Expert Q&A: Closing the Gap in Rural Health Outcomes

Recent health care metrics demonstrate a concerning trend: rural Americans face higher mortality rates than urban residents.

People in rural communities live an average of three years fewer than their urban counterparts and have a 40% higher likelihood of developing heart disease compared with people living in small metropolitan and urban areas — a gap that has grown over the past decade.1 This has experts focused on how to improve rural health care and ensure rural professionals have the resources they need to continue offering the best care possible to their communities.

One such expert is Karen Joynt-Maddox, M.D., MPH, an American Heart Association volunteer, associate professor at Washington University School of Medicine and co-director of the Washington University in St. Louis Center for Advancing Health Services, Policy & Economics Research.

Joynt-Maddox provides some insight into the unique strengths rural hospitals bring to their communities, as well as opportunities through which rural health care professionals can overcome disparities and improve patients’ health and outcomes.

What is your experience in rural health care settings, and why this is an important topic to you?

KJM: One side of my family is from a rural part of Virginia and I had some experience dealing with rural health care when my grandmother was ill. I also did a rural family medicine rotation in medical school, which was so different than the rest of my rotations — much more personal and community-based, in a small town where everyone knew each other, but where many people faced unemployment and other challenges. Later, I started doing research on rural health, particularly focused on rural hospitals, and was struck by the major differences in the care patients received and the outcomes they attained. 

I think this is an incredibly important topic because of the widening gaps in health equity between rural and urban areas. As technologies and advancements have taken place in medical care, rural areas have fallen farther and farther behind, and we have really had a lack of successful coordinated policy responses to preserve access and improve outcomes in rural areas. There’s so much need for innovation and investment, along with strategy, to improve rural health.

What are the particular challenges these areas face, and what unique strengths do rural health systems and communities have? 

KJM: Rural communities face a number of challenges when it comes to health and health care. There are higher rates of traditional risk factors, such as diabetes and hypertension; higher rates of other key risk factors such as mental health and substance use diagnoses; and a higher burden of adverse social determinants of health, such as poverty and limited education.2 Rural areas in states that have not expanded Medicaid have even greater challenges with access to care for people living in poverty. On top of those factors, rural areas are also facing a significant and growing challenge with health care access, particularly to specialty care and to high-acuity care. Finally, the intersection of rurality, poverty, and minoritized race or ethnicity defines the parts of our country with the lowest life expectancy and worst health outcomes.

On the other hand, rural communities have attributes that provide some key strengths. There tend to be tight community bonds in rural areas, which can facilitate peer-to-peer health coaching and other local strategies. Primary care professionals tend to be trusted and well-integrated into communities, which can facilitate care continuity.

How are care opportunities different in rural hospitals versus urban hospitals?

KJM: Rural hospitals have a complex job. They need to quickly determine which patients’ needs can be met in the local hospital and which patients would be better served by being transferred to a hospital with specific capabilities (such as cardiac catheterization or interventional neurology). A tailored program that focuses hospitals on these decisions is critically important. On the other hand, for a condition like heart failure, many patients can be cared for in their local hospital, and the quality metrics are much more similar.

How can rural stroke and cardiac quality programs help rural hospitals implement evidence-based guidelines?

KJM: One of the major barriers that small rural hospitals face in delivering consistent, high-quality care is a lack of infrastructure with which to measure and evaluate their own performance. Programs that can help these facilities stay up to date on and follow evidence-based guidelines provide structure around key quality measures, which gives hospitals both a place to focus and a mechanism to do so.

One new opportunity to implement such a program at no-cost to the hospital is the American Heart Association’s Rural Health Care Outcomes Accelerator. It is open to federally designated critical access hospitals, as well as geographically rural short-term acute care hospitals classified by Rural Urban Commuting Areas Code classifications. The program provides no-cost access to newly added Get With The Guidelines quality programs for coronary artery disease, heart failure and stroke.

Each hospital may differ in where they have particular strengths or weaknesses — one hospital might have great processes in place for patients having heart attacks, while another might have great care transition programs to prevent readmissions in patients with heart failure. The Get With The Guidelines programs provide benchmarking and peer learning opportunities so hospitals can identify areas where they can do better and receive recognition for areas in which they excel.

Why is acute heart failure treatment using optimized, guideline-directed medical care measurement particularly important in the rural setting, where access to specialty services may be limited?

KJM: Heart failure treatment is rapidly changing. Clinicians in rural areas, where specialty care may not be available, face a real challenge in being able to keep up with new treatments and recommendations across a wide range of conditions and procedures. A program that makes it very clear what the current guidelines and benchmarks are for different patient populations can enable local health care clinicians to keep up with advances in medicine on a real-time basis.

How beneficial are learning collaboratives and community networks for health care professionals in rural areas? 

KJM: Incredibly beneficial. What works in urban areas won’t necessarily work in rural ones, so it’s crucial to connect rural hospitals to each other to facilitate sharing best practices and innovative ideas. Often, health care professionals in rural areas are doing so many jobs at once – generalist and specialist, front line clinician and administrator, practitioner and counselor – and there’s not much in the way of support for these challenging circumstances. Rural learning collaboratives and community networking can provide ideas, support, encouragement, and motivation.

The people providing care in rural hospitals and health systems care so deeply about their communities and are so embedded in their communities. The Rural Health Care Outcomes Accelerator is one way to bring resources and support to the clinicians and patients in rural areas and, in doing so, better the cardiovascular health of their communities.  

Learn more about the Rural Health Care Outcomes Accelerator at

These views do not necessarily reflect the American Heart Association’s official positions.

1. American Heart Association issues call to action for addressing inequities in rural health. February 10, 2020.; American Heart Association. Public Health AmeriCorps to address health inequity in rural communities. April 6, 2022.


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