ENCORE: ElectroNic Consultations for cardiOvasculaR diseasEs in rural community clinics

About This Grant

Project Summary. Cardiovascular disease (CVD) is the leading cause of death in the United States. Rural populations experience increasingly higher rates of CVD and CVD risk factors; from 2010 to 2022, preventable deaths due to CVD decreased 10.2 percentage points in urban populations but increased 9.5 percentage points in rural populations. Specialty care can be essential to CVD management, but rural residents face substantial barriers to accessing specialists such as cardiologists; for example, specialists may be unavailable locally, have long wait times, or only accept privately insured patients. This leaves the care of medically complex rural patients to primary care providers who do not have the specialized expertise that such patients may need. Community-based / rural health centers (CHCs) are the main source of primary care for many rural populations, yet most lack on-site specialists. Electronic consultations (eConsults) offer a promising approach to address this care gap by virtually connecting primary care providers with specialists, reducing the need for patients to see specialists directly. While eConsults have been shown to reduce wait times to specialist input and avoid unnecessary in-person referrals, little is known about uptake of / barriers to eConsult requests in rural CHCs, or how eConsult requests in this setting affect patient outcomes. This study leverages electronic health record (EHR) data from a national network of >2,200 CHCs across 36 states, along with linked Medicaid claims data and interviews from CHC providers and administrators, to address these knowledge gaps and develop effective strategies to increase eConsult use in CHCs. Aim 1 will describe patterns of primary care to specialty provider eConsults for CVD care in rural versus urban CHCs. Aim 2 will identify the impact of eConsult requests on CVD management outcomes, including testing and control of hemoglobin A1c, blood pressure, medication management, and referrals to specialists comparing rural and urban patients. Aim 3a will identify barriers and facilitators to successful implementation of eConsults among urban as compared to rural providers and clinic administrators through provider and administrator interviews. Aim 3b will integrate findings from Aims 1, 2, and 3a to develop an actionable Pragmatic Adoption Guide to eConsults in Rural CHCs. Using a mixed-methods design, integrating quantitative analyses and qualitative interviews, we will triangulate findings to identify strategies that are evidence-based, feasible, and tailored to the rural CHC context. By providing the first large-scale, multi-state assessment of eConsults for CVD in rural safety net clinics, this project will generate urgently needed evidence on how eConsults are used, how they influence care, and what strategies can improve their uptake and impact. As rural hospitals close, direct access to specialists will likely become more scarce for rural patients. Understanding how eConsults can alleviate those challenges may improve the health of those patients.