HEART DISEASE AND STROKE IN RURAL
by Miguel Zuniga, D’Arcie Anderson, and Kristie Alexander
Combating heart
disease and stroke are pivotal to improving the nation’s health. Given this
disease is the leading cause of death in the
The objectives2 addressed in the heart disease and stroke review are as follows:
Approximately 61 million individuals in the United States suffer from some form of cardiovascular disease, which includes heart disease and stroke.8 Although heart disease is sometimes considered a disease mostly affecting men, half of all cardiovascular disease deaths occur in women.8 The highest rates of heart disease deaths among women occur in northeastern large urban areas followed by the South’s most rural counties. For men, the highest heart disease-related deaths occur in the South’s most rural counties.9 For women and men, the lowest death rates from heart disease occur in the West.9
The death rate for African-American males from cardiovascular disease is 42 percent higher than white males, and the rate for African-American females is 65 percent higher than white females.10 Other vulnerable populations to heart disease and stroke include older Hispanic Americans,3 individuals of lower socioeconomic status,11 and rural populations,5, 6 particularly those in the South and Appalachian region.4, 12
According to self-reported data in the 1996 National Health Interview Survey, heart disease, cerebrovascular disease, and hypertension were more prevalent in nonmetropolitan than metropolitan areas.13 From 1985-1995, declines in mortality rates for premature coronary heart disease in African Americans and whites were found to be slower in the rural South than their counterparts in other geographic areas.12
IMPACT
Heart disease and stroke are respectively the first and third leading causes of death in the United States.1 In 1999, there were 725,192 heart disease deaths and 167,366 stroke deaths. The age-adjusted death rate for heart disease was 265.9 deaths per 100,000, and for stroke was 61.4 deaths per 100,000.14
Other measures
of the effects of cardiovascular disease are the associated long-term costs.
Heart disease and stroke are leading causes of disability, annually costing the
Rural populations are faced with certain behaviors, attitudes, and access challenges that may contribute to their heightened risks of coronary heart disease and stroke. Among these include a comparatively decreased rate of lifestyle change from behaviors associated with heart disease such as smoking, high-fat diets, sedentary lifestyle,5 and decreased perception of heart disease risk especially among older rural women.20 Other factors include long travel distances to comprehensive post discharge care for heart failure,21 limited access to screening services, variances in utilization of antithrombolytic therapy,22, 23 availability of technology and specialists,24 and limited access to cardiac rehabilitation services.6
Modifiable risk factors such as smoking, high cholesterol, hypertension, physical activity, obesity, diabetes, and stress5 can be influenced through evidence-based preventive measures. Assessing the presence of risk factors and targeting modifiable risk factors should begin as early as 20 years of age.25 Secondary prevention strategies are those that increase the likelihood of early diagnosis, such as through screening efforts and warning-sign information dissemination, and those that address the treatment of the disease.
Tertiary prevention strategies are those that aggressively treat heart disease and stroke, endeavoring to decrease their severity and occurrence of complications, such as through antithrombolytic therapy.
Heart disease and stroke are the leading causes of morbidity and mortality. Rates of reduction are varied, and certain populations are particularly vulnerable, including rural populations. Several modifiable risk factors for heart disease and stroke are more predominant in rural areas; however, access to services and preventive measures, such as screening, are not as readily available. This disease will continue to be a priority health issue in rural areas as long as access to quality care and prevention efforts are not addressed and modifiable risk factors are not effectively changed.
The following models for practice are examples of programs utilized to address this rural health concern.
1. Minino, A.M., and Smith, B.L. Deaths: Preliminary data for 2000. National Vital Statistics Reports 49(12), 2001.
2.
3. Sundquist, J.; Winkleby, M.A.; and Pudaric, S. Cardiovascular disease risk factors among older black, Mexican-American, and white women and men: An analysis of NHANES III, 1988-1994. Third National Health and Nutrition Examination Survey. Journal of the American Geriatrics Society 49:109-116, 2001.
4. Barnett, E., and Halverson, J. Local increases in coronary heart disease mortality among blacks and whites in the United States, 1985-1995. American Journal of Public Health 91(9):1499-1506, 2001.
5. Pearson, T.A., and Lewis, C. Rural epidemiology: Insights from a rural population laboratory. American Journal of Epidemiology 148(10):949-957, 1998.
6. Barnett, E.;
Halverson, J.A.; Elmes, G.A.; et al. Metropolitan and
non-metropolitan trends in coronary heart disease mortality within
7. Gamm, L.; Hutchison, L.; Bellamy, G.; et al. Rural healthy people 2010: Identifying rural health priorities and models for practice. Journal of Rural Health 18(1):9-14, 2002.
8. Centers for Disease Control and Prevention (CDC). Preventing heart disease and stroke. Addressing the nation's leading killers, 2002. <http://www.cdc.gov/nccdphp/aag/aag_cvd.htm>December 17, 2002.
9. Eberhardt, M.; Ingram, D.; Makuc,
D.; et al. Urban and Rural Health Chartbook. Health
10. Huston, S.L.; Lengerich, E.J.; Conlisk, E.; et al. Trends in ischemic heart disease death rates for blacks and whites – United States, 1981-1995. Morbidity and Mortality Weekly Report 47(44):945-949, 1998.
11. Wing, S. Social inequalities in the decline of coronary mortality. American Journal of Public Health 78(11):1415-1416, 1988.
12. Barnett, E., and Halverson, J. Disparities in premature coronary heart disease mortality by region and urbanicity among black and white adults ages 35-64, 1985-1995. Public Health Reports 115(1):52-64, 2000.
13. Adams, P.F.; Hendershot, G.E.; and Marano, M.A. Current estimates from the National Health Interview Survey, 1996. Vital Health Statistics 10(200):1999.
14. Hoyert, D.L.; Arias, E.; Smith, B.L.; et al. Deaths: Final data for 1999. National Vital Statistics Reports 49(8), 2001.
15. National
Institutes of Health and National Heart, Lung, and Blood Institute. Morbidity
and Mortality: 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases.
16. Lichtman, J.H.; Krumholz, H.M.; Wang, Y.; et al. Risk and predictors of stroke after myocardial infarction among the elderly: Results from the Cooperative Cardiovascular Project. Circulation 105(9):1082-1087, 2002.
17. Glassman, A.H., and Shapiro, P.A. Depression and the course of coronary artery disease. American Journal of Psychiatry 155(1):4-11, 1998.
18. Morris, P.L.; Robinson, R.G.; Andrzejewski, P.; et al. Association of depression with 10-year poststroke mortality. American Journal of Psychiatry 150(1):124-129, 1993.
19. Roose, S.P.; Glassman, A.H.; and Seidman, S.N. Relationship between depression and other medical illnesses. Journal of the American Medical Association 286(14):1687-1690, 2001.
20. Fiandt, K.; Pullen, C.H.; and Walker, S.N. Actual and perceived risk for chronic illness in rural older women. Clinical Excellence for Nurse Practitioners 3(2):105-115, 1999.
21. Philbin, E.F.; Dec, G.W.; Jenkins, P.L.; et al. Socioeconomic status as an independent risk factor for hospital readmission for heart failure. American Journal of Cardiology 87(12):1367-1371, 2001.
22. Gage, B.F.; Boechler, M.; Doggette, A.L.; et al. Adverse outcomes and predictors of underuse of antithrombolytic therapy in Medicare beneficiaries with chronic atrial fibrillation. Stroke 31(4):822-827, 2000.
23. Sheikh, K., and Bullock, C. Urban-rural differences in the quality of care for Medicare patients with acute myocardial infarction. Archives of Internal Medicine 161(5):737-743, 2001.
24. Baker, D.W.;
Fitzgerald, D.; and Moore, C.L. Quality of care for Medicare patients hospitalized
with heart failure in rural
25. Pearson, T.A.; Blair, S.N.; Daniels, S.R.; et al. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: Consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation 106(3):388-391, 2002.
26. Popovic, J.R., and Hall, M.J. 1999
27. Buczko, W. Rural Medicare beneficiaries’ use of rural and urban hospitals. Journal of Rural Health 17:53-58, 2001.
28.
29. CDC. WISQARS leading causes of death reports, 1999-2000. 2002. <http://webapp.cdc.gov/sasweb/ncipc/ leadcaus10.html>2002.
Zuniga, M.; Anderson, D.; and Alexander, K. (2003). Heart
Disease and Stroke in Rural
MODELS FOR PRACTICE
FOCUS AREA: HEART DISEASE AND STROKE
Program Name:
Location:
Problem Addressed: Heart Disease and Stroke
Healthy People 2010 Objective: 12-1, 12-11, 12-15
Web Address: http://www.fchn.org (click “Heart Health”) and http://www.franklinscorekeeper.org
Blueprint: WMCHH, an individual department in a not-for-profit
hospital, works with other entities, such as physician practices, school
systems, employers, insurers, Bureau of Health, Maine Cardiovascular Health,
universities, and research departments. The center’s mission is to develop
coordinated community approaches to reduce the health and economic burdens of
cardiovascular disease in rural
WMCHH is composed of four main divisions: HeartWarmers, Franklin ScoreKeeper,
Research and Development, and Consultation and Training. The Franklin HeartWarmers program offers education, supervised exercise,
lifestyle modification, and emotional support following a heart attack, bypass
surgery, unstable angina, or congestive heart failure through a unique program
that integrates traditional cardiac rehabilitation and sustained nurse-managed
telephonic contacts with enrolled clients. The program began four years ago,
and the model has been adopted by 34 of
The Franklin ScoreKeeper system is an innovative cardiovascular disease prevention program based on decades of documented success by the Franklin Cardiovascular Wellness Program in reducing cardiovascular mortality in West Central Maine. The program is founded on research endorsed by the American Heart Association and focuses on identifying five risk factors specific to cardiovascular disease: high blood pressure, high total cholesterol and/or low HDL cholesterol, smoking, physical inactivity, and overweight. The program works by promoting five behaviors for heart healthy living including: a heart healthy diet, regular physical activity, being tobacco free, using medications as directed, and improving coping skills and managing stress. Franklin ScoreKeeper software reflects the “Franklin Health Model” of care; has guidelines based on internal logic; is intuitive and easy to use; and efficiently shapes, tracks, documents, reports, and evaluates both process and outcomes of risk factor screening and control in multiple settings. ScoreKeeper nurses and other counselors provide one-on-one screening, counseling, and follow-up services in many community settings, including schools, worksites, medical practices, hospital, and community. The client/patient leaves the session with an individualized cardiovascular risk and behavior “ScoreCard,” an action plan for heart-healthy living, pertinent educational materials, linkage to community resources, and an appropriate follow-up strategy.
The Consultation and Training portion of the center involves leaders and staff of the center welcoming the opportunity to share their knowledge and expertise based on over a quarter of a century of experience in developing and implementing successful community programs that integrate public health and medical practice. Consultation may be provided at a location and via media of the client’s choice, i.e., face-to-face, telephone, electronically, or by mail.
The center
treats citizens of West Central Maine of all ages and ethnicities. No patient
is turned away, and insurance is not a consideration. Currently, the center has
eight full and part-time employees, including two co-directors. In addition,
students do preceptorships and internships from
Making a Difference: The death rate in
Beginnings:
In the early 1970s, a group
of idealistic, young doctors with new ideas about health care and medical
organization assembled in
The idea of the group innovation was underscored by the formation of the state’s first HMO in the late 1970s. Designed to give more people health care, it failed financially in the mid-1980s because it did not achieve sufficient scale.
Dr. Burgess Record, one of the young RHA doctors, wanted to do more than help people when they became ill. He and his wife, Sandy, a nurse, decided to take their blood-pressure cuffs and other equipment to grocery stores, businesses, and fairs to screen for problems and talk about prevention measures. The number of screenings grew when Record, who had Army Reserve duty every month in Auburn, asked if he could spend half of his required time performing screenings and counseling back in Franklin County. His superiors agreed but asked him to get approval of the hospital’s medical staff. The medical staff’s endorsement provided a foundation for the program to develop medical community support and minimal political opposition.
Thus the
Franklin Cardiovascular Health Program has served the region continuously for
29+ years. The high blood pressure program was implemented in 1974; cholesterol
was added in 1986, smoking in 1988, and Center for Heart Health in 1998. The
mortality impact of this integrated community program has been reported in the American
Journal of Preventive Medicine (Record, N.B.; et al. American Journal of
Preventive Medicine 19(1):30-38, 2000) and highlighted by the
Challenges and Solutions: Paul Judkins, former RHA head, asserts that the program is completely replicable. In addition, he points out that the biggest ingredient for any area trying to replicate the program is for community leaders to have the will. Lastly, he points out that the RHA doctors were community leaders and were interested in doing this for the people, not to make “bundles of money.”
Other issues that may be encountered include funding and
physician/administrator buy-in. The Center is
constantly looking for funds. Originally, funding was 33 percent
fee-for-service, 33 percent external state grants, and 33 percent in-kind
contributions. Now, with its focus on environmental and policy changes,
Burgess Record, MD, Co-Director
111 Franklin Health Commons
Phone: (207) 779-2720
MODELS FOR PRACTICE
FOCUS AREA: HEART DISEASE AND STROKE
Program Name:
Location:
Problem Addressed: Chronic Disease including Heart Disease
Healthy People 2010 Objective: 12
Web Address: http://www.lcpfh.org
Blueprint:
The
In 1999, the
Lowndes County Partnership for Health (LCPH) received a three-year Federal Rural
Health Outreach grant to combat cardiovascular disease in
The
The program is staffed with three full-time salaried staff members, 20 nursing students, four community volunteers, and is overseen by a 24 member board of directors.
Making a Difference: The program was initiated after LCPH
received a three-year Federal Rural Health Outreach grant to combat
cardiovascular disease in
Currently, success is measured by the number of companies that have signed up to participate in the project. Most worksite wellness programs require three to five years of operation before measurable results are available. As the program progresses, success will be measured by health screen data and progress through the stages of behavior change by individuals.
Beginnings:
The program began in
November 2001 after a community health needs assessment identified chronic
disease as a problem in
Challenges and Solutions: The primary challenge facing the program today is keeping up with the demand for services. The program is the only agency providing worksite wellness programs, and demand at this point is overwhelming.
The original
program was funded through
The program is brought to the attention of potential funders through grant proposals and speaking engagements. The program is publicized to the public through company and church communication channels, newspaper articles, speaking engagements, and through the board of directors’ contacts with state officials.
Currently, the
program has received the endorsement of the Mayor and City Council, the
John Sparks
Phone: (229) 245-0020
Fax: (229) 245-9855
MODELS FOR PRACTICE
FOCUS AREA: HEART DISEASE AND STROKE
Program Name: Healthy Hearts Program
Location:
Problem Addressed: Heart Disease and Stroke
Healthy People 2010 Objective: 12-8
Web Address: None
Blueprint: The
Healthy Hearts Program is a collaborative effort designed to identify and
reduce modifiable risk factors for heart disease in Schley County through
screening and health education for employers, and elementary and high school
students. EPMC provides overall project responsibility and coordination while
the
The project was designed by EPMC to allow nurse practitioners (NPs) together with registered nurses (RNs) to provide screening, health education, and follow up. The services are offered at the clinic and in a community setting, such as schools and industries. Outreach is also provided to local churches, senior citizen centers, and recreation programs. Services are available to the entire community, and the outreach programs are targeted to county elementary and high school students, and factory employees. Bilingual outreach workers assist with health education to those with limited English proficiency. NPs manage chronic, stable, and common acute episodic health problems at EPMC and refer more complicated medical problems to a physician, who like EPMC, provides care on a sliding fee scale. Eight local industries agreed to participate in the program by allowing employees to be screened at work and receive health education during working hours.
A Federal Rural Health Outreach grant supports the program. It is funded for three years, with decreasing funding over the course of the grant’s life. The program supports an NP (0.5 full-time employee [FTE]), half-time RN, and licensed practical nurse (0.5 FTE). Office personnel are paid by EPMC, while three health outreach workers are paid from a Migrant Health Program federal/state grant. In addition, there are limited in-kind donations from a local internal medicine doctor and pediatrician in the community.
Making a Difference: The program was fully implemented in September 2001. Currently, the program works with local industries to develop an ongoing work wellness program. The program intends to measure success by:
Beginnings: The program, in the demonstration phase, was initiated in May 2001 and fully implemented in September after the family nurse practitioner and health outreach workers began health screenings at the local industries and elementary school. The screening results showed that there were a high number of adults and children who had modifiable risk factors, undiagnosed or untreated hypertension.
The program was developed by EPMC, which enlisted the help of the above mentioned network members. Local industries participated in the program by having employees screened at work and receiving health education during working hours.
Challenges and Solutions: Currently, the program faces challenges
relating to the participating employer setting aside time and space for the
program to do the screening. It is also difficult to coordinate efforts with
the
The program only
works with clients in
Mary Anne Shepherd, RN, FNP-C
Healthy Hearts
Program,
Phone: (229) 937-5321
Fax: (229) 937-2232
MODELS FOR PRACTICE
FOCUS AREA: HEART DISEASE AND STROKE
Program Name:
Location:
Problem Addressed: Heart Disease and Stroke
Healthy People 2010 Objective: 12-1, 12-11
Web Address: http://www.dhss.state.mo.us
The Oregon County Heart Health Coalition began in May 2001 and primarily addresses heart disease, diet/meal planning, and fitness and health. The program is a collaborative effort between the BB Road Fire Department, Oregon County Health Department, senior citizens, and local churches. The coalition’s goal is to provide the community with education, equipment, literature, videos, smoking cessation classes, and water aerobics classes. Services are delivered through individual coalition members.
Blueprint: The Oregon County Heart Health Coalition serves all age groups, with a primary emphasis on senior citizens. The Oregon County Health Department assisted in the initiation of the program by providing start-up money and staff support. Currently, the program staff includes three registered nurses (RNs), one licensed practical nurse, one health educator, five paid staff, one donated staff person, and one retired RN who provides exercise programs on a volunteer basis.
Making a Difference: Historically, the Health Department provides health education to the community. The coalition anticipates that other agencies will initiate the other aspects of the program, and outside funding will not be needed. The program will measure outcomes based on attendance of programs initially and, in the long run, will reevaluate the health statistics.
Beginnings:
The program was
initiated in
Challenges and Solutions: This program is still in its infancy. Major challenges have not been encountered because the coalition is made up of individuals who are concerned about the health of their county. As the program matures, issues of funding may surface.
Sheila Russell
4th
Phone: (417) 778-7450