Abstract
The Coronavirus 2019 (COVID-19) pandemic created disruptions in usual medical care delivery for
cardiovascular and cerebrovascular disease (CVD) across the U.S. that could have devastating downstream
effects long after COVID-19 is controlled. COVID’s “spillover” could manifest via delays in presentation,
disruptions to acute care, deferral of usual outpatient care, and negative health effects of economic conditions
and worsening social risk.
Older adults living in rural areas experience worse CVD outcomes than their urban counterparts, and may be
particularly vulnerable to each of these spillover effects, particularly if they also live in poverty or are members
of racial or ethnic minority groups. Rural older adults may also have less access to potential mitigation
strategies, such as inpatient and outpatient telehealth, restarting elective procedures under new precautions,
and reaching out to patients proactively to manage chronic disease. However, because the rural population is
smaller, and less-often included in commercial and health system databases, this group is understudied. It is
crucial to understand COVID spillover in rural areas in order to counteract it.
The central premise of this proposal is that understanding the magnitude of COVID’s spillover effects on CVD
in rural areas, as well as the impact of key mitigation strategies, will enable us to deal with future waves of this
pandemic, with other outbreaks in the future, and with challenges to rural care delivery more broadly. We will
use national Medicare claims data, which allows us near-complete, long-term capture of clinical care and
outcomes for roughly 70% of older adults in the US, to achieve three Aims:
Aim 1: Quantify COVID spillover effects on a monthly basis in the first 12 months of the pandemic, and
characterize the use of spillover mitigation strategies, among rural compared to urban areas.
Aim 2: Quantify the short- and long-term clinical effects of delay and disruption of acute care in rural versus
urban areas, and determine if mitigation strategies reduced negative impacts of spillover.
Aim 3: Quantify the short- and long-term clinical effects of deferral of chronic care and worsening social risk in
rural versus urban areas, and determine if mitigation strategies reduced negative impacts of spillover.
The proposed work will provide national estimates of how COVID spillover and its mitigation strategies were
associated with clinical cardiovascular and cerebrovascular outcomes among older rural adults, and allow
successful strategies to be deployed in the future. It will also quantify whether access to these strategies was
equitable among rural individuals living in poverty or those who identify as racial or ethnic minorities, enabling
future efforts to monitor and achieve equity goals.