Rural‐serving primary care practitioners’ and cardiologists’ care adaptations for cardiovascular services: A qualitative analysis

Abstract

Purpose

Rural populations in the United States have less access to cardiovascular care relative to their urban counterparts while bearing a higher burden of heart disease. To understand rural patients’ access to cardiovascular care services, we conducted a qualitative study investigating which cardiovascular services rural‐serving primary care practitioners offered, how they adapted care, and what factors influenced cardiovascular scope of practice and adaptations among rural‐serving primary care practitioners and cardiologists.

Methods

We conducted semi‐structured interviews with rural‐serving primary care physicians, advanced practice providers, and pharmacists, as well as cardiologists, in Alaska, Idaho, and Washington state.

Findings

Twenty health care practitioners participated in this study. We identified two themes characterizing cardiovascular services: expanded scope of practice (e.g., primary care physician prescribing a higher‐risk anti‐arrhythmic medication, dofetilide, for atrial fibrillation) and altered care (e.g., cardiologist ordering fewer cardiovascular imaging tests when needed technology was unavailable). Using a socio‐ecological approach, we found factors affecting care adaptations at four levels: local communities; individual practitioners; local clinics and health systems; and the broader health care, law, and policy environment.

Conclusions

When caring for rural cardiovascular patients, primary care practitioners and referring cardiologists expanded their scope of practice and altered care. Multiple factors affected these shifts. Future research could address whether and how expansion of scope of practice (e.g., through team‐based care) may improve access to cardiovascular care among rural populations.

INTRODUCTION

Cardiovascular disease is the leading cause of death in the United States, with rural populations bearing a 40% higher prevalence of cardiovascular morbidity and mortality than urban populations. ¹ Limited access to primary care practitioners ² and cardiologists ¹ may exacerbate these disparities. To mitigate health care workforce shortages in rural and other underserved areas, scope of practice expansion occurs and is supported by health care advocates and policy analysts. ¹ , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² However, most studies on scope expansion examine primary care broadly (e.g., whether care is clinic‐ versus hospital‐based ¹³ ), or focus on non‐cardiology specialties such as obstetrics ⁶ and emergency medicine. ¹⁴ Few studies have addressed how rural‐serving primary care practitioners and cardiologists actually address cardiovascular disease and its risks (but see brief discussions of care for atrial fibrillation, ¹⁵ cardiac stress testing, ⁵ and cardiac care overall ¹⁶ ).

The adaptation of rural cardiovascular care prompts examination of the factors driving such adaptation. Researchers identify multiple contributors to scope of practice expansion in rural and underserved areas. At the practitioner level, individuals trained in rural areas may maintain broader scopes than urban counterparts. ¹³ , ¹⁴ Similarly, practitioners’ preference for area of scope (e.g., emergency department care), ¹⁷ and confidence in performing clinical tasks ¹⁵ , ¹⁷ may affect care adaptations.

Beyond individual‐level factors, adaptation is shaped by local community, organizational, and broader health care contexts. Community influences include geography and travel distance to clinics, regional economics, and population health characteristics such as age trends or substance use rates. ¹⁷ , ¹⁸ , ¹⁹ Organizational factors include practice type (e.g., whether rural, federal, urgent care, or safety net), ²⁰ institutional policies on nonphysician scope, ²¹ workplace culture (e.g., collegial support for expanded roles) ¹⁷ , ²¹ and staff skills. ¹⁸ Broader health care factors include workforce shortages ¹⁷ and insurance and possible liability. ¹⁸ , ²² , ²³ In the United States, state‐based agency regulations allowing scope expansion are associated with broader scopes among rural nurse practitioners ¹² and physician assistants/associates. ²⁴ Similarly, state‐level laws and regulations allow pharmacists to play increasingly diverse roles, ²⁵ and regulations for the Indian Health Services and Tribal Nations affect scope of practice. ²⁶

Existing literature demonstrates that multiple levels of social influence impact rural scope of practice. Building on this foundation, we explored not only primary care practitioners’ cardiovascular scope expansion for rural patients but also broader adaptations for rural cardiovascular care by primary care physicians and cardiologists. This wider focus allowed us to highlight additional modifications, competencies, and innovations among practitioners to increase rural access to care. Accordingly, we aimed to (1) examine how primary care practitioners and cardiologists adapted care for rural patients with cardiovascular disease and its risks and (2) identify factors influencing adaptation. Guided by a socio‐ecological model that situates individuals within multiple levels of social context, ²⁷ we sought to clarify how and why adaptations occurred so as to inform future adaptations to address patient and practitioner needs.

METHODS

We conducted this research as part of the Global to Rural Innovation Network (GROW‐Rural) project, which aims to translate global cardiovascular care solutions to US rural‐serving primary care practices and to share local rural innovations internationally. To achieve these aims, we collaborated with the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) Region Practice and Research Network (WPRN), a network of primary care practices throughout the Pacific Northwest and Mountain West that conducts shared research to enhance primary care and patients’ health in their communities.

The research was part of a broader formative needs assessment for rural cardiovascular care. We invited all rural‐serving WPRN practices to participate and purposively sampled affiliated health care practitioners for range of professional experience. ²⁸ For the present analysis, we explored the experiences of rural‐serving primary care practitioners including physicians, advanced practice providers, and pharmacists. We also studied the work of cardiologists to whom the primary care practitioners’ clinics referred patients. Practices were defined as rural‐serving if located in a county with a Rural–Urban Continuum Code (RUCC) ≥ 3. The University of Washington Institutional Review Board (IRB) reviewed the study and certified it exempt from full IRB review.

Data collection

From December 2023 through October 2024, we conducted semi‐structured interviews with health care workers by videoconference or phone and collected demographic survey data via REDCap, a set of online data capture tools hosted at the University of Washington. ²⁹ , ³⁰ Interviews explored the cardiovascular services primary care practitioners offered to rural patients, referral practices to cardiologists, rural–urban practice differences, and how primary care practitioners and cardiologists tailored services to meet rural patients’ needs. We reviewed interview guides and refined them periodically to ensure question relevance and capture emergent themes. Interviews lasted a median of 39 minutes (range 25–59 minutes). We audio‐recorded all interviews with permission and had them transcribed verbatim.

Data analysis

We summarized quantitative data with descriptive statistics and analyzed qualitative data using thematic analysis. ³¹ Research group members (SGM, SB, KBS, AGS, EW, BS, AJ) drafted initial coding memos to summarize and interpret segments of text within transcripts and met as a team to create preliminary codes marking text relating to scope of practice and care adaptation. The first author then developed more detailed subcodes for scope of practice, care adaptation and factors impacting them (e.g., health care providers’ “professional or personal rural background”), applied those codes to all transcripts, refined codes into themes and finalized themes after discussing findings with the team.

Reflexivity/positionality

To ensure representation of relevant perspectives in project design and implementation, the team included social scientists, implementation scientists, and health care practitioners. Furthermore, although interviews were conducted by SGM and SB, who are research staff from an urban academic medical center, these authors and nearly all team members had prior professional and/or lived experience in rural areas. The entire team shared input by commenting on multiple iterations of the interview guide and participating in manuscript review. Our diverse identities and previous experiences sensitized us to a range of social factors that might influence practitioners’ scopes, as well as how our backgrounds might influence our interpretations. Accordingly, we focused on participant perspectives and attempted to treat our own as only starting points for knowledge generation. We also probed in interviews and analysis for convergence and variation in participants’ accounts, so as to prevent focusing on a predetermined narrative.

RESULTS

We included 20 practitioners in this analysis including primary care physicians (50.0%), advanced practice providers (15.0%), pharmacists (15.0%), and cardiologists (20.0%). Participants’ mean age was 45.0 years (standard deviation: 11.5) and most participants were women (60.0% women and 40.0% men). All participants identified as white and one as Hispanic or Latino. Participants worked in primarily rural clinical sites, with RUCCs ranging from 3 (25.0%) to 8 (40.0%). Participants’ demographic characteristics are listed in Table 1.

TABLE 1.

Study participant demographics (N = 20).

Characteristic	N (%)
Profession
Primary care physician	10 (50.0%)
Advanced practice provider (physician assistant/associate or nurse practitioner)	3 (15.0%)
Pharmacist	3 (15.0%)
Cardiologist	4 (20.0%)
Mean age in years (SD)	45.0 (11.5)
Gender
Man	8 (40.0%)
Woman	12 (60.0%)
Race a
White	20 (100.0%)
Whether Hispanic/Latino a
Yes	1 (5.0%)
Rural–Urban Continuum Code (RUCC) of health care workers b
3: Metro—counties in metro areas of fewer than 250,000 population	5 (25.0%)
4: Nonmetro—urban population ≥ 20,000, adjacent to a metro area	3 (15.0%)
7: Nonmetro—urban population of 5000–20,000, not adjacent to a metro area	4 (20.0%)
8: Nonmetro—urban population < 5000, adjacent to a metro area	8 (40.0%)

Abbreviation: SD, standard deviation.

^a We invited participants to choose as many Census 2020 racial and ethnic categories as applied to them.

^b We assigned RUCCs to participants according to the primary care sites with which they affiliated.

Our participants cared for patients at six rural‐serving primary care clinics that were part of four larger health systems. Each health system was comprised of at least one site housing a cardiology practice located in an urban area and one or more rural‐serving primary care clinics, all owned or managed within a single organization.

We list two sets of themes resulting from our analysis in Table 2, including rural‐serving practitioner practice patterns for cardiovascular care and factors influencing these practice patterns.

TABLE 2.

Themes in rural‐serving practitioner practice patterns for cardiovascular care and influences on practice patterns.

Theme	Definition/subthemes	Example quote
Rural‐serving practitioner practice patterns for cardiovascular care
Expanded scope of practice for cardiovascular care among primary care practitioners	Offering services that a cardiologist might undertake in an urban setting	“[I offer] day‐to‐day … [management] of atrial fibrillation, heart failure—these are patients in an urban setting that would probably be managed by a heart failure clinic or a cardiologist's office.” —Primary care physician
Altered services for cardiovascular care among primary care practitioners and cardiologists	Tailoring services to meet the needs of rural patients and align care with available resources	“I think I depend much more on my clinical acumen since I don't have advanced tests to confirm the diagnosis. … Your history and physical, you depend more on that.” —Cardiologist
Influences on practice patterns
Local community	Social determinants of health (e.g., patients’ access to transportation, income, and access to safe, affordable housing)	“Transportation is a huge issue for our patients, and so trying to do as much as we can locally is really important in order for them to get the optimal workup and care that they need.” —Primary care physician
	Patient preferences for care	“Oftentimes the patients … prefer not to travel…, and so that definitely impacts our decision on what we end up managing … [and] there's the trust. We have the relationship with them. And I think for the most part, they obviously would rather see somebody they know and trust, instead of just getting referred to somebody they don't know.” —Primary care physician
Health care practitioner	Professional or personal rural background	“[I learned in my prior rural practice] how to be lean with your resources and cost‐aware of what you're doing as well. I don't want to say ‘MacGyvering,’ but the ability to shift and use what you have to treat patients.” —Primary care physician
	Prior education	“Once I started meeting my patient population here, I quickly saw a gap in my knowledge, which I also very promptly filled. I took a lot of extra classes, did a lot of extra CE [continuing education] for it.” —Pharmacist
	Beliefs about race	“We have the tribal population with generations of trauma from outsiders and stuff. And so how to embrace a population and bring them into a medical system where none of their own individuals are represented is almost an impossible task.” —Primary care physician
Clinic and health system	Intra‐organizational practitioner connections	“We have great relationships with our cardiologists, so they've taught me a lot, just over the phone … They also are here and have a clinic … one or two days a month. So they're also available for questions on management.” —Primary care physician
	Explicitly supporting expanded scope of practice in activities	“We've aligned for patient care and continuity sort of a team or a pod approach where two or three of the physicians will generally pair with one of the APPs [advanced practice providers] to be more useful. And so for instance, with my APP, I'll see the patients and come up with a treatment plan and then the follow‐ups can be with them.” —Primary care physician
	Offering training	“A lot of … [our rural health trainees’] time is spent in the emergency department … Almost every … [trainee] has experiences of an acute MI [myocardial infarction] or a cardiac event walking through the door … and in the rural setting, providing evidence‐based standards of care, connecting with a cardiologist at the tertiary center, transferring for acute MI cath [cardiac catheterization] …, and then on the other end accepting that patient and doing it there.” —Primary care physician
	Organizational culture	“If you have someone who promotes professional collaboration, that's a culture that trickles down to everyone else. I have my doctorate as a PharmD, and the respect that I receive here is, ‘Oh, this is our doctor of pharmacy. This is Dr. [X].’ So there's a lot of peer‐to‐peer appreciation.” —Pharmacist
	Providing equipment for cardiovascular care	“We have a lot of the imaging at our disposal that's needed … We can efficiently get people scheduled for echos [echocardiograms], Holter monitors, those sorts of things.” —Advanced practice provider
Broader health care, law, and policy environment	Shortage of workforce, equipment and medication	“I toe the edge of my scope of practice here, where I'm doing more than what an urban [advanced practice provider] would be, because we don't have the specialists available just down the hall sort of thing, or down the street, around the block, to even just consult with in passing.” —Advanced practice provider
	Reimbursement by insurers	“I haven't had success with being able to prescribe a PCSK9 inhibitor [medication] before. I've had to get them [the patients] physically to cardiology.” —Advanced practice provider
	Connections between clinic and other organizations	Connection to a practice‐based research network “helps us drum up the idea for quality improvement projects, scholarly activity, and some evidence‐based medicine.” —Pharmacist
	Law, policy, and programs that act as supports or barriers to expanded scope of practice	“I have full prescriptive authority here underneath the collaborative drug therapy agreement. So patients … frequently get referred to me … and then I end up helping manage that disease state, either in collaboration with the primary care physician or also on my own.” —Pharmacist

Rural practitioner cardiovascular care practice patterns

We identified two themes in practice patterns among rural‐serving practitioners offering cardiovascular care to characterize how practitioners adapt services and clinical care to meet rural patients’ needs and respond to resources available in the rural context.

Expanded scope of practice for cardiovascular care among primary care practitioners

Primary care practitioners reported having a broad scope of practice for cardiovascular care, offering services that they believed a cardiologist might provide in an urban setting. For example, primary care physicians and advanced practice providers completed diagnostic workups and management for cardiovascular issues before cardiologists could see patients. Sometimes, workups involved studies that cardiologists would perform or supervise in other settings, such as echocardiograms, stress testing, and Holter monitoring.

Usually, by the time we send patients to the cardiologist, we've done the workup for the most part, in terms of the treadmill or the nuclear study. We essentially have them all packaged up when they go to the cardiologist.

—Primary care physician

After diagnosis, primary care physicians and advanced practice providers offered expanded services in the form of day‐to‐day management of chronic cardiovascular illnesses including hypertension, heart failure, atrial fibrillation, angina, and coronary artery disease. As part of these services, they prescribed and administered guideline‐directed medical therapy for heart failure and higher‐risk anti‐arrhythmic medications. Similarly, pharmacists offered medical management for patients. Primary care physicians also offered procedures that would typically be performed and/or supervised by urban cardiologists, such as electrical cardioversions.

[I offer] day‐to‐day … [management] of atrial fibrillation, heart failure—these are patients in an urban setting that would probably be managed by a heart failure clinic or a cardiologist's office.

—Primary care physician

Rural primary care physicians cared for patients in the hospital. In the emergency department, these doctors treated myocardial infarctions, sometimes by administering thrombolytics and preparing patients to be medically transported to a cardiac catheterization lab that might be hours away. When patients with primary cardiovascular indications needed inpatient care, primary care physicians routinely admitted and managed them in the hospital.

Not only do we admit them [patients] to the hospital if they have chest pain we're trying to work up and decide whether or not it's cardiac‐related, we also, if there is an MI [myocardial infarction] occurring, for example, in the ER, we do push thrombolytics.

—Primary care physician

Altered services for cardiovascular care among primary care practitioners and cardiologists

Cardiologists and primary care practitioners displayed what we call “altered” care when they adapted services beyond expanding scope of practice for cardiovascular care to meet rural patients’ needs and align care with available resources. These adaptations included mastering new forms of technology, honing clinical acumen to work in resource‐limited settings, and acquiring skills typically associated with other non‐medical practitioners.

At most study sites, cardiologists offered altered care through visiting or telehealth services, or by modifying diagnosis or treatment methods. Visiting services involved cardiologists travelling a few days per month or less frequently to rural clinics for in‐person service, while telehealth included cardiologist and primary care practitioner videoconference or phone consultations with patients as well as interprofessional consultations between cardiologists and primary care practitioners. One clinic also offered remote heart failure case management. Altered diagnosis might entail greater reliance on patient history rather than cardiac catheterization testing.

I think I depend much more on my clinical acumen since I don't have advanced tests to confirm the diagnosis. … Your history and physical, you depend more on that.

—Cardiologist

Altered treatment might include offering to implant a left atrial appendage closure device to reduce the risk of blood clotting in place of prescribing a blood thinner. This shift would occur because a patient taking a blood thinner might be at risk of bleeding in a location far from medical care, or they might not be able to make the routine monitoring visits required when taking such medications.

With atrial fibrillation, so you have to be on a blood thinner, typically, … to reduce the risk of strokes. That's not necessarily an ideal situation. … We have people that live very remotely, that can live in these villages that they're almost by themselves in the wintertime and they're going out hunting and things like that. So there's risk of injury and bleeding. … And so I have a much lower threshold to offer them alternatives than being on a blood thinner.

—Cardiologist

Practitioners also altered care by offering services that other non‐medical professionals otherwise might. Primary care practitioners sometimes offered informal social work or care coordination services, such as finding food or housing assistance, or assessing social determinants of health (non‐medical factors influencing health and well‐being).

To be a complete holistic provider for your patients, in particular with cardiovascular disease and the risk factors that I mentioned, we have to be exploring … [social determinants of health].

—Primary care physician

Influences on practice patterns

We used a socio‐ecological approach to characterize key influences in the social environment shaping practitioners’ scope expansion and care adaptation. We begin with local community influences and follow with health services‐related influences.

Local community

At the local level, participants most often discussed the effect of transportation and geography on patients’ ability to access care. Patients lived in remote or mountainous locales without public transportation, lacked reliable transportation of their own, or experienced winter ice and snow, all of which made traveling to clinics difficult. In response, clinicians would expand or alter services to reduce patients’ travel burden.

Transportation is a huge issue for our patients, and so trying to do as much as we can locally is really important in order for them to get the optimal workup and care that they need.

—Primary care physician

Other community influences included patients’ limited income, health literacy, and access to safe, affordable housing, as well as health issues such as substance use. As one nurse practitioner noted, many patients were “struggling so much that it's hard to get to talking about their heart health.”

In response, practitioners assessed and addressed social determinants of health, at times by doing the work of case managers or social workers. Primary care practitioners also expanded their scope to address cardiac emergencies, or altered care by, for example, prescribing more affordable generic medications to low‐income patients rather than brand‐name drugs.

[Patients] don't have the finances nor the means to getting these medications that are recommended. … We've had to prescribe medicines that are not grade A recommendation because they're cheap and generic.

—Pharmacist

Patients’ preferences about how far they wanted to travel and their trust in specific providers shaped rural practice patterns. Primary care practitioners noted that strong patient–provider trust increased patients’ willingness to receive care locally.

Oftentimes the patients … prefer not to travel…, and so that definitely impacts our decision on what we end up managing … [and] there's the trust. We have the relationship with them. And I think for the most part, they obviously would rather see somebody they know and trust, instead of just getting referred to somebody they don't know.

—Primary care physician

Health care practitioner

Practitioners who had previously lived or worked in rural or other underserved settings in the United States or abroad said they had learned to make the most of the means at hand.

[I learned in my prior rural practice] how to be lean with your resources and cost‐aware of what you're doing as well. I don't want to say ‘MacGyvering,’ but the ability to shift and use what you have to treat patients.

—Primary care physician

Experience in resource‐scare settings also motivated practitioners to learn about rural patients’ challenges and appropriately expand their scope of practice. Practitioners reported receiving rural‐ and cardiology‐focused training in medical school, residency, and fellowship, and through continuing education and certificates.

Once I started meeting my patient population here, I quickly saw a gap in my knowledge, which I also very promptly filled. I took a lot of extra classes, did a lot of extra CE [continuing education] for it.

—Pharmacist

Practitioners expressed beliefs about American Indian and Alaska Native (AI/AN) patients and how these might affect their work. Practitioners reported awareness of AI/AN populations’ history and of present inequity in the medical system for those patients, and that therefore work was needed to provide equitable care for AI/AN people. Occasionally, however, stereotyped beliefs regarding AI/AN patients (e.g., that AI/AN patients might be less motivated to care for their health) were expressed in our data.

We have the tribal population with generations of trauma from outsiders and stuff. And so how to embrace a population and bring them into a medical system where none of their own individuals are represented is almost an impossible task.

—Primary care physician

Clinic and health system

Primary care practitioners’ scope expanded when they were physically distant from cardiologists and health systems facilitated connections between the two groups for consults. For example, a cardiology clinic provided a “cardiologist of the day” triage line to its rural affiliate practices that supported learning and collaboration in cardiovascular care.

We have a system for questions and triage here, so it's been not only important for patient access, but also for our relationship with the referring doctors, primary care doctors.

—Cardiologist

Several clinics offered visiting cardiology services with cardiologists traveling to rural sites to offer routine, less complex care. Shared electronic medical records enabled primary care practitioners to learn from cardiologists’ progress notes and instructions, while phone consultations empowered primary care practitioners to manage patients. Multiple individuals described the importance of these connections.

We have great relationships with our cardiologists, so they've taught me a lot, just over the phone … They also are here and have a clinic … one or two days a month. So they're also available for questions on management.

—Primary care physician

Organizations explicitly supported scope expansion by recruiting practitioners who already had expanded skills, increasing advanced practice provider staffing, and using advanced practice providers in team‐based care. In multiple clinics, primary care physicians joined pharmacists in collaborative practice agreements allowing pharmacists to prescribe and manage medications, order labs, and provide patient education.

We've aligned for patient care and continuity sort of a team or a pod approach where two or three of the physicians will generally pair with one of the APPs [advanced practice providers] to be more useful. And so for instance, with my APP, I'll see the patients and come up with a treatment plan and then the follow‐ups can be with them.

—Primary care physician

Organizations supported scope expansion through training, including rural‐focused undergraduate medical education, residency and fellowship programs, grand rounds on cardiology advances, and rural cardiovascular care‐specific instruction.

A lot of … [our rural health trainees’] time is spent in the emergency department … Almost every … [trainee] has experiences of an acute MI [myocardial infarction] or a cardiac event walking through the door … and in the rural setting, providing evidence‐based standards of care, connecting with a cardiologist at the tertiary center, transferring for acute MI cath [cardiac catheterization] …, and then on the other end accepting that patient and doing it there.

—Primary care physician

Organizational culture influenced scope of practice. Practitioners at sites offering training highlighted a “culture of learning,” openness to new techniques, and drive to enhance quality as organizational characteristics that supported evaluation and adoption of scope expansion. Advanced practice providers and pharmacists also noted that professional courtesy from colleagues and reduced hierarchy in relationships supported their expanded roles.

If you have someone who promotes professional collaboration, that's a culture that trickles down to everyone else. I have my doctorate as a PharmD, and the respect that I receive here is, ‘Oh, this is our doctor of pharmacy. This is Dr. [X].’ So there's a lot of peer‐to‐peer appreciation.

—Pharmacist

Investment in technology for cardiovascular care in rural clinics provided support for primary care practitioners to expand their practice scope. Primary care physicians and nurse practitioners at rural sites reported that, when available, they used equipment such as echocardiograms, electrocardiograms, Holter monitors, and treadmills.

We have a lot of the imaging at our disposal that's needed … We can efficiently get people scheduled for echos [echocardiograms], Holter monitors, those sorts of things.

—Advanced practice provider

Broader health care, law, and policy environment

At the broader health care, legal, and policy level, primary care practitioners primarily expanded scope in response to local shortages of cardiologists, equipment, and medications. Since the wait time for a cardiology appointment could be several months, practitioners reported providing advanced care management before patients could be seen by a cardiologist.

I toe the edge of my scope of practice here, where I'm doing more than what an urban [advanced practice provider] would be, because we don't have the specialists available just down the hall sort of thing, or down the street, around the block, to even just consult with in passing.

—Advanced practice provider

Practitioners also found themselves hindered by policies and practices within the broader health care environment. For example, nonphysician practitioners sometimes faced more difficulty obtaining insurance coverage for medications they prescribed rather than physicians did.

I haven't had success with being able to prescribe a PCSK9 inhibitor [medication] before. I've had to get them [the patients] physically to cardiology.

—Advanced practice provider

At the same time, other health care organizations enhanced practitioners’ scope through connections to their clinics. Acting as a training site, such as serving as a continuity clinic for medical residents, was one such connection. Other connections included hosting clinicians from partner organizations to provide specialized services onsite, such as advanced heart failure care, as well as involvement in a practice‐based research network to link to new means of care.

[Connection to a practice‐based research network] helps us drum up the idea for quality improvement projects, scholarly activity, and some evidence‐based medicine.

—Pharmacist

A final key factor in expanded scope of practice was that in the US states where participant clinics were located, scope of practice regulations allowed expanded scopes for nurse practitioners, physician assistants/associates, and pharmacists. These practitioners reported they were able to provide health care services that physicians offered elsewhere, delivering comprehensive care through task shifting.

I have full prescriptive authority here underneath the collaborative drug therapy agreement. So patients … frequently get referred to me … and then I end up helping manage that disease state, either in collaboration with the primary care physician or also on my own.

—Pharmacist

DISCUSSION

Scholars and advocates have described scope of practice expansion as important for meeting rural health care needs, ¹ , ³ yet few studies have examined how it unfolds in cardiovascular care among rural‐serving primary care practitioners or how cardiologists adapt rural care. The present analysis addressed how rural‐serving primary care physicians, advanced practice providers, pharmacists, and cardiologists adapted cardiovascular care, and it suggested factors that may contribute to adaptations.

We found that primary care practitioners and cardiologists adapted care to address rural patients’ needs. Rural‐serving primary care practitioners expanded their scope of practice for cardiovascular care, offering services that a cardiologist might offer elsewhere, a practice that may help address rural health care shortages. This result is consistent with other literature finding that rural primary care providers expand their scope. ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² Our study adds cardiology‐specific detail to this scholarship, addressing scope expansion in both diagnosis and treatment, noting, for example, primary care physicians’ use of stress tests and administration of thrombolytics. We also find that primary care practitioners and cardiologists altered care in other ways to address rural communities’ needs through innovation such as visiting cardiology. These adaptations underscore the scarcity of rural cardiovascular care and clinicians’ creativity in addressing it. Future research could address how such adaptations affect quadruple aim outcomes, ³² and it could explore technologies that enhance rural practitioners’ capacity. For example, artificial intelligence (AI)‐guided ultrasound or AI electrocardiogram risk prediction models might improve access and interpretation of study results.

We identified several factors influencing whether rural‐serving providers would offer expanded or altered cardiovascular services. Consistent with prior studies, practitioner‐level influences included educational background. ¹³ , ¹⁴ , ¹⁷ One novel finding was that prior experience living or working in rural or underserved settings fostered a sense of resourcefulness. Another was that practitioner beliefs about race or patients’ citizenship in AI/AN Nations might positively or negatively influence care practices, suggesting a need to examine how such beliefs affect scope of practice and to develop strategies to reduce bias in care. These findings also point to the importance of investing in rural graduate medical education and rural advanced practice provider education to create a robust rural primary care workforce.

Beyond individual factors, local community circumstances affecting scope included patients’ socioeconomic status, access to reliable transportation, and other social determinants of health. This result is consistent with other literature finding that challenges with income, housing, and reliable transportation affect rural populations. ¹ , ³³

Clinic‐ and health system‐level influences shaping scope of practice included intra‐organizational linkages between practitioners, explicit support for expanded roles, training opportunities, organizational culture, and access to cardiology equipment such as treadmills. Prior research highlights the value of intra‐organizational linkages to improve mentoring and communication between practitioners, ¹⁷ , ²³ and our study adds detail about how such connections develop formally and informally, Further research could examine how these linkages build trust, facilitate education, and support information‐sharing, particularly in rural health care settings. Organizational activities to support expanded scope of practice, such as team‐based care, also warrant continued study. ¹⁷ , ³⁴ Although federal policy for patient‐centered medical homes emphasizes team‐based care, ³⁵ more work is needed to understand how it is implemented in practice and its effects on care outcomes.

Broader health care and government‐level influences supported and constrained practitioners’ practice. Constraints included shortages of cardiologists, medical equipment and medications, and challenges with insurance reimbursement. Supports included interorganizational training partnerships, policies enabling advanced practice providers to expand scope, and collaborative practice agreements between pharmacists and physicians. For primary care practitioners with limited specialist access, leveraging intra‐ and inter‐organizational connections may be vital for scope of practice expansion and merits further study. Even where federal, Tribal, and state laws allow expanded scope of practice, policy and practice within health systems and insurers may still impose limits; examining these factors together could clarify how policy shapes practice. In general, learning from and supporting research into Tribal policies and how AI/AN Nations exercise sovereignty in determining scopes of practice in their health systems would be beneficial.

The study has limitations related to sample composition and geography. All participants identified as white; a more diverse sample might have yielded additional insight into practice experiences. Further, we did not account for variables such as a participant's education level, years of rural practice, and years of cardiovascular care provision, which could influence practitioners’ experiences and expectations. Finally, participants practiced in three US states in the rural Mountain West and Pacific Northwest, where scope of practice laws and contextual factors may differ from those elsewhere. Therefore, our results may not be generalizable to all rural areas around the world.

CONCLUSION

Cardiovascular disease is a significant burden for rural populations, making it critical to understand how primary care practitioners and cardiologists deliver care in these settings. We identified which cardiovascular services rural‐serving primary care practitioners provided, how services were altered, and factors influencing scope expansion across individual, community, organizational, and broader health care, law, and policy levels. Findings suggest activities that may facilitate scope expansion, such as AI‐guided ultrasound or AI electrocardiogram risk prediction models to improve access and interpretation of study results, as well as directions for research, including how team‐based care may affect outcomes and how organizational connections may improve linkages between specialty and rural primary care practitioners.

CONFLICT OF INTEREST STATEMENT

We report no relevant conflicts of interest.

Miller SG, Burchim S, Beima‐Sofie K, et al. Rural‐serving primary care practitioners’ and cardiologists’ care adaptations for cardiovascular services: A qualitative analysis. J Rural Health. 2026;42:e70129. 10.1111/jrh.70129