Rural Healthcare Research

People who need medical care in rural settings have significantly worse outcomes from cardiovascular conditions compared with those in non-rural settings, including treatment of arrhythmias with a CIED, like a pacemaker or defibrillator. These ubiquitous implantable devices store copious amounts of medical information related to device function and disease progression, among other items.

These data are available to treating physicians and other clinicians through RM, which relies on wireless connectivity between people who need medical care, a remote server, healthcare facilities and treating physicians. Monitoring of people who need medical care with a CIED through this RM paradigm as an adjunct to periodic in-person evaluations has been associated with a variety of improved outcomes over in-person evaluations alone, ranging from improvements in individual satisfaction to decreased mortality. Thus, RM is unequivocally recommended in combination with in-person evaluations. While known disparities in RM exist among the uninsured and elderly, the geographic distribution of RM remains unstudied.

A number of factors suggest that RM of CIEDs may be particularly vulnerable to geographic disparities. For one, people who need medical care in rural areas face greater barriers to connectivity, including less access to high-speed internet and less-consistent cell phone coverage. These barriers couple with the challenge of greater geographic distances that must be traveled to access in-person subspecialty services, a necessary aspect of CIED care.

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Dr. Zeitler is a cardiac electrophysiologist at DHMC. Her body of work focuses on cardiovascular clinical outcomes and health policy and builds on clinical training and research completed during fellowships at Duke University and the Duke Clinical Research Institute. Prior to that, Dr. Zeitler served as a medical device officer at the U.S. Food and Drug Administration, participating in the regulatory activities related to cardiovascular medical devices. She has experience designing and working with data from regional and national databases, administrative claims and clinical trials, and has participated in multi-stakeholder working groups to address systematic shortcomings of cardiovascular investigation and health policy evaluation. Learn about her current Digital Health Utilization Research Program at our Center, "Remote monitoring for cardiac arrhythmia."

Low-value care, defined as care for which the likely degree of benefit is outweighed by harms or costs, is a critical domain of healthcare waste. Efforts to reduce low-value care have intensified as literature has elucidated the magnitude of associated patient- and system-level harms associated with this care.

In the pediatric hospital setting (inclusive of inpatient and emergency departments), describing the impact of low-value care has been identified as a research priority. Low-value care persists for many conditions commonly cared for in this environment despite increasing evidence of their ineffectiveness. While a growing body of literature describes the prevalence of pediatric low-value care, research on this topic in the United States to date has focused largely on freestanding children’s hospitals, all of which are located in urban regions. Little is known about the prevalence and impact of pediatric low-value care in rural hospitals, which provide the majority of hospital care for children in the U.S. This is particularly relevant because rural-residing children are under-represented in research and have poorer health outcomes and child mortality than their urban-residing peers.

This study will use Medicaid data to measure the delivery of 30 low-value pediatric services in the hospital setting in eight rural states. Through application of this tool, we will: 1) measure urban-rural disparities in pediatric low-value care delivery and determine if these disparities are moderated by hospital type and setting; 2) characterize downstream healthcare utilization (hospital revisits, imaging studies and prescription fills) and Medicaid spending associated with low-value care delivery; and 3) using qualitative methods, identify unique deimplementation considerations in rural regions from the perspectives of rural hospital stakeholders.

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Dr. House is a Pediatric Hospitalist and the Vice Chair of Quality and Safety for the Department of Pediatrics at Dartmouth Health Children’s. She completed her MPH at The Dartmouth Institute for Health Policy and Clinical Practice prior to attending medical school and re-engaged in research and educational efforts at TDI during her pediatric residency at Dartmouth. Since this time, she has been actively engaged in Health Services Research, focusing on the quality of healthcare delivered to children in the hospital setting. She has experience with analyzing administrative data to assess variation in care delivery, developing and implementing quality improvement initiatives, and operationalizing quality measurement. She recently worked with the Children’s Hospital Association to develop a calculator measuring the delivery of low-value care in large children’s hospitals; her current project, “Measuring pediatric hospital-based low-value care: Urban-rural disparities and associated downstream healthcare utilization,” will expand this work into rural settings to assess for differences in hospital-based care quality among children residing rurally, who are known to have poorer health outcomes than urban-residing peers.

Individuals with chronic obstructive pulmonary disease (COPD) who live in rural areas of the United States have worse health outcomes compared with their non-rural counterparts, outcomes not completely explained by higher rates of cigarette smoking. Both ongoing cigarette exposure and environmental exposures other than cigarettes, including particulate matter (PM) air pollution, are associated with worse COPD morbidity. Use of solid fuels (e.g. wood and pellet) for heating is common in rural areas and can generate high concentration of indoor PM. However, there is a common belief is that rural areas are free from air pollution, and rural residents are often not aware of pollution sources within their own homes and communities. There are few studies that assess environmental exposures, their association with COPD morbidity, and the risk perceptions of such exposures in rural areas of the United States.

Our long-term goal is to identify potentially modifiable environmental risk factors that contribute to greater COPD morbidity in rural U.S., leading to future targeted interventions designed to improve outcomes. Our overall objective for this application is to determine the association of environmental exposures with respiratory morbidity in individuals with COPD living in rural areas, and to explore the risk perceptions of such exposures. The rationale for this project is that identifying the sources, health effects, and risk perceptions of environmental exposures will inform development of a future comprehensive intervention that is sensitive to the needs and priorities in a population where continued inhalational exposures are associated with disease progression and death.

We will recruit individuals with COPD living in northern New England (NNE), and comprehensive environmental exposure assessment will be paired with extensive clinical outcomes to address the following aims: 1) To identify individual and community characteristics that are associated with environmental exposures among those with COPD living in NNE; 2) To quantify the relationship between environmental exposures and morbidity in individuals with COPD living in NNE; and 3) To use semi-structured interviews and focus groups to explore risk perceptions, knowledge, attitudes, and behaviors surrounding environmental risk factors and potential strategies to mitigate such exposures among individuals with COPD living in NNE. The proposed research will generate crucial information on the associations between environmental exposures and respiratory morbidity as well as the predictors of such exposures in NNE residents with COPD. Results from this study will lead to future trials designed to mitigate environmental exposures and improve health outcomes for individuals living with COPD in the rural U.S.

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Dr. Paulin is a physician-scientist practicing adult pulmonary and critical care with a research focus on the association between environmental exposures (including air pollution, occupational exposures, and cigarette and e-cigarette use) and clinical outcomes in respiratory disease. Her primary interest is in indoor air pollution, including particulate matter and nitrogen dioxide, and studies how indoor sources and home behaviors in rural environments influence concentrations of these important pollutants, and the impact of these airborne exposures on clinical outcomes in individuals with respiratory disease, focusing on those with chronic obstructive pulmonary disease (COPD).

People who need medical care in rural settings have significantly worse outcomes from cardiovascular conditions compared with those in non-rural settings, including for peripheral artery disease (PAD). Despite strong evidence supporting guideline-directed medical therapy and structured exercise therapy (SET) for patients with intermittent claudication, fewer than 50% of patients receive GDMT and less than 10% participate in SET programs—gaps that are likely compounded in rural settings where geographic isolation, limited healthcare infrastructure, and socioeconomic constraints further restrict access.

Northern New England presents a particularly important context for studying these disparities. Patients with PAD in rural areas must travel greater distances to access subspecialty vascular care, face higher rates of uninsurance and underinsurance, and encounter limited availability of hospital-based exercise programs. The geographic distribution of evidence-based PAD care and the factors driving these gaps remain poorly understood.

This project employs a mixed-methods approach—including computable phenotyping of EHR data, qualitative interviews with patients and providers, and implementation of a smartphone-based exercise program—to characterize and address these disparities.

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Dr. Scully is a vascular and endovascular surgeon at Dartmouth Hitchcock Medical Center (DHMC) and Assistant Professor of Surgery at the Geisel School of Medicine at Dartmouth. Her research focuses on cardiovascular outcomes, health equity, and improving access to evidence-based care for patients with vascular disease in rural settings. She completed her general surgery residency and vascular surgery fellowship at Brigham and Women's Hospital, and holds a Master of Public Health in Quantitative Methods from the Harvard T.H. Chan School of Public Health. Dr. Scully has authored peer-reviewed work on PAD healthcare expenditures, surgical outcomes, and health disparities, and brings expertise in national registry analysis and health policy research to this project. She practices at DHMC and the White River Junction VA Hospital, where she serves as chief of Vascular Surgery, giving her direct insight into the rural patient populations this work aims to serve.

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Dr. Gunn is a health services researcher at the Dartmouth Institute for Health Policy and Clinical Practice and Health Equity Liaison to the Dartmouth Cancer Center’s Community Outreach and Engagement Program. Her research program is focused on risk communication, decision-making, and the utilization of evidence-based care. She uses community-engaged research methods to design and test interventions to improve cancer outcomes, especially for populations with limited health literacy and people living in rural areas.

Inequities in maternal and health outcomes based on income, geography, and race in the U.S. are well documented, with those who are rural-residing, from racial and ethnic minority groups, and low-income bearing a disproportionate burden of adverse maternal health outcomes. In terms of health access and utilization, rural-residing pregnant women tend to have higher rates of Medicaid coverage compared to urban-residing pregnant women; they tend to access services such as prenatal care later than their urban-residing counterparts and are also more likely to be adversely affected by hospital closures compared to women residing in urban areas. While there is well-documented evidence of racial and ethnic disparities and inequities in maternal health access and health outcomes in the general population, there is a dearth of research on these disparities, specifically within rural areas. As such, there is a need to study the racial and ethnic disparities and inequities in health access among rural-residing women to inform policies that could reduce these knowledge gaps.

This study will use Texas maternal and infant Medicaid claims data merged with natality and infant mortality records to examine maternal and infant health service access, utilization, and health outcomes at the intersection of rurality, race, and ethnicity and determine how the timing of Medicaid enrollment may be associated with these outcomes.

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Dr Toyin-Thomas is a general pediatrician in the Department of Pediatrics at Dartmouth Health Children’s and an early-career pediatric health services researcher. She completed her MPH at the Harvard T.H. Chan School of Public Health and has a PhD in Health Services and Policy from the University of Iowa College of Public Health. She is currently a Health Equity faculty fellow at The Dartmouth Institute of Health Policy and Clinical Practice, and her research focuses on disparities in care access among Medicaid women and children, historically economically disadvantaged populations that are particularly vulnerable to adverse health effects.

In the U.S., approximately 11 million unpaid care partners of persons with dementia, (i.e., Alzheimer’s disease/Alzheimer’s disease-related dementia), provide services supporting 7 million persons with dementia living in the community instead of assisted living. This often unrecognized and under-appreciated workforce, most of whom are over age 60, would greatly benefit from accessible brief mental health assessments and interventions to support their mental wellbeing while managing the stress of providing care. One-quarter of care partners live in rural areas of the U.S. and have challenges accessing limited services and providers; they travel longer distances for care, and have greater educational and socioeconomic barriers than urban populations.

Care partners’ interaction with clinicians is primarily through their visits accompanying persons with dementia, and not visits for their own care. While opportunities exist to assess care partners’ mental health at these visits, care partners report that this is not often discussed. Given the anticipated increase in the number of rural older adults, it is important to understand and find opportunities to assess and support the specific mental health care needs of rural care partners of persons with dementia. How best to identify mental health needs and effectively support care partners is unknown.

To address this knowledge gap, this Pilot Project will determine how rural and urban primary care clinicians caring for persons with dementia view their roles regarding assessing psychosocial supports and mental health in care partners. In addition, this study will describe the context in which care partners’ mental health arises during routine visits for the person with dementia, and identify barriers to and facilitators of clinicians inquiring about care partner mental health. Our objective is to understand how rural and urban clinicians engage with care partners around mental health issues and well-being in order to guide development of future interventions in rural populations.

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Dr. Mistler is an Associate Professor of Psychiatry at Dartmouth Health and Geisel School of Medicine, and attending at New Hampshire’s only state hospital in Concord, New Hampshire. After several years conducting research focused on inpatient violence in psychiatric settings, she transitioned her research to focus on mental health of care partners. She has since completed a T32 Primary Care Research Fellowship at Dartmouth Health and received a prestigious National Institute of Aging Grant for Early Medical/Surgical Specialists’ Transition to Aging Research (GEMSSTAR; R03 AG088962-01). The objective of the GEMSSTAR is to develop a digital intervention to promote screening and referral to services for rural-dwelling care partners of persons with dementia.