTICIPANTS

Screening policies were simulated for a hypothetical cohort of 500 000 patients with parameters based on the literature and electronic medical records of 2457 patients who received teleretinal imaging from 2013 to 2020 from the Harris Health System.

METHODS

Population-based mathematical modeling study. Interventions included dilated fundus examinations referred to as clinical screening, teleretinal imaging, and wait and watch recommendations.

MAIN OUTCOME MEASURES

Personalized screening recommendations based on patient-specific factors. Accumulated quality-adjusted life-years (QALYs) and cost (USD) per patient under different screening policies. Incremental cost-effectiveness ratio to compare different policies.

RESULTS

For the base cohort, on average, teleretinal imaging was recommended 86.7% of the time over each patient's lifetime. The model-based personalized policy dominated other standardized policies, generating more QALY gains and cost savings for at least 57% of the base cohort. Similar outcomes were observed in sensitivity analyses of the base cohort and the Harris Health-specific cohort and rural population scenario analysis.

CONCLUSIONS

A mathematical model was developed as a decision support tool to identify a personalized screening policy that incorporates both teleretinal imaging and clinical screening and adapts to patient characteristics. Compared with current standardized policies, the model-based policy significantly reduces costs, whereas it is performing comparably, if not better, in terms of QALY gain. A personalized approach to DR screening has significant potential benefits that warrant further exploration.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Invasive Management and In-Hospital Outcomes of Myocardial Infarction Patients in Rural Versus Urban Hospitals in the United States

OBJECTIVES

The variation in the management and outcome of acute myocardial infarction (AMI) between rural and urban settings has been previously recognized, but there has previously been no nationwide data reported that is inclusive of the whole adult population.

METHODS

All discharge records between 2004 and 2018 with AMI diagnosis were extracted from the National Inpatient Sample (NIS) database and stratified by hospital location. The primary outcome was in-hospital mortality, and secondary outcomes included (a) major adverse cardiovascular and cerebrovascular events (MACCE), (b) major bleeding, (c) acute ischemic stroke, the utilization of invasive management in the form of (d) coronary angiography (CA), and (e) percutaneous coronary intervention (PCI). The adjusted odds ratios (aOR) and 95 % confidence interval (95 % CI) were determined using multivariable logistic regression.

RESULTS

9,728,878 records with AMI were identified, of which 1,011,637 (10.4 %) discharges were from rural hospitals. Rural patients were older (median of 71 years vs. 67 years, p < 0.001) and had lower prevalence of the highest risk presentations of AMI than their urban counterparts. After multivariable adjustment, patients from rural hospitals had increased aOR of all-cause mortality (aOR 1.15 95 % CI 1.13-1.16) and MACCE (aOR 1.04 95 % CI 1.04-1.05), as well as the decreased aOR of coronary angiography (aOR 0.29, 95 % CI 0.29-0.29, p < 0.001) and PCI (aOR 0.40, 95 % CI 0.39-0.40, p < 0.001), compared to their urban counterparts.

CONCLUSION

Between 2004 and 2018, the risk of in-hospital mortality and MACCE in AMI patients was significantly higher in rural hospitals, with considerably lower utilization of invasive angiography and revascularization.

The response to the COVID-19 pandemic: With hindsight what lessons can we learn?

The purpose of this paper is to put forward some evidence-based lessons that can be learned from how to respond to a Pandemic that relate to healthy living behaviours (HLB). A 4-step methodology was followed to conduct a narrative review of the literature and to present a professional practice vignette. The narrative review identified 8 lessons: 1) peer review; 2) historical perspectives; 3) investing in resilience and protection; 4) unintended consequences; 5) protecting physical activity; 6) school closures; 7) mental health; and 8) obesity. As in all probability there will be another Pandemic, it is important that the lessons learned over the last three years in relation to HLB are acted upon. Whilst there will not always be a consensus on what to emphasise, it is important that many evidence-based positions are presented. The authors of this paper recognise that this work is a starting point and that the lessons presented here will need to be revisited as new evidence becomes available.

Health-related information needs and preferences for information of individuals with cardiovascular disease from underserved populations: A systematic review

OBJECTIVE

This systematic review aimed to identify the information needs and preferences of individuals with CVD from underserved populations.

METHODS

Five databases were searched from data inception to February 2022. Pilot and case report studies, non-peer-reviewed literature, and studies published in a language other than English, Portuguese, or Spanish were excluded. Structured and thematic analysis of all included studies were performed. The Critical Appraisal Skills Program and the Downs and Black Checklist were used to assess the quality of the qualitative and quantitative studies, respectively.

RESULTS

Of 35,698 initial records, 19 studies were included, most in observational design and classified as "fair" quality. Underserved populations - women, people living in rural areas, ethnic minority groups, older people, and those with low socioeconomic status - presented unique needs in four main groups, with some similarities across them: information about CVD, primary and secondary prevention of CVD, CVD management, and health care, policies and practices. Across the studies there was a lack of standardization on how individuals' needs were assessed and reported.

CONCLUSION

Underserved populations with CVD have unique information needs and preferences that should be address during their care.

PRACTICAL IMPLICATION

Information from this study may assist health care professionals with the development of comprehensive strategies to improve their provision of care for specific CVD patient groups.

Improvements and Maintenance of Clinical and Functional Measures Among Rural Women: Strong Hearts, Healthy Communities-2. 0 Cluster Randomized Trial

BACKGROUND

Cardiovascular disease is the leading cause of death in the United States; however, women and rural residents face notable health disparities compared with male and urban counterparts. Community-engaged programs hold promise to help address disparities through health behavior change and maintenance, the latter of which is critical to achieving clinical improvements and public health impact.

METHODS

A cluster-randomized controlled trial of Strong Hearts, Healthy Communities-2.0 conducted in medically underserved rural communities examined health outcomes and maintenance among women aged ≥40 years, who had a body mass index >30 or body mass index 25 to 30 and also sedentary. The multilevel intervention provided 24 weeks of twice-weekly classes with strength training, aerobic exercise, and skill-based nutrition education (individual and social levels), and civic engagement components related to healthy food and physical activity environments (community, environment, and policy levels). The primary outcome was change in weight; additional clinical and functional fitness measures were secondary outcomes. Mixed linear models were used to compare between-group changes at intervention end (24 weeks); subgroup analyses among women aged ≥60 years were also conducted. Following a 24-week no-contact period, data were collected among intervention participants only to evaluate maintenance.

RESULTS

Five communities were randomized to the intervention and 6 to the control (87 and 95 women, respectively). Significant improvements were observed for intervention versus controls in body weight (mean difference: -3.15 kg [95% CI, -4.98 to -1.32]; P=0.008) and several secondary clinical (eg, waist circumference: -3.02 cm [-5.31 to -0.73], P=0.010; systolic blood pressure: -6.64 mmHg [-12.67 to -0.62], P=0.031; percent body fat: -2.32% [-3.40 to -1.24]; P<0.001) and functional fitness outcomes; results were similar for women aged ≥60 years. The within-group analysis strongly suggests maintenance or further improvement in outcomes at 48 weeks.

CONCLUSIONS

This cardiovascular disease prevention intervention demonstrated significant, clinically meaningful improvements and maintenance among rural, at-risk older women.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03059472.

The need for a complex systems approach in rural health research

On a global scale, many major rural health issues have persisted for decades despite the introduction of new health interventions and public health policies. Although research efforts have generated valuable new knowledge about the aetiology of health, disease and health inequities in rural communities, rural health systems remain to be some of the most deprived and challenged in both the developing and developed world. While the reasons for this are many, a significant factor contributing to the current state of play is the pressing need for methodological innovation and relevant scientific approaches that have the capacity to support the translation of novel solutions into 'real world' rural contexts. Fortunately, complex systems approaches, which have seen an increase in popularity in the wider public health literature, could provide answers to some of the most resilient rural health problems in recent times. The purpose of this article is to promote the value and utility of a complex systems approach in rural health research. We explain the benefits of a complex systems approach and provide a background to the complexity sciences, including the main characteristics of complex systems. Two popular computational methods are described. The next step for rural health research involves exploring how a complex systems approach can help with the identification and evaluation of new and existing solutions to policy-resistant rural health issues. This includes generating awareness around the analytical trade-offs that occur between the use of traditional scientific methods and complex systems approaches.

Design and rationale of the mobile health intervention for rural atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is a highly morbid condition which requires long-term adherence to oral anticoagulation and may be associated with adverse quality of life and health care utilization. We developed a relational agent-an interactive smartphone-based intervention accessible regardless of digital or health literacy-to assist individuals residing in rural, Western Pennsylvania, with AF with chronic disease self-management.

METHODS

The "Mobile health intervention for rural atrial fibrillation" is a single center, parallel-arm randomized clinical trial for adults with AF funded by the National Institute of Health's National Heart, Lung, and Blood Institute to enroll 264 participants. All participants receive a smartphone with data plan: The intervention is a 4 month relational agent coupled with the AliveCor Kardia for heart rate and rhythm monitoring provided by smartphone, and the control a pre-installed, smartphone-based application for health-related information (WebMD). The study uses remote recruitment and engagement to enroll individuals who would otherwise be unlikely to participate in clinical research due to rurality. The primary outcome of the trial is adherence to oral anticoagulation, determined by proportion of days covered, as measured at 12 months. The secondary outcomes are quality of life, both AF-specific and general, and health care utilization. The study entails a baseline visit, a 4 month intervention phase, and 8 and 12 month follow-up visits.

CONCLUSIONS

This mobile health trial tests the effectiveness of a smartphone-based relational agent to improve clinical and patient-reported outcomes in rural-dwelling individuals.

Drivers of racial, regional, and socioeconomic disparities in late-stage breast cancer mortality

BACKGROUND

The authors identified tumor, treatment, and patient characteristics that may contribute to differences in breast cancer (BC) mortality by race, rurality, and area-level socioeconomic status (SES) among women diagnosed with stage IIIB-IV BC in Georgia.

METHODS

Using the Georgia Cancer Registry, 3084 patients with stage IIIB-IV primary BC (2013-2017) were identified. Cox proportional hazards regression was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) comparing mortality among non-Hispanic Black (NHB) versus non-Hispanic White (NHW), residents of rural versus urban neighborhoods, and residents of low- versus high-SES neighborhoods by tumor, treatment, and patient characteristics. The mediating effects of specific characteristics on the association between race and BC mortality were estimated.

RESULTS

Among the study population, 41% were NHB, 21% resided in rural counties, and 72% resided in low SES neighborhoods. The authors observed mortality disparities by race (HR, 1.27; 95% CI, 1.13, 1.41) and rurality (HR, 1.14; 95% CI, 1.00, 1.30), but not by SES (HR, 1.04; 95% CI, 0.91, 1.19). In the stratified analyses, racial disparities were the most pronounced among women with HER2 overexpressing tumors (HR, 2.30; 95% CI, 1.53, 3.45). Residing in a rural county was associated with increased mortality among uninsured women (HR, 2.25; 95% CI, 1.31, 3.86), and the most pronounced SES disparities were among younger women (<40 years: HR, 1.46; 95% CI, 0.88, 2.42).

CONCLUSIONS

There is considerable variation in racial, regional, and socioeconomic disparities in late-stage BC mortality by tumor, treatment, and patient characteristics.

Demographic and Regional Trends of Infective Endocarditis-Related Mortality in the United States, 1999 to 2019

BACKGROUND

We sought to identify temporal, geographic, age and sex-based mortality trends of IE in the US over the past two decades.

METHODS

This population-based study utilized the CDC WONDER database to identify IE-related deaths occurring within the US between 1999 and 2019. IE-related crude and age-adjusted mortality rates (CMRs and AAMRs, respectively) were determined. Joinpoint regression was used to determine trends in CMR/AAMR using annual percent change (APC) in the overall sample in addition to demographic (sex, race/ethnicity, age) and geographic (rural/urban, statewide) subgroups.

RESULTS

Between 1999 and 2019, a total of 279,154 deaths related to IE were reported. The overall AAMR declined from 54.2 per 1,000,000 in 1999 to 51.4 in 2019. However, AAMRs increased among several sub-groups over the past decade including men [2009-2019 APC=0.4%, 95%CI, 0.1%-0.6%], non-Hispanic (NH) whites [APC of 0.8% from 2009 to 2019 (95%CI 0.5%-1.1%)], NH American Indians or Alaskan Natives [APC of 1.4% during the study period (95%CI, 0.7%-2.0%)], and those in rural areas [APC of 1.0% from 2009 to 2019 (95%CI 0.5%-1.5%)]. The CMRs increased among subjects 40-64 years old [APC of 2.8% from 2010 to 2019 (95%CI 2.2%-3.5%)] and 15-39 years old [APC of 16.4% from 2010 to 2017 (95%CI 13.5%-19.4%)].

CONCLUSIONS

IE-related CMR/AAMR increased among men, NH whites, NH American Indian or Alaskan Natives, those <65-year-old, and those from rural areas. Discerning the reasons for the increase in IE-related mortality among these groups and examining the impact of the social determinants of health may represent important opportunities to enhance care.

Demographic and Regional Trends in Stroke-Related Mortality in Young Adults in the United States, 1999 to 2019

Background Despite improvements in the management and prevention of stroke, increasing hospitalizations for stroke and stagnant mortality rates have been described in young adults. However, there is a paucity of contemporary national mortality estimates in young adults. Methods and Results Trends in mortality related to stroke in young adults (aged 25-64 years) were assessed using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Age-adjusted mortality rates per 100 000 people with associated annual percentage change were calculated. Joinpoint regression was used to assess the trends in the overall sample and different demographic (sex, race and ethnicity, and age) and geographical (state, urban-rural, and regional) subgroups. Between 1999 and 2019, a total of 566 916 stroke-related deaths occurred among young adults. After the initial decline in mortality in the overall population, age-adjusted mortality rate increased from 2013 to 2019 with an associated annual percentage change of 1.5 (95% CI, 1.1-2.0). Mortality rates were higher in men versus women and in non-Hispanic Black people versus individuals of other races and ethnicities. Non-Hispanic American Indian or Alaskan Native people had a marked increase in stroke-related mortality (annual percentage change 2010-2019: 3.3). Furthermore, rural (nonmetropolitan) counties experienced the greatest increase in mortality (annual percentage change 2012-2019: 3.1) compared with urban (metropolitan) counties. Conclusions Following the initial decline in stroke-related mortality, young adults have experienced increasing mortality rates from 2013 to 2019, with considerable differences across demographic groups and regions.

Assessment of Disparities in Diabetes Mortality in Adults in US Rural vs Nonrural Counties, 1999-2018

IMPORTANCE

US rural vs nonrural populations have striking disparities in diabetes care. Whether rurality contributes to disparities in diabetes mortality is unknown.

OBJECTIVE

To examine rates and trends in diabetes mortality based on county urbanization.

DESIGN, SETTING, AND PARTICIPANTS

In this observational, cross-sectional study, the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database was searched from January 1, 1999, to December 31, 2018, for diabetes as a multiple cause and the underlying cause of death among residents aged 25 years or older in US counties. County urbanization was categorized as metro, medium-small, and rural. Weighted multiple linear regression models and jackknife resampling, with a 3-segment time component, were used. The models included exposures with up to 3-way interactions and were age standardized to the 2009-2010 population. The analyses were conducted from July 1, 2020, to February 1, 2022.

EXPOSURES

County urbanization (metro, medium-small, or rural), gender (men or women), age group (25-54, 55-74, or ≥75 years), and region (Midwest, Northeast, South, or West).

MAIN OUTCOMES AND MEASURES

Annual diabetes mortality rate per 100 000 people.

RESULTS

From 1999-2018, based on 4 022 238 309 person-years, diabetes was a multiple cause of death for 4 735 849 adults aged 25 years or older. As a multiple cause, diabetes mortality rates in 2017-2018 vs 1999-2000 were highest and unchanged in rural counties (157.2 [95% CI, 150.7-163.7] vs 154.1 [95% CI, 148.2-160.1]; P = .49) but lower in medium-small counties (123.6 [95% CI, 119.6-127.6] vs 133.6 [95% CI, 128.4-138.8]; P = .003) and urban counties (92.9 [95% CI, 90.5-95.3] vs 109.7 [95% CI, 105.2-114.1]; P < .001). In 2017-2018 vs 1999-2000, mortality rates were higher in rural men (+18.2; 95% CI, 14.3-22.1) but lower in rural women (-14.0; 95% CI, -17.7 to -10.3) (P < .001 for both). In the 25- to 54-year age group, mortality rates in 2017-2018 vs 1999-2000 showed a greater increase in rural counties (+9.4; 95% CI, 8.6-10.2) compared with medium-small counties (+4.5; 95% CI, 4.0-5.0) and metro counties (+0.9; 95% CI, 0.4-1.4) (P < .001 for all). Of all regions and urbanization levels, the mortality rate in 2017-2018 vs 1999-2000 was higher only in the rural South (+13.8; 95% CI, 7.6-20.0; P < .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, US rural counties had the highest overall diabetes mortality rate. The determinants of persistent rural disparities, in particular for rural men and for adults in the rural South, require investigation.

Blood Pressure Control Among US Adults, 2009 to 2012 Through 2017 to 2020

BACKGROUND

The National Health and Nutrition Examination Survey data indicate that the proportion of US adults with hypertension that had controlled blood pressure (BP) declined from 2013 to 2014 through 2017 to 2018. We analyzed data from National Health and Nutrition Examination Survey 2009 to 2012, 2013 to 2016, and 2017 to 2020 to confirm this finding.

METHODS

Hypertension was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg or antihypertensive medication use. BP control among those with hypertension was defined as systolic BP <140 mm Hg and diastolic BP <90 mm Hg.

RESULTS

The age-adjusted prevalence of hypertension was 31.5% (95% CI, 30.3%-32.8%), 32.0% (95% CI, 30.6%-33.3%), and 32.9% (95% CI, 31.0%-34.7%) in 2009 to 2012, 2013 to 2016, and 2017 to 2020, respectively (P trend=0.218). The age-adjusted prevalence of hypertension increased among non-Hispanic Asian adults from 27.0% in 2011 to 2012 to 33.5% in 2017 to 2020 (P trend=0.003). Among Hispanic adults, the age-adjusted prevalence of hypertension increased from 29.4% in 2009 to 2012 to 33.2% in 2017 to 2020 (P trend=0.029). In 2009 to 2012, 2013 to 2016, and 2017 to 2020, 52.8% (95% CI, 50.0%-55.7%), 51.3% (95% CI, 47.9%-54.6%), and 48.2% (95% CI, 45.7%-50.8%) of US adults with hypertension had controlled BP (P trend=0.034). Among US adults taking antihypertensive medication, 69.9% (95% CI, 67.8%-72.0%), 69.3% (95% CI, 66.6%-71.9%), and 67.7% (95% CI, 65.2%-70.3%) had controlled BP in 2009 to 2012, 2013 to 2016, and 2017 to 2020, respectively (P trend=0.189). Among all US adults with hypertension and those taking antihypertensive medication, a decline in BP control between 2009 to 2012 and 2017 to 2020 occurred among those ≥75 years, women, and non-Hispanic black adults.

CONCLUSIONS

These data confirm that the proportion of US adults with hypertension who have controlled BP has declined.

Urban and rural differences in new onset type 2 diabetes: Comparisons across national and regional samples in the diabetes LEAD network

Introduction

Geographic disparities in diabetes burden exist throughout the United States (US), with many risk factors for diabetes clustering at a community or neighborhood level. We hypothesized that the likelihood of new onset type 2 diabetes (T2D) would differ by community type in three large study samples covering the US.

Research design and methods

We evaluated the likelihood of new onset T2D by a census tract-level measure of community type, a modification of RUCA designations (higher density urban, lower density urban, suburban/small town, and rural) in three longitudinal US study samples (REGARDS [REasons for Geographic and Racial Differences in Stroke] cohort, VADR [Veterans Affairs Diabetes Risk] cohort, Geisinger electronic health records) representing the CDC Diabetes LEAD (Location, Environmental Attributes, and Disparities) Network.

Results

In the REGARDS sample, residing in higher density urban community types was associated with the lowest odds of new onset T2D (OR [95% CI]: 0.80 [0.66, 0.97]) compared to rural community types; in the Geisinger sample, residing in higher density urban community types was associated with the highest odds of new onset T2D (OR [95% CI]: 1.20 [1.06, 1.35]) compared to rural community types. In the VADR sample, suburban/small town community types had the lowest hazard ratios of new onset T2D (HR [95% CI]: 0.99 [0.98, 1.00]). However, in a regional stratified analysis of the VADR sample, the likelihood of new onset T2D was consistent with findings in the REGARDS and Geisinger samples, with highest likelihood of T2D in the rural South and in the higher density urban communities of the Northeast and West regions; likelihood of T2D did not differ by community type in the Midwest.

Conclusions

The likelihood of new onset T2D by community type varied by region of the US. In the South, the likelihood of new onset T2D was higher among those residing in rural communities.

Sociotechnical Intervention for Improved Delivery of Preventive Cardiovascular Care to Rural Communities: Participatory Design Approach

Background

Clinical practice guidelines recommend antiplatelet and statin therapies as well as blood pressure control and tobacco cessation for secondary prevention in patients with established atherosclerotic cardiovascular diseases (ASCVDs). However, these strategies for risk modification are underused, especially in rural communities. Moreover, resources to support the delivery of preventive care to rural patients are fewer than those for their urban counterparts. Transformative interventions for the delivery of tailored preventive cardiovascular care to rural patients are needed.

Objective

A multidisciplinary team developed a rural-specific, team-based model of care intervention assisted by clinical decision support (CDS) technology using participatory design in a sociotechnical conceptual framework. The model of care intervention included redesigned workflows and a novel CDS technology for the coordination and delivery of guideline recommendations by primary care teams in a rural clinic.

Methods

The design of the model of care intervention comprised 3 phases: problem identification, experimentation, and testing. Input from team members (n=35) required 150 hours, including observations of clinical encounters, provider workshops, and interviews with patients and health care professionals. The intervention was prototyped, iteratively refined, and tested with user feedback. In a 3-month pilot trial, 369 patients with ASCVDs were randomized into the control or intervention arm.

Results

New workflows and a novel CDS tool were created to identify patients with ASCVDs who had gaps in preventive care and assign the right care team member for delivery of tailored recommendations. During the pilot, the intervention prototype was iteratively refined and tested. The pilot demonstrated feasibility for successful implementation of the sociotechnical intervention as the proportion of patients who had encounters with advanced practice providers (nurse practitioners and physician assistants), pharmacists, or tobacco cessation coaches for the delivery of guideline recommendations in the intervention arm was greater than that in the control arm.

Conclusions

Participatory design and a sociotechnical conceptual framework enabled the development of a rural-specific, team-based model of care intervention assisted by CDS technology for the transformation of preventive health care delivery for ASCVDs.