Studying the effects of at-home heart failure care in rural America

Rural Americans face a higher risk of developing and succumbing to deadly chronic conditions like heart disease, cancer, and diabetes. Caring for this population poses a perennial problem for healthcare providers as these high-risk patients face numerous barriers to accessing the healthcare that they need. As virtual and home-based care options emerge, healthcare stakeholders are evaluating the best approaches to enhancing chronic disease management in rural areas.

To this end, virtual specialty care provider Access TeleCare and the UT Southwestern Medical Center announced in March that they are launching a two-year project to assess care for heart failure patients in rural communities nationwide. The project involves creating a rural heart failure patient registry to document patterns of care and conducting a home-based cardiac rehabilitation program pilot.

“[Rural heart failure patients] tend not to have access to the highest level of care that you get at a tertiary referral care center or a major medical hospital or a medical center,” said Pritam Ghosh, MD, chief medical officer and medical group president of Access TeleCare, in an interview with mHealthIntelligence. “And so, this is our way of reaching out to them, and then taking those patients, de-identifying their information, and looking at it from an objective lens.”

Improving heart failure care in rural America is essential; however, there are numerous considerations for successfully expanding access to specialty care in these communities.   

A PRESSING NEED TO ADDRESS HEART FAILURE IN RURAL AMERICA

Heart failure refers to a condition in which the heart isn’t pumping as well as it should. According to an article published in the Journal of Cardiac Failure in 2023, approximately 6.7 million Americans over 20 have heart failure. The prevalence is expected to rise to 8.5 million Americans by 2030.

The risk of developing heart failure is higher in rural areas. A study supported by the National Institutes of Health (NIH) found that US adults living in rural areas have a 19 percent higher risk of developing heart failure compared to their urban counterparts. The study, published in January 2023, also shows that Black men living in rural areas have an especially high risk of developing the disease.

Not only are rural residents more susceptible to developing heart failure, but they experience worse outcomes and barriers to specialty care access.

“Patients with heart failure who reside in rural communities have worse post-discharge outcomes than those in urban communities,” said Ambarish Pandey, MD, associate professor of internal medicine and medical director of the Heart Failure with Preserved Ejection Fraction (HFpEF) Program at UT Southwestern Medical Center, in an interview with mHealthIntelligence. “There are also differences in care utilization, with rural-residing patients participating in cardiac rehabilitation after heart failure hospitalization at a much lower rate due to transportation barriers and limited access to cardiac rehabilitation centers. Additionally, patients in rural communities frequently need more access to specialty cardiac care centers to participate in clinical trials.”

The prevalence of heart disease in rural America has a widespread impact on healthcare resources, with heart failure being one of the primary drivers of admissions in rural hospitals across the country, Ghosh noted. Thus, healthcare providers experience the burden of providing advanced care, and patients feel the burden of accessing that care.

The research project aims to alleviate patient and provider burdens by improving access to rural heart failure care.

“You're looking at a large population of patients that, if you manage them appropriately, would not continue coming back to the hospital for acute care,” he added. “And the goal for any therapy, whether it's heart failure or not, is to make the patient better so they don't have to come back to the hospital.”

THE RESEARCH PROJECT AND IT’S GOALS

As noted above, the research project has two parts. First, it aims to create a registry of 1,000 heart failure patients and study them for two years.

Ghosh explained that Access TeleCare and UT Southwestern researchers will first create a list of patients with a diagnosis of congestive heart failure who were hospitalized. They will examine de-identified data from these patients’ charts weekly to assess whether suitable therapies were used while the patients were in an inpatient setting and whether they were discharged with an appropriate treatment plan.

The registry will collate data from across 10-plus rural hospitals in multiple states, Pandey added.

“Findings from the registry will be used to identify future areas for intervention to ensure consistent, evidence-based treatment for patients experiencing cardiovascular conditions,” he said.

The second part of the project is a 50-patient pilot of a home-based cardiac rehabilitation program that will begin later this year and run through the end of 2025. Rural areas lack access to home-based cardiac rehabilitation, even though the therapy has proven effective for heart failure patients.

“We know that being plugged in a situation like that, with outpatient monitoring and cardiac rehab access, helps with their cardiac function, helps with their daily quality of life,” Ghosh said.

One of the major reasons patients keep coming back to the hospital with exacerbations of their heart failure is not having access to advanced therapies like home-based cardiac rehabilitation.

“The study bridges that gap,” Ghosh said. “It allows these patients who would really not have access otherwise to advanced therapies into the latest standard of care.”

The patients will be selected for the pilot based on registry data analysis. According to Ghosh, the focus will be on identifying the patients who would benefit most from cardiac rehab, such as those who are symptomatic, who experience frailty, and who have ejection fractions.

Another collaborator on the research project is the American Heart Association (AHA), which is not only sponsoring the project but also working with Access TeleCare and UT Southwestern to evaluate the findings from the registry and the pilot clinical trial. The organizations will measure performance using content and tools licensed from the AHA’s Get with the Guidelines initiative.

“This partnership between UT Southwestern, the AHA, and Access Telecare will generate additional knowledge surrounding the care of patients with heart failure in rural communities and pilot potential home-based cardiac rehabilitation interventions,” Pandey said.

However, the organizations are considering some critical operational and socioeconomic factors as they begin the project.

Pandey noted that integrating data from multiple EMRs can be challenging, so they have selected a study team with experience with EMR-based research and data curation.  

Challenges may also stem from the lack of resources in rural areas. For instance, home-based cardiac rehab often involves modifications to patients' lifestyles, which may be more difficult for patients to achieve in rural areas.

“Lifestyle modifications are somewhat easier in urban populations,” said Ghosh. “You have access to gyms, you have access to food that has proper nutritional value, and those who live in rural areas may not have access to those things.”

Further, Ghosh noted that rural heart failure patients may not have the resources to continue with new activity patterns or be able to access physicians with the requisite expertise to manage their advanced clinical needs after they have completed the cardiac rehab program.

Thus, the project's long-term goal is to sustain expanded access to advanced therapies for heart failure patients in rural areas. Additionally, the researchers hope to better understand the clinical benefits of in-home cardiac rehab programs and collect data that can inform program implementation in rural areas.

“Because at the end of the day, these are all non-traditional patient care delivery [models],” Ghosh said. “And I don't think that enough literature exists right now in the academic world that really describes and highlights projects like this, right? We're coming up on a time when the traditional brick-and-mortar location for healthcare is not the only way to have healthcare delivered to you. But I think, to get real traction and investment from people and communities, healthcare field literature is needed to substantiate a lot of the things that we're doing, whether it's telemedicine, remote monitoring, whatever the case is.”