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

County-Level Urbanization and Cardiovascular Death in Patients With Cancer

CONTEXT

Cardiovascular death (CVD) is a leading cause of mortality in patients with cancer, with sociodemographic factors such as urbanization influencing outcomes.

OBJECTIVE

To examine the impact of county-level urbanization on CVD mortality in patients with cancer in the United States from 1999 to 2020.

DESIGN

Retrospective cross-sectional analysis using CDC WONDER mortality data.

SETTING

US counties categorized as rural or urban based on the 2013 NCHS Urban-Rural Classification Scheme.

PARTICIPANTS

Patients with cardiovascular disease (ICD-10: I00-I78) and comorbid cancer (ICD-10: C00-C97), spanning all U.S. counties from 1999 to 2020.

MAIN OUTCOME MEASURES

Age-adjusted mortality rates (AAMRs) per 100 000 population and rural-to-urban rate ratios (RRs) with 95% confidence intervals.

RESULTS

The cumulative rural-to-urban RR for CVD in patients with cancer was 1.11 (95% CI: 1.10-1.11), increasing from 1.00 in 1999 to 1.20 in 2020 (β = 0.009, P < .001). Rural AAMRs were higher across demographic groups, including males (12.85 vs 11.62 per 100 000), females (6.08 vs 5.58), Black individuals (9.76 vs 9.64), and White individuals (8.79 vs 7.94). Rural Black populations showed a rising RR from 0.85 in 1999 to 1.04 in 2020 (β = 0.005, P = .01). Hispanic populations exhibited lower rural mortality, with a stable RR (0.93, P = 1.0). The most common CVD cause was ischemic heart disease (53.93% of rural and 55.9% of urban deaths).

CONCLUSIONS

An increasing rural-to-urban disparity in CVD mortality among cancer patients highlights the role of urbanization in health inequities. Interventions targeting rural health care access and socioeconomic disparities are essential to address this growing gap.

Psychosocial factors and associations with preventive cardiovascular screening among U.S adults: Findings from the National Health Interview Survey, 2023

OBJECTIVE

Structural and COVID-related factors have been linked with the decline in preventive health screenings among adults. However, associations between psychosocial factors and undergoing preventive cardiovascular screening are not fully known. The current study examined associations between psychosocial factors and preventive cardiovascular screening among U.S. adults.

METHODS

We used data from the 2023 National Health Interview Survey (N = 23,428). Data were collected from January to December from adults living in U.S. Preventive cardiovascular (CV) screening (i.e., blood pressure, cholesterol, or blood sugar level) was defined as no screening, and undergoing screening for any CV risk within the past year. Psychosocial factors were defined as discrimination, life satisfaction, and depression. Multivariable logistic regression models examined the associations between psychosocial factors and preventive cardiovascular screening, adjusted for sociodemographic characteristics.

RESULTS

Adults with diagnosis of depression (OR: 1.93, 95 % CI: 1.65-2.25) had higher odds of undergoing screening for any CV risk. Adults who experienced discrimination had lower odds of undergoing screening for cholesterol (OR: 0.77, 95 % CI: 0.71-0.84) and blood sugar level specifically (OR: 0.78, 95 % CI: 0.72-0.85), while life dissatisfaction was associated with lower odds of screening for blood pressure (OR: 0.76, 95 % CI: 0.58-0.99) and blood sugar level specifically (OR: 0.80, 95 % CI: 0.65-0.97).

CONCLUSIONS

Discrimination and life dissatisfaction were associated with decreased odds of undergoing specific preventive cardiovascular screening, and depression is associated with increased odds of undergoing any preventive cardiovascular screening. Equitable health care policies focused on addressing psychosocial factors are needed to increase preventive cardiovascular screening among U.S. adults.

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.

Rural Culture and Diabetes Self-Management Beliefs, Behaviors, and Health Outcomes

BACKGROUND

Rural populations in the United States face a diabetes mortality penalty. Self-management is a core component of treatment for Type 2 diabetes, but there is low uptake of self-management education and support interventions in rural areas. Rural structural barriers to diabetes self-management have been described, yet the role of rural culture has not been extensively explored.

OBJECTIVE

The purpose was to examine the relationships among rural culture, diabetes beliefs, self-management behaviors, and health outcomes.

METHODS

A stratified random sample of 500 adults with Type 2 diabetes were recruited from a rural integrated healthcare system and invited to participate in this nonexperimental cross-sectional study. Participants completed a survey that included validated measures of rural identity, self-reliance, perceived diabetes threat, and diabetes self-management behaviors. The most recent A1c was collected from the medical record. Descriptive, bivariate, multivariate, and moderation analyses were conducted.

RESULTS

One hundred twenty-eight participants returned completed surveys. Having an A1c <8% was associated with better diabetes self-management behaviors, lower perceived threat, being female, and older age. Better diabetes self-management behaviors were associated with lower self-reliance, lower perceived threat, and older age. The combined moderation effect of both self-reliance and rural identity on the relationship between perceived threat and self-management behaviors was significant.

DISCUSSION

Findings highlight the complex relationship between diabetes beliefs and behavior in rural populations and demonstrate that components of the rural culture have both direct and moderating effects on diabetes beliefs and self-management behaviors. These findings have important ramifications for nurses practicing in rural settings.

AI-Assisted Point-of-Care Ultrasound Networks-Considerations for Rural Health Care Delivery

This Viewpoint explores how artificial intelligence–assisted point-of-care ultrasound could be used to create coordinated networks of care to improve health care access and delivery in rural communities.

Income, Healthy Food Availability, and Consumption Mediate Rural-Urban Health Disparities

BACKGROUND

Examine the role of income, perceived healthy foods availability, and consumption as mediators of rural-urban health disparities.

METHOD

Pre-registered simple mediation models with post hoc multi-mediator models were tested using national- and state-level survey data. Oregon data was collected in an online Qualtrics survey between October 8 and November 9, 2021 using CloudResearch; Health Information National Trends Survey (HINTS) 5, a nationally representative dataset, was collected over 4 cycles from 2017 to 2020. Oregon residents (n = 771; rural = 313, urban = 458) self-reported online: income, perceived fruits and vegetable (FV) availability, FV consumption, and BMI measures (height, weight). HINTS respondents (rural n = 1235; urban n = 13,912) self-reported the same variables of interest without FV availability, and with an additional self-rated health variable detailed below.  RESULTS: The effect of rurality on BMI (b = 0.012, SE = 0.005, p = 0.01) and self-rated health (b = 0.003, SE = 0.001, p = 0.008) when combining datasets was mediated by a series of income, perceived FV availability, and FV consumption.

CONCLUSION

To address rural-urban health disparities, individual (cognition, behavior), social (household income), and community (healthy food availability) factors should be targeted together.

Impact of rural status on lower extremity bypass outcomes for patients with chronic limb threatening ischemia

OBJECTIVES

Previous studies noted that the rural population experienced higher peripheral artery disease (PAD) related mortality than their urban counterparts. Our study aimed to assess the impact of rural status on lower extremity bypass (LEB) outcomes for patients with chronic limb threatening ischemia (CLTI).

METHODS

We analyzed data from the Blue Cross Blue Shield Michigan Cardiovascular Consortium (BMC2) registry data from 2016 to 2022. Primary exposure included patient's residence based on rural-urban commuting area (RUCA) codes. Primary outcome was major adverse cardiac events (MACE). Secondary outcomes include 30-day and 1-year mortality, hospital readmission, bypass revision, wound complications, amputations, and 30-day renal failure requiring dialysis. We conducted univariate and multivariate analysis to evaluate association between rural status and LEB outcomes.

RESULTS

Rural patients tended to be White (p<.001), had insurance (p<.001), were current smokers (p<.001), had hyperlipidemia (p<.001), prior CHF (p=.031), COPD (p<.001), prior CVD/TIA (p=.005), and take pre-procedure aspirin (p=.011) and statin (p=.007), and were less likely to live in a distressed community (p<.001). They were not at increased risks of 30-day and 1-year MACE. They had higher odds of bypass revision (p=.028) at 1-year. However, they did not have higher odds of amputation at 30-days and 1-year.

CONCLUSIONS

Rural status does not impact LEB outcomes. Rural patients achieve comparable outcomes compared their urban counterparts due to overwhelmingly White rural demographics, optimal medical therapy, socioeconomic status (SES) and increased healthcare utilization.

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.

Rural/Urban Disparities in Cardiovascular Disease in the US-What Can be Done to Improve Outcomes for Rural Americans?

For the last forty years in the United States, there has been a progressively widening disparity in cardiovascular disease (CVD) morbidity and mortality between rural and urban areas known as the "rural mortality penalty." Drivers of rural-urban disparities in CVD are multifactorial, including differences in demographics, education, economic opportunity, access to care, and healthcare quality. Because of the complex and heterogenous nature of rural areas in the United States, definitions of rural vary significantly, leading to challenges in quantifying disparities and targeting interventions. Potential solutions to increase access to cardiovascular care in rural areas include initiatives to expand the primary care and cardiology workforces, build partnerships between rural healthcare providers and academic medical centers (AMC), establish more outreach clinics in underserved or poorly resourced rural communities, develop rural provider training programs, expand and improve telemedicine offerings, develop community wide CVD prevention programs, expand health insurance coverage in rural areas, continue government support of rural hospitals and address social determinants of health as rural populations often face higher rates of poverty, food insecurity, unemployment, housing instability, and limited access to education, all of which exacerbate health disparities.

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.

Cardiovascular Health Among Rural and Urban US Adults-Healthcare, Lifestyle, and Social Factors

Importance

Improving cardiovascular health in rural areas is a national priority in the US. However, little is known about the current state of rural cardiovascular health and the underlying drivers of any rural-urban disparities.

Objective

To compare rates of cardiometabolic risk factors and cardiovascular diseases between rural and urban US adults and to evaluate the extent to which health care access, lifestyle factors, and social risk factors contribute to any rural-urban differences.

Design, Setting, and Participants

This nationally representative cross-sectional study analyzed data from US adults aged 20 years or older residing in rural vs urban areas using the 2022 National Health Interview Survey. Data were analyzed between August 2024 and February 2025.

Exposure

County-level rurality.

Main Outcomes and Measures

The primary outcomes were age-standardized rates of cardiometabolic risk factors (hypertension, hyperlipidemia, obesity, and diabetes) and cardiovascular diseases (coronary heart disease [CHD] and stroke).

Results

The study population consisted of 27 172 adults, including 4256 adults (14.0%) residing in rural areas, 14 741 (54.8%) in small or medium metropolitan areas, and 8175 (31.2%) in urban areas. Mean (SD) participant age was 49.1 (17.8) years, and 4399 participants (50.8%) were female. Compared with their urban counterparts, rural adults were more likely to smoke, be insufficiently physically active, and have more social risk factors. Age-standardized rates of cardiometabolic risk factors were significantly higher in rural areas, including hypertension (37.1% vs 30.9%; rate ratio [RR], 1.20; 95% CI, 1.13-1.27), hyperlipidemia (29.3% vs 26.7%; RR, 1.10; 95% CI, 1.03-1.18), obesity (41.1% vs 30.0%; RR, 1.37; 95% CI, 1.27-1.47), and diabetes (11.2% vs 9.8%; RR, 1.15; 95% CI, 1.02-1.29). The same pattern was observed for CHD (6.7% vs 4.3%; RR, 1.58; 95% CI, 1.35-1.85), but no differences were observed for stroke. The magnitude of rural-urban disparities was largest among young adults (aged 20-39 years) for hypertension (RR, 1.44; 95% CI, 1.12-1.86), obesity (RR, 1.54; 95% CI, 1.34-1.77), and diabetes (RR, 2.59; 95% CI, 1.54-4.38). Rural-urban disparities in cardiovascular health were not meaningfully attenuated after adjustment for measures of health care access (insurance coverage, usual source of care, and recent health care utilization) and lifestyle factors (smoking and physical activity). However, accounting for social risk factors (poverty, education level, food insecurity, and home ownership) completely attenuated rural-urban disparities in hypertension (adjusted RR [aRR], 0.99; 95% CI, 0.93-1.06), diabetes (aRR, 1.02; 95% CI, 0.90-1.15), and CHD (aRR, 1.08; 95% CI, 0.91-1.29), but only partially attenuated disparities in obesity (aRR, 1.29; 95% CI, 1.20-1.39).

Conclusions and Relevance

This national cross-sectional study found substantial rural-urban disparities in cardiometabolic risk factors and cardiovascular diseases, which were largest among younger adults and almost entirely explained by social risk factors. These findings suggest that efforts to improve socioeconomic conditions in rural communities may be critical to address the rural-urban gap in cardiovascular health.

A descriptive analysis of rural-urban overdose experiences among incarcerated women with opioid use disorder

BACKGROUND AND OBJECTIVES

Despite elevated overdose risk in rural communities, rural/urban differences in overdose risk factors are understudied among women with criminal legal system involvement. This study examines substance use and overdose among incarcerated women.

METHODS

Women (N = 900) were randomly selected from nine Kentucky jails, screened, and interviewed as part of a larger study. Bivariate analyses were used to identify group differences.

RESULTS

Rural women were less likely to report pre-incarceration overdose and to receive emergency services post-overdose. Substance use also varied.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Results underscore the importance of Opioid Overdose Education and Naloxone Distribution in rural communities.

Supporting Physical and Mental Health in Rural Veterans Living With Heart Failure: Protocol for a Nurse-Led Telephone Intervention Study

BACKGROUND

Heart failure (HF) remains a disease of notable disparity for rural veterans, despite recent advancements in clinical treatment. Managing HF in the home is stressful and complex for rural veterans who experience unique barriers to optimal physical and mental health, necessitating adequate support and problem-solving skills.

OBJECTIVE

This study aims to (1) adapt, to the rural sociocultural context, a culturally sensitive, tailored, telephone support and problem-solving intervention (CARE-HF [Supporting Physical and Mental Health in Rural Veterans With Heart Failure]) using findings from preliminary qualitative research and (2) evaluate the effects of CARE-HF on problem-solving and physical and mental health outcomes among rural veterans with HF.

METHODS

This study involves a repeated-measures, single-group design. The intervention content was adapted and tailored to the rural sociocultural context using preliminary qualitative data and guided by the Theories of Social Problem-Solving and Stress, Appraisal, and Coping. Veterans are recruited from Veterans Administration home-based cardiac rehabilitation clinics, cardiology clinics that serve veterans, veterans-based community resource centers, and social media campaigns. Veterans with HF (N=100) receive the CARE-HF intervention. This nurse-led intervention comprises 8 telephone sessions that use a five-step, problem-solving process to manage common HF problems in the home: (1) identifying the problem and viewing it in a positive manner, (2) goal setting, (3) generating potential strategies for problem management, (4) choosing and implementing strategies to manage the problem, and (5) evaluating strategy effectiveness. Veterans receive initial problem-solving training during the first session, with follow-up sessions focusing on problem-solving skill reinforcement and assisting veterans in applying these principles to manage self-identified, HF-related problems experienced in the home. Data are collected at baseline and 3, 6, 12, and 18 months from baseline on problem-solving and outcomes of interest (ie, HF self-care; HF symptoms; health care utilization; depressive symptoms; anxiety; HF-specific, health-related quality of life; stress; resilience; and coping). Demographic data will be analyzed using descriptive statistics and multilevel growth curve modeling with restricted maximum likelihood estimation to compare a series of models using Akaike information criteria and Bayesian information criteria fit indices while controlling for covariates.

RESULTS

Recruitment started in April 2023. As of December 2024, we have enrolled 56 veterans. Recruitment is anticipated to end in June 2025, with data collection continuing until all enrolled veterans have completed the 18-month follow-up period.

CONCLUSIONS

Adapting and testing a culturally sensitive, tailored, telephone intervention to aid support and problem-solving in the home has the potential to provide individualized care to rural veterans where they reside, thereby reducing travel burden while also increasing access to evidence-based care programs. If effective, telephone support and problem-solving interventions could be a low-cost, accessible method to improve physical and mental health in rural veterans with HF.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05839067; https://clinicaltrials.gov/study/NCT05839067.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63498.

Demographic and regional mortality trends in dilated cardiomyopathy in the United States; 1999-2020

Background

Dilated cardiomyopathy significantly impacts mortality and hospitalizations in the U.S., yet trends in dilated cardiomyopathy-related mortality are underreported. This retrospective study examines the trends in dilated cardiomyopathy-related mortality between 1999 and 2020.

Methods

The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database was analyzed to study the trends in dilated cardiomyopathy-related mortality. Age-adjusted mortality rates per 100,000 people and annual percent changes with 95% CIs were determined. Joinpoint regression analysis was used to assess the trends in the overall demographic, geographic, and place-of-death variables.

Results

There were 168,702 dilated cardiomyopathy-related deaths reported between 1999 and 2020. The age-adjusted mortality rate declined from 3.40 in 1999 to 1.71 in 2020. Men unfailingly had a higher age-adjusted mortality rate than women. Non-Hispanic Black or African Americans had the highest age-adjusted mortality rate compared to other races, with a recent increase in annual percent change from 2015 to 2020. Hispanics, or Latinos, also showed an alarming rise in annual percent change of 11.10 from 2018 to 2020. Significant geographical variations were noted, with states in the top 90th percentile (Michigan, Washington, and Delaware) having approximately three times the age-adjusted mortality rate compared to states that fell in the lower 10th percentile.

Conclusion

Despite overall declines, racial and regional disparities persist, owing to the growing clinical burden. Targeted research and interventions are key to addressing disparities and reducing dilated cardiomyopathy-related mortality.

Spearfishing and public health promotion: A cross-sectional analysis of the Hawai'i Behavioral Risk Factor Surveillance System Survey

Spearfishing, a culturally relevant practice in many locations globally, may foster physical activity and enhance well-being by promoting social cohesion, food security, and nature connectedness, but is understudied in public health promotion and surveillance. This study measured the population-level prevalence of lifetime spearfishing engagement in Hawai'i and identified associated factors for public health promotion. The Hawaiian Islands present an ideal setting for such activities due to its central Pacific location and a diverse population with cultural ties to spearfishing. In 2019 and 2020, lifetime spearfishing engagement was added to the Hawai'i Behavioral Risk Factor Surveillance System (N = 12,737). Prevalence ratios (PR) and 95% confidence intervals (95%CI) were estimated for spearfishing "sometimes," "often," or "very often" during one's lifetime, considering sociodemographic, health behavior, and health status variables. A quarter of respondents statewide reported engagement, with higher rates amongst men (41%), Native Hawaiians (43%), other Pacific Islanders (36%), American Indian or Alaskan Native (32%), and rural island residents of Lāna'i (51%) and Moloka'i (43%). All age groups reported similar lifetime engagement. After statistical adjustment, those with a high school diploma or less were significantly more likely to have engaged in spearfishing than those with higher education. Spearfishing engagement was also associated with a higher likelihood of meeting physical activity guidelines (PR 1.45 95%CI 1.29-1.63). There is widespread lifelong engagement in spearfishing in Hawai'i, especially among Indigenous and rural populations. Supporting culturally relevant activities, such as spearfishing, is a strength-based approach to health promotion with global relevance, including encouraging physical activity.

Rural-urban disparities in mortality of patients with acute myocardial infarction and heart failure: a systematic review and meta-analysis

AIMS

Patients with cardiac disease living in rural areas may face significant challenges in accessing care, and studies suggest that living in rural areas may be associated with worse outcomes. However, it is unclear whether rural-urban disparities have an impact on mortality in patients presenting with acute myocardial infarction (AMI) and heart failure (HF). This meta-analysis aimed to assess differences in mortality between rural and urban patients presenting with AMI and HF.

METHODS AND RESULTS

A systematic search of the literature was performed using PubMed, Embase, MEDLINE, and CENTRAL for all studies published until 16 January 2024. A grey literature search was also performed using a manual web search. The following inclusion criteria were applied: (i) studies must compare rural patients to urban patients presenting to hospital with AMI or HF, and (ii) studies must report on mortality. The primary outcome was all-cause mortality. Comprehensive data were extracted including study design, patient characteristics (sex, age, and comorbidities), sample size, follow-up period, and outcomes. Odds ratios (ORs) were pooled with fixed-effects model. A subgroup analysis was performed to investigate causes for heterogeneity in which studies were separated based on in-hospital mortality, post-discharge mortality, and region of origin including North America, Europe, Asia, and Australia. In total, 37 studies were included (29 retrospective studies, 4 cross-sectional studies, and 4 prospective cohort studies) in our meta-analysis: 24 studies for AMI, 11 studies for HF, and 2 studies for both AMI and HF. This included a total of 21 107 886 patients with AMI (2 230 264 of which were in rural regions) and 18 434 270 patients with HF (2 655 469 of which were in rural regions). Rural patients with AMI had similar age (mean age 69.8 ± 5.7; vs. 67.5 ± 5.1) and were more likely to be female (43.2% vs. 38.5%) compared to urban patients. Rural patients with HF had similar age (mean age 77.1 ± 4.4 vs. 76.5 ± 4.2) and were more likely to be female (56.4% vs. 49.5%) compared to urban patients. The range of follow-up for the AMI cohort was 0 days to 24 months, and the range of follow-up for the HF cohort was 0 days to 24 months. Compared with urban patients, rural patients with AMI had higher mortality rate at follow-up [15.5% vs. 13.4%; OR 1.18, 95% confidence interval (CI), 1.13-1.24; I2 = 97%]. Compared with urban patients, rural patients with HF had higher mortality rate at follow-up (12.3% vs. 11.6%; OR 1.11, 95% CI, 1.11-1.12; I2 = 98%).

CONCLUSION

To our knowledge, this is the first systematic review and meta-analysis assessing mortality differences between rural and urban patients presenting with AMI and HF. We found that patients living in rural areas had an increased risk of mortality when compared to patients in urban areas. Clinical and policy efforts are required to reduce these disparities.

LAY SUMMARY

A total of 37 studies were included in our meta-analysis, involving over 39.5 million patients, and found higher mortality rates in rural patients with AMI and HF compared to those in urban areas. Clinical and policy efforts should focus on improving access to care and outcomes to reduce disparities between rural and urban areas.

Strategies for Overcoming Barriers in Access to Cardiovascular Care for Women

Women face unique barriers to equitable health care. To ensure access to quality cardiovascular care across the lifespan of women, several systemic and social challenges need to be addressed. With the understanding that women often direct health care decisions, not only for themselves but for their family unit as well, a holistic approach to address health care barriers is warranted. This review aims to highlight key barriers to equitable health care access for women and propose potential strategies to overcome these barriers. This review is structured around 5 key areas in which there are gender- or sex-specific barriers to optimal outcomes: (1) insurance-related barriers, (2) geographic and social barriers, (3) health care delivery capacity and workforce issues, (4) quality and accountability measures, and (5) global health challenges. More research is needed on the sustainability, costs, and sex- and gender-specific outcomes of these solutions to drive transformative change.

Social Inequities in Cardiovascular Disease Risk Factors at Multiple Levels Persist Among Mothers in Texas

The life stage between the ages of 30-45 years for women is critical, given the competing demands of occupational advancement, intimate partner relationships, and childcare responsibilities. Cardiovascular disease (CVD) is the leading cause of death among women in the US, which is experienced inequitably by race/ethnicity/nativity and socioeconomic status and is embedded within geographic contexts. The objective of the current study was to examine social inequities in pre-pregnancy risk factors for cardiovascular disease. We analyzed 16 years of geocoded natality data in Texas (N = 2,089,588 births between 2005 and 2020 to mothers aged 30-45 years) linked with census tract- and county-level data. Dependent variables included pre-pregnancy diabetes, hypertension, obesity, and smoking. Independent variables included individual-level race/ethnicity/nativity and educational attainment, tract-level poverty and racial/ethnic concentrations, and county-level urban/rural status, with controls for other sociodemographic characteristics and time trend. Two-level, random intercept hierarchical generalized logistic models were used to estimate associations and model fit. Significant social inequities at the individual-, tract-, and county-levels in each risk factor were found. For example, tract-level variables had substantial and significant association with the four CVD risk factors, ranging from 13% to 72% higher odds in adjusted models. For all four risk factors, the more rural the county of residence was, the higher the odds of having the risk factor (24% to 256% higher odds). Individual-level social inequalities by race/ethnicity/nativity (ORs ranging from 0.04 to 2.12) and education (ORs ranging from 1.25 to 5.20) were also observed. Enhancing our understanding of this important period of life may enable policy and interventions to better support women through this critical life stage.

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.

Variation in U.S. county-level cardiovascular disease death rates by measure of rural-urban status

This study examined variation in county-level cardiovascular disease (CVD) death rates among adults aged 35-64 years using four measures of rural-urban status: Urban Influence Codes, Rural-Urban Continuum Codes (RUCC), National Center for Health Statistics Urban-Rural Classification Scheme, and Core-Based Statistical Areas. We estimated 2021 CVD death rates and used Poisson regression models to calculate rate ratios (RR) for full and dichotomized rural-urban measures. All measures identified the largest RR in the middle of the rural-urban spectrum. RUCC demonstrated patterns by population size and adjacency. RR magnitude varied across dichotomization methods. These findings demonstrate complexity underlying rural-urban differences and can guide public health practice.

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.

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.

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.

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.

Carbon Monoxide Poisoning: Diagnosis, Prognostic Factors, Treatment Strategies, and Future Perspectives

Carbon monoxide (CO) poisoning is a significant public health issue, with diagnosis often complicated by non-specific symptoms and limited access to specialised tools. Early detection is vital for preventing long-term complications. The review examines diagnostic challenges, prognostic factors, management strategies, and future advancements in CO poisoning. It highlights the limitations of current diagnostic techniques such as blood carboxyhaemoglobin levels and pulse CO-oximetry, while exploring emerging methods for rapid detection. Prognosis is influenced by exposure severity and delayed treatment, which increases the risk of neurological damage. Hyperbaric oxygen therapy (HBOT) remains the primary treatment but is not always accessible. Advances in portable CO-oximeters and biomarkers offer potential for improved early diagnosis and monitoring. Addressing resource limitations and refining treatment protocols are crucial for better patient outcomes. Future research should focus on personalised management strategies and the integration of modern technologies to enhance care.

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

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<.0001). There was a greater proportion of abnormal test results among the risk-positive than the risk-negative group (23.4% vs. 6.6%; P<.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<.0001). Risk-positive patients had 4.31 times the odds of having an abnormal test than risk-negative patients (P<.0001).

CONCLUSION

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.

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.

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.

Community Health Worker-delivered tobacco cessation in a small rural county

PURPOSE

We evaluated a Community Health Worker (CHW)-Tobacco Treatment Specialist (TTS) model for delivering tailored tobacco treatment counseling and support in a rural, low-resourced county.

METHODS

This was an exploratory, prospective study of people 18 years or older who used any tobacco product including e-cigarettes or vapes in the past 30 days. The CHW assessed tobacco use, secondhand smoke exposure, and quit history; and collected an expired breath carbon monoxide sample and a brief health history before providing 4-6 in-person or phone-based sessions involving tailored tobacco treatment counseling and support. The CHW connected participants to a prescriber at a federally qualified health care center (FQHC) for cessation medications as needed and/or helped them obtain free or low cost medications as available. Six weeks after intake, the CHW conducted a final in-person assessment, carbon monoxide measurement, and tobacco treatment counseling. We then referred participants to the free Quit line and to their primary care provider or the FQHC for additional treatment.

FINDINGS

Median cigarettes smoked per day decreased from 20 at intake to 4.5 at the final visit. Most participants reported at least one or more 24-h quit attempts, and 38% reported they had stopped smoking entirely after the final visit. There was a significant increase in participants' confidence in quitting from intake to final.

CONCLUSIONS

Using a CHW-TTS-delivered tobacco treatment approach in a low-resourced rural community demonstrated promise in helping tobacco users quit.

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.

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-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.

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.