Access to Key Cardiac Services Remains Uneven Across the US

Access to various cardiac services is not the same across all parts of the United States, a new analysis affirms.

Rural areas and regions outside of the Northeast are significantly less likely to have hospitals that provide general cardiology or diagnostic or interventional catheterization services, Gabriel Benavidez, PhD (Baylor University, Waco, TX), and colleagues report in a research letter published in the January 7, 2025, issue of Circulation.

And consistent with prior research, US counties with the highest rates of coronary heart disease mortality also were the most likely to lack a hospital offering those three cardiac services.

“Our findings underscore the urgent need to address structural inequities in healthcare delivery by investing in workforce expansion, telehealth integration, and regionalized care networks to ensure that all communities—regardless of geographic location—have access to lifesaving cardiac care,” Benavidez told TCTMD in an email.

“Moreover,” he continued, “policy reforms, including Medicaid expansion and financial support for rural hospitals, are critical to sustain healthcare infrastructure and reduce financial barriers to care. Improving access to cardiac services in underserved areas is not only a matter of equity but also essential for reducing preventable deaths and improving cardiac outcomes nationwide.”

The researchers note that over the last several decades, coronary heart disease mortality has declined in conjunction with improvements in prevention, diagnosis, and treatment. But many Americans don’t have access to these services, with one study showing that nearly half of all counties didn’t have a single practicing cardiologist.

In this study, Benavidez said, “our primary goal was to focus on vital hospital-based cardiac services (ie, general cardiology, interventional catheterization, or diagnostic catheterization) and determine whether the availability of these services differed across county rurality designations and across geographic regions.”

To find out, they used data from the 2020 American Hospital Association annual survey and the Centers for Medicare & Medicaid Services Provider of Services File to identify which general and community hospitals offered the three cardiac services.

We have to prioritize expanding the rural healthcare workforce through loan forgiveness programs, rural residency training, and financial incentives to attract and retain cardiologists and specialists in underserved areas. Gabriel Benavidez

The analysis included 3,145 counties and 4,419 hospitals (42% in rural areas and 58% in urban areas). Overall, 53.5% of hospitals offered general cardiology services, 43.7% diagnostic catheterization, and 40.7% interventional catheterization.

There were regional variations, however. Urban hospitals, for instance, were much more likely to offer general cardiology services compared with their rural counterparts (72% vs 28%). More than half (52%) of hospitals in the Northeast provided interventional catheterization, which was nearly double the proportion of centers in other parts of the country (28%).

After adjustment, these differences persisted: hospitals in rural versus urban countries were more likely to lack general cardiology (OR 2.88; 95% CI 2.36-3.52), diagnostic catheterization (OR 4.68; 95% CI 3.75-5.85), and interventional catheterization (OR 5.43; 95% CI 4.31-6.86). Compared with centers in the Northeast, those in all other regions were significantly more likely to lack each of the three services.

For the mortality analysis, the researchers looked at county-level coronary heart disease mortality rates from 2018 to 2020 from the Centers for Disease Control and Prevention’s WONDER database, finding that counties in the highest quartile of mortality were significantly more likely to not offer all three services compared with those in the lowest quartile (ORs ranging from 2.25 to 2.73).

“While our findings are not surprising, it is crucial to provide high-quality data demonstrating that these disparities exist and likely contribute to poor cardiac outcomes,” Benavidez said, noting that the poorer access to cardiac services in certain parts of the country is likely due to a combination of geographic, economic, and infrastructure issues. “This evidence is essential to garner the support of policymakers and key stakeholders who have the power to address these challenges and enact policies to combat access disparities.”

In terms of what should be done to address these issues, Benavidez pointed to a call to action on rural health put out by the American Heart Association and American Stroke Association in 2020.

“In line with the recommendations from the paper, we have to prioritize expanding the rural healthcare workforce through loan forgiveness programs, rural residency training, and financial incentives to attract and retain cardiologists and specialists in underserved areas,” he said, adding that telehealth and digital health technologies need to be used to improve access to specialists and diagnostic services for people living in remote areas. Broadband infrastructure needs to be improved to facilitate this.

In addition, “establishing regionalized care networks that connect rural hospitals to larger urban centers can provide timely access to advanced cardiac care without requiring patients to travel long distances,” he said.

And finally, Benavidez said, along with improving financial support for rural hospitals, “it is also vital that we continue to support and fund research and policy development to explore innovative rural healthcare models and flexible payment systems that ensure the long-term sustainability of these efforts.”