Improving Cardiovascular Health in Rural United States

Graphical abstract

particularly severe problem in Appalachia. 5 Widespread investment in infrastructure beyond the scope of AMCs is needed to reduce this disparity and take advantage of telemedicine's benefits.One strategy to mitigate this barrier is for patients to utilize telemedicine not at home, but at their primary physician's office where they virtually connect to specialists.We recently implemented this model at our institution with a primary care clinic in rural Kentucky without a local cardiologist on site.
Although requiring the patient to leave their home, this model offers several advantages, including the opportunity to partner with local offices to assess vital signs, verify medications, and ensure patients understand the care plan described by the cardiologist.Telemedicine partnerships such as this between local health systems and AMCs can hopefully expand in the future and improve CV care delivery.
Management of complex disease may require inperson assessment, as opposed to telemedicine.
Outreach clinics provide the opportunity for rural residents to be seen by a cardiologist close to home, thereby reducing travel burden on patients.In regions where general cardiology care is available locally, there is often an unmet need for subspecialty support such as electrophysiology or structural heart disease.Although a procedural intervention such as transcatheter aortic valve implantation may require travel to an urban center, preprocedure testing and specialist consultation could occur locally.For patients with limited financial resources, this could ease the burden and should increase the number of patients who undergo the procedure indicated.Major health systems outside of AMCs have resources to establish outreach clinics, but there are 2 subspecialties which are predominantly part of AMC CV programs: adult congenital heart disease (ACHD) and advanced HF (AHF).This type of specialized care is not often found in rural environments, given the majority of ACHD and AHF specialists work in AMCs or large health systems.One analysis showed that distance from an ACHD center was associated with a decreased probability of ACHD-specific follow-up, but more utilization of health care resources due to increased hospitalizations. 6  Our article is a call to action for AMCs and large health systems to collaborate with rural hospitals to improve the CV health of rural residents, which continues to lag behind urban residents. 1AMCs and health systems have the resources and clinicians to assist these facilities with the development and E-mail: nra224@uky.edu.
By establishing community-based ACHD outreach clinics, AMCs ensure that these patients, who are often "lost to follow-up," get appropriate management and receive referrals to a main center when surgical or percutaneous interventions are necessary.Similarly, AHF specialists are typically employed by centers offering heart transplantation or left ventricular assist devices, which are often located in urban areas and are limited in number. 7Rural communities are likely to experience worsening HF burden due to the aging population, high prevalence of HF risk factors, and frequency of multiple comorbidities.Rural HF clinics are needed to manage this patient population, which likely requires multidisciplinary team members in addition to cardiologists.The goal of HF rural outreach clinics should be to optimize the medical management of HF patients,

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FIGURE 1 Academic Medical Centers Can Use Their Resources to Help Rural Hospitals Enhance Their Cardiovascular Programs, Allowing Rural Residents to Have the Same Access to Care As Urban Residents

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A C C : A D V A N C E S , V O L . 3 , N O .7Cardiovascular Health in Rural United States improvement of CV programs.Improving rural health requires major political and societal shifts to decrease an ever-increasing gap in health equity.AMCs and health systems can help take the lead to ensure that rural residents have similar access to advanced CV medicine as their urban counterparts.ACKNOWLEDGMENTSThis paper is dedicated to the memory of Dr Susan Smyth, who during her distinguished career was dedicated to improving health care in rural communities.FUNDING SUPPORT AND AUTHOR DISCLOSURESDr Rajagopalan has served as a consultant for Abbott Laboratories.Dr Bailey has served as a consultant for OptumRx and Novo Nordisk.All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.ADDRESS FOR CORRESPONDENCE: Dr Navin Rajagopalan, University of Kentucky, 900 South Limestone Street, Lexington, Kentucky 40536, USA.