Practice-based cardiovascular research in rural primary care: research priorities and implementation insights

Abstract

Background

Cardiovascular disease is the leading cause of death in the United States, and cardiovascular mortality is higher in rural areas than in urban areas. However, innovations in cardiovascular care are typically produced in urban areas where social structures and culture can differ from those of rural areas.

Methods

From 2023 to 2024, we surveyed rural-serving primary care health care workers and cardiologists (n = 31) and rural patients (N = 14) in Alaska, Idaho, and Washington about their priorities for cardiovascular health services and disease research in rural areas. We also conducted semi-structured interviews with 27 of the health care workers we surveyed to explore their prior experiences with barriers to and facilitators of intervention implementation. We summarized the quantitative survey results with descriptive statistics and write-in responses using content analysis. To analyze the qualitative interview results, we used thematic analysis.

Results

The highest rated research priorities focused on developing data sharing systems for rural clinics and hospitals and strengthening regional connections to support cardiovascular care. Patients also prioritized increasing health insurance coverage in rural communities. Both patients and health care workers rated studying the use of telemedicine and digital tools as their lowest priority but wrote in various technology-related topics as top research priorities. When evaluating key influences on previous implementation experiences, the interview participants highlighted factors including the need for time, money, and dedicated staff to run interventions; organization and provider buy-in; opportunities to partner with other organizations; and the importance of considering patients’ perspectives and needs.

Conclusions

Rural patients and rural-serving health care workers prioritize cardiovascular research areas that are patient-focused, focus on technology that is feasible in the rural context, and aim to increase resources in rural communities. Funding for rural health care and improving rural healthcare provider shortages remain key issues. However, partnering with other organizations may be a means to support intervention implementation in rural clinics.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12875-026-03451-x.

Introduction

Cardiovascular disease is responsible for one in every five deaths in the United States (U.S.) [1], and cardiovascular mortality rates are higher in rural areas than in urban areas [2]. Many rural communities are characterized by high community connectedness [3], yet rural–urban disparities in cardiovascular mortality have grown in recent years [4], largely due to trends in social factors such as poverty, education, and food and housing insecurity [5]. People living in rural communities also have higher rates of cardiovascular risk factors than people living in urban communities, including diabetes, obesity, tobacco use, and hypertension [6–9]. There are less cardiologists per capita in rural than urban areas and the rural cardiologist workforce is older than their urban counterparts [10]. The shortage of cardiologists is projected to worsen in the coming years as older cardiologists retire and there are not enough cardiologists to replace them [11]. Rural primary care providers play an integral role in preventing and treating heart disease; however, there is also a lower per capita supply of primary care providers in rural areas than in urban areas [12].

The confluence of increasing cardiovascular mortality and the growing cardiologist workforce shortage highlights the need for rural primary care clinics to find innovative solutions to educate patients, provide care to reduce risk, and detect and treat heart disease. However, research is primarily performed in academic health centers, which are mostly concentrated in urban areas [13]. Because of this, innovations in research are informed primarily by urban residents, urban health systems, and urban infrastructure, and adaptation or additional research is often needed for evidence-based intervention implementation in rural settings, widening the implementation gap.

In rural areas, geographic isolation can impede implementation [14, 15], making it difficult for patients to access a clinic and take advantage of an intervention [16]. Other barriers found in rural areas may not be unique to rural places, such as time constraints faced by staff [17], staff turnover [18], difficulty accessing innovations [14, 17], or challenges with buy-in from clinicians and staff [17]. Primary care practice-based research networks (PBRNs) exist as “groups of primary care clinicians and practices working together to answer community-based health care questions and translate research findings into practice” [19]. The practice-based nature of PBRNs allows them to center community participation in research by researching health issues that matter to their patients and health care workers [20]. This approach fosters health equity by including patients in the process of shaping a research agenda [21] and facilitating implementation research to understand barriers and facilitators to adapting evidence-based interventions to community-specific contexts [22].

Therefore, to begin to address disparities in cardiovascular health and care while supporting equity in intervention implementation, in this study we aimed to (1) identify local priorities for cardiovascular research in rural primary care practice members of a PBRN and (2) explore practice-level barriers and facilitators to implementing such research. We collected survey data on health care workers’ and patients’ priorities for research, as well as semi-structured interview data on practitioners’ prior experiences with implementing new programs, changes to workflow, or participating in research. Together, these data bridge the identification of local research priorities and implementation by informing the operationalization and equitable adaptation of cardiovascular interventions within rural primary care practices.

Methods

Study aims, design, and setting

The present analysis was part of the Global-to-Rural Innovation Network (GROW-Rural), an implementation research project designed to (1) adapt and implement globally sourced, evidence-based cardiovascular interventions in collaboration with rural primary care practices in the U.S. and (2) to share results with health care workers elsewhere in the world. To understand the social context and needs of the rural locales where our projects would be implemented and to ensure that interventions would be equitably adapted, the aims of the present analysis were to understand (1) rural and rural-serving health care workers’ and rural patients’ priorities for research on cardiovascular care and (2) health care workers’ prior experiences implementing research, quality improvement, or other new interventions, especially those related to cardiovascular care.

The setting for this research was the rural Pacific Northwest and Mountain West of the U.S. We carried out the study in partnership with the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region Practice and Research Network (WPRN), a primary care PBRN of rural and urban clinics, and clinical organizations located in the five-state WWAMI region. We invited all rural and rural-serving WPRN member clinics to participate, as well as cardiology practices that saw patients referred from those clinics. We considered a practice rural or rural-serving if its Rural Urban Continuum Code (RUCC) [23] was ≥ 3. Although RUCC 3 counties are classified as metropolitan, we drew this distinction because small metropolitan practices frequently serve as regional referral sites for patients living in outlying rural communities. The Institutional Review Board (IRB) of a public research university in the WWAMI region reviewed the study and certified it as exempt from full Board review.

Selection eligibility criteria

At each clinic that agreed to participate, we invited health care workers to complete surveys and interviews, using the purposive strategy of “sampling for range” [24]: that is, we designed our sample to include a range of professions and attempt to maximize variation in response by including primary care physicians, cardiologists, advanced practice providers (physician assistants/associates and nurse practitioners), pharmacists, nurses, and social workers. We used quotas to ensure adequate representation of the various professions and avoid over-representation from one profession. WPRN practice champions who were health care workers at participating sites identified and recruited other workers and their own patients to participate in the research, and we invited them to participate in interviews as well. Health care workers were recruited in person, via email, and by phone.

Patient participants included adults age 18 years or older who were receiving care through the participating clinics during the period of the study and living with heart disease or who had been identified as having risk factors for heart disease. Patients were included if they met any of the following medical criteria: heart failure with reduced ejection fraction, atherosclerotic cardiovascular disease (history of myocardial infarction, prior coronary intervention, ischemic stroke, or peripheral artery disease), and/or one or more select cardiovascular disease risk factors (diabetes, Body Mass Index ≥ 30, tobacco use, treated hypertension, or high cholesterol). Patients were identified by their clinicians participating in the study or research staff through review of electronic medical records. Patients also were required to live in an area with RUCC ≥ 3 or self-identify as rural. Patients were recruited in person, by email, by phone, and by mail.

Data collection

We conducted a convergent parallel mixed methods formative assessment via surveys and individual interviews, with integration of qualitative and quantitative findings in the discussion to provide a comprehensive analysis. Data were collected concurrently and analyzed separately prior to integration.

We developed and administered a survey to health care workers and patients to gather demographic data and assess respondents’ priorities for rural cardiovascular health. The survey included 9 questions on rural cardiovascular health services research priorities, which were drawn from an American Heart Association (AHA) call to action to address rural-urban cardiovascular inequity but do not necessarily represent the AHA’s priorities (see Table 2 for topics) [2]. Each item proposed a possible area of research related to the improvement of cardiovascular care in rural areas that addressed known barriers to and facilitators of cardiovascular care implementation in rural areas (e.g., “developing rural-specific care team models”), asking the respondent to rate the topic’s priority from low (1) to high (10) via a visual analog scale. The survey also included a single open-ended question asking participants what additional research topics they would prioritize for cardiovascular research. The survey was designed to identify cardiovascular research priorities among patients and health care workers within participating clinics, with the goal of informing locally relevant research planning rather than to produce generalizable estimates.

Table 2.

Rural patient and rural-serving health care worker mean rural cardiovascular research priority ratings

Topic	Patient	Health care worker	Overall
Developing data sharing systems for rural health clinics and the hospitals where patients are referred	8.0	8.3	8.2
Developing regional connections between organizations to support cardiovascular care	8.6	7.8	8.0
Studying funding models for rural-serving hospitals and clinics	8.5	7.6	7.9
Studying ways to increase the number of people with health insurance in rural areas	8.7	7.3	7.7
Developing research strategies to address the shortage of rural health workers	8.1	7.4	7.6
Economic development to support healthcare infrastructure	8.0	7.2	7.5
Developing rural-specific care team models	7.5	7.1	7.2
Studying the use of rural-specific care sites	7.8	7.0	7.2
Studying the use of telemedicine and digital tools for health care	6.5	7.0	6.9

All health care workers completing the survey also were invited to complete an interview with questions about how they had implemented new interventions in the past to provide additional details about day-to-day real-world implementation of projects and the context in which implementation occurred. We developed an original interview guide, piloting it with five participants and updating it periodically to investigate developing themes and ensure question applicability. While interviews primarily focused on other topics related to care for cardiovascular patients in rural communities, we also asked the interview participants to describe their experiences with implementing new programs, changing workflows, or conducting quality improvement or research, with a focus on cardiovascular-related experiences when they could recall them. These data are the focus of the present analysis. Please see Additional Files 1 and 2 for relevant survey and interview questions.

We collected data from December 2023 through October 2024. We administered surveys online, on the phone, and on paper, inviting participants to choose the means, depending on their preference. Online surveys were administered via REDCap, a set of online data capture tools hosted at the University of Washington [25, 26]. Paper surveys were added as an option in March 2024 to increase patient enrollment. We administered paper surveys via postal mail and provided participants with a pre-addressed, stamped envelope to mail the survey back to our study team.

Two study team members [SB and SGM], research scientists (both women) who were trained in qualitative data collection and analysis and had professional experience conducting research with people living in rural communities, conducted semi-structured interviews. No personal relationship was established with participants prior to the study. Participants were told the interviewers’ roles in the study and read an informed consent script that stated the purposes of the study to understand their perspective on innovations for rural and rural-serving practices and to use the data to design and implement interventions to help patients of clinics like theirs. For virtual interviews, participants provided verbal consent (including permission to record), which was reconfirmed at the start of the recording session. To avoid predetermined judgments about participants, the interviews were designed to elicit a range of responses, with interviewers focusing on participant perspectives and seeking to identify data that might challenge our initial interpretations.

Interviews were conducted by videoconference or phone, audio-recording with participants’ agreement, and participants were encouraged to be in private rooms while interviewed for their privacy. Interviews were transcribed verbatim; participants were not given transcripts for correction or comment but were given a chance to provide comment at a meeting to discuss findings held approximately midway through data collection. Participants were provided with a $25 incentive for each study component they completed (survey and interview) in the form of a gift card. There were no repeat interviews, and field notes were not taken. No participants withdrew.

Data analysis

We used Microsoft Excel (Microsoft 365, Version 2507) for data analysis. Categorical data (e.g., demographic data) were analyzed using descriptive statistics and presented as frequencies and percentages. Write-in survey responses addressing rural cardiovascular research priorities were analyzed using content analysis to identify additional research topics and emergent themes [27]. We analyzed the interview data with a thematic analysis approach [28], facilitated by ATLAS.ti (version 25), including inductive coding to maximize attention to issues as expressed by participants. One team member [SGM] constructed emergent codes for the data that summarized and interpreted segments of text, drawing on all transcripts, and then developed a set of broader themes based on those codes, incorporating both into an initial codebook. Analysis proceeded with data collection and reached saturation. A second study team member [SB] reviewed the analysis, suggesting additional themes, and then the two analysts discussed the relative importance of the various themes and refined all codes and themes into a final codebook, organized into a table (in place of a code tree). The first analyst then used this final codebook to ensure that the codes were applied consistently to all transcripts. The larger study team then discussed results and commented on drafts. A final step in our analysis was to synthesize shared findings from the surveys and interviews, which we present in our discussion. We integrated findings by assessing whether there was overlap in which topics participants reported as important in the survey and interviews, and if so, how the qualitative results might provide insights to explain quantitative findings.

To assess the reporting of the qualitative study, we used the Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist (see Additional File 3) [29].

Results

Survey participant demographics

A total of 48 participants enrolled in the study by completing the survey, including 17 patients and 31 health care workers, representing seven different clinics, most of which were part of critical access hospitals. Three patient participants declined to answer any research priorities questions and were omitted from our sample. Most health care workers in our study were women (71%), but there was greater gender parity in our patient sample (50% women). Participants largely identified their race as white (93% patients; 90% health care workers), and, in response to a separate question on Hispanic/Latino ethnicity, more patients than health care workers identified their ethnicity as Hispanic/Latino (21% patients; 3% health care workers). The average patient age was nearly 20 years older than the average health care worker’s age (68.5 years of age for patients; 49.0 years of age for health care workers). Nearly two-thirds of the participants resided in Idaho or were affiliated with a clinic in an area with a RUCC of 7 or 8 (both 60%). 86% of patients did not have a college degree and reported a range of household incomes (Table 1).

Table 1.

Demographic characteristics of rural patients and rural-serving health care workers

Characteristic	Patient, % (N)	Health care worker, % (N)	Overall,% (N)
Total	14	31	45
Participant type
Cardiologist	--	13% (4)	9% (4)
Primary care physician	--	23% (7)	16% (7)
Advanced practice provider	--	10% (3)	7% (3)
Pharmacist	--	10% (3)	7% (3)
Nurse	--	16% (5)	11% (5)
Social worker/care coordinator	--	13% (4)	9% (4)
WPRN Practice championa	--	16% (5)	11% (5)
Patient	100% (14)	--	31% (14)
Gender
Man	50% (7)	29% (9)	38% (17)
Woman	50% (7)	71% (22)	62% (28)
Raceb
American Indian/Alaska Native	7% (1)	0% (0)	2% (1)
Asian	0% (0)	3% (1)	2% (1)
Native Hawaiian or Other Pacific Islander	0% (0)	3% (1)	2% (1)
Black or African American	0% (0)	3% (1)	2% (1)
White	93% (13)	90% (28)	91% (41)
Other	7% (1)	0% (0)	2% (1)
Ethnicity
Hispanic/Latino	21% (3)	3% (1)	9% (4)
Age
Mean age in years (SD)	68.5 (14.7)	49.0 (11.6)	55.2 (15.5)
Education (patient only)
12th grade or less	14% (2)	--	--
Completed high school or GED	29% (4)	--	--
Some college, no degree	43% (6)	--	--
Bachelor’s degree	7% (1)	--	--
Did not answer	7% (1)	--	--
Income (patient only)		--	--
$0 - $29,999	29% (4)	--	--
$30,000 - $69,999	24% (4)	--	--
$70,000 - $99,999	0% (0)	--	--
$100,000+	21% (3)	--	--
Did not answer	21% (3)	--	--
State of residencec
Alaska	14% (2)	13% (4)	13% (6)
Idaho	64% (9)	58% (18)	60% (27)
Washington	21% (3)	29% (9)	27% (12)
Rural-Urban Continuum Code (RUCC)d
3 – Metro - Counties in metro areas of fewer than 250,000 population	21% (3)	23% (7)	22% (10)
4 – Nonmetro - Urban population of 20,000 or more, adjacent to a metro area	21% (3)	16% (5)	18% (8)
7 – Nonmetro - Urban population of 5,000 to 20,000, not adjacent to a metro area	14% (2)	19% (6)	18% (8)
8 - Nonmetro - Urban population of fewer than 5,000, adjacent to a metro area	43% (6)	42% (13)	42% (19)

^aThe WWAMI region Practice and Research Network is a primary care PBRN of rural and urban clinics and clinical organizations located in the 5-state WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region. WPRN Champions are also health care workers and may be counted twice

^bParticipants could select more than one race

^cThe state of residence was different than the location where some health care workers practiced

^dCorresponds to the RUCC of the location of the affiliated clinic with which the participant was affiliated

Research areas

Patient and health care worker average Likert scale ratings (1 low priority to 10 high priority) of the rural cardiovascular research priorities are displayed in Table 2. The three topics with the highest mean ratings were “developing data sharing systems for rural health clinics and the hospitals where patients are referred” (8.2), “developing regional connections between organizations to support cardiovascular care” (8.0), and “studying funding models for rural-serving hospitals and clinics” (7.9). “Studying the use of telemedicine and digital tools for health care” was the only topic with a mean rating below 7 (6.9). Mean ratings for “studying ways to increase the number of people with health insurance in rural areas” diverged between groups, with a mean of 8.7 among patients and 7.3 among health care workers. “Studying the use of telemedicine and digital tools for health care” had the lowest mean rating among items assessed with an overall average rating of 6.9, and ratings of 6.5 and 7.0 by patients and health care workers, respectively.

Summary results from patient and health care worker survey write-in responses identifying cardiovascular health research topics that participants believed were important to study in rural areas are presented in Fig. 1, with exemplar quotes. We identified three overarching research topic areas: technology-related, patient-focused, and resource-related. Technology-related research topics included focusing on patient access to telemedicine, making use of existing technology, providing remote access to cardiac rehabilitation, and comparing the effectiveness of remote cardiology consults to that of in-person cardiology care. Patient-focused topics emphasized prevention, education, and trust, including resources for patients to promote lifestyle changes to prevent disease, education on recognizing the signs of cardiac conditions (i.e., heart attack and stroke) and how they may differ for men and women, and patient trust in health care workers. Resource-related topics centered workforce needs and equipment including research on improving reimbursement for health care workers, methods for recruiting cardiologists to rural communities, and increasing the availability of defibrillators in rural areas.

Fig. 1.

Cardiovascular health research topics that rural patients and rural-serving health care workers identified as important

Interview participant demographics

A total of 27 health care worker survey respondents also participated in semi-structured interviews. Demographic characteristics for the subset of respondents completing interviews mirrored that of the larger sample (i.e., most interviewees were women (70.4%), with an average age of 48 years (standard deviation 12), and almost all were white (92.6%), with one who was Black/African American and one who was Latino/Hispanic). Participation by profession also was similar, with the largest grouping being primary care physicians, as was rurality. Interviews ranged in length from 25 to 59 min (median 39 min). Interviewees came from all seven participant clinics.

Interview emergent themes: factors affecting implementation

Six emergent themes characterize these data (Table 3).

Table 3.

Emergent themes: factors affecting implementation

Emergent themes: definitions	Exemplar quotes
Time, money, and dedicated staff to implement intervention: The importance of time, money, and dedicated staff to implement a new intervention	Providers “are so pressed for time and for billing, and you have to see, whatever, X amount of patients a day, and get through your day – to try to add on more work … is very difficult. Then they might have one person that already has a full-time job and then they’ll tack on this additional responsibility, which is still going to take a back burner to their primary job. So they don’t have the resources that they need to successfully implement this.” – Pharmacist “We do have a small research department of a handful of people, and actually they’re quite helpful when we get them [to help with an intervention]” – Cardiologist
Organization and provider buy-in: The importance or process of getting buy-in from health care workers and/or organization leaders to implement the intervention	“Usually the falter is getting the approval for that financial burden that … [the larger organization of which the clinic is part], they ultimately say yay or nay, where for us, we are all on board, but we have to get the okay financially from it. So, that’s what usually slows the process down.” – Advanced practice provider “And then I think giving up control for some providers is also I think a little bit hard. So a provider saying, ‘Okay, I’m going to let this nurse manage the hypertension part of my panel to a certain extent,’ some providers have a little bit of hard time giving up medication management. So I think that would be a barrier.” – Primary care physician
Education for staff, patients on the intervention protocol: Education for staff or patients related to the research or implementation protocol as well as communicating that the service is available within the organization	“I think the biggest issue that we have dealt with is it is more work to take an accurate blood pressure in our clinic now and every six to 12 months, some of our staff kind of get … busy or preoccupied by other things and don’t follow what they should to get accurate blood pressures.” – Primary care physician “I’m a huge fan of simple, one-page algorithms … especially if there are new changes from what [providers are] used to, new medications or new procedures.” – Pharmacist
Establishing workflows and acquiring or committing needed resources: Needing or establishing plans for workflows, how changes will be implemented in electronic medical record, how needed technology or space will be acquired or committee	For a hypertension intervention, “…getting [patients] access to the right [blood pressure] cuff that we know is in good functional shape and they record twice per day and send their readings in to us [is very important].” – Advanced practice provider For a new intervention to work, it is important to know “how this change is going to be implemented in the electronic medical record, and who’s going to be responsible for that, and how is it going to affect workflow” –Primary care physician
Considering patients’ perspectives and needs: Health care workers’ considerations of an intervention and how it does/does not improve access or care for a patient	“I think what went well [with that intervention] is we had the ability to have, particularly my girls, seen by a therapist in the same clinic where they got their primary care.” – Social worker “My patients are older, many of them are kind of hearing impaired, right? So it [a new intervention’s technology] needs to be a fairly simple technology that doesn’t require exceptional auditory acuity.” – Cardiologist
Partnering with other organizations: Working with other organizations to acquire funding or run the intervention	“We’re working in a collaboration …, and so that’s been huge. It was like [the other organization] set up the entire structure of the program. We’re working with multiple clinics to learn from each other’s experiences, and we meet, someone meets with them once or twice a month and at the start of the program and then a little less frequently as that’s been ongoing.” – Advanced practice provider “And part of what made that successful was that it had an ECHO component to it … [A partnering university’s physician faculty member] did case reviews with us and he was just a really approachable person but kept leading us to what we needed to do.” –Primary care physician

Time, money, and dedicated staff needed to implement an intervention

The participants described how the time, money, and dedicated staff needed to implement an intervention substantially affected their ability to adopt new interventions. Given health care workforce shortages in rural areas, particularly of workers with advanced formal training such as cardiologists and primary care physicians, participants reported that they were stretched thin as they tried to meet patients’ needs. There were, participants said, already more patients than they could see with the staff their clinics had. Money also was tight in our participant clinics, many of which were part of critical access hospitals, as noted above. Therefore, health care workers found they were very busy in clinic and lacked resources to start a new effort. New projects might not get the support and resources needed to be successful, and new efforts might be forgotten amid the pursuit of existing priorities. However, when time, money, and dedicated staff had been made available for past interventions, those interventions more often proceeded as planned. In addition to the importance of clinical staff, the availability of research and quality improvement staff in particular was valued.

Providers “are so pressed for time and for billing, and you have to see, whatever, X amount of patients a day, and get through your day – to try to add on more work … is very difficult. Then they might have one person that already has a full-time job and then they’ll tack on this additional responsibility, which is still going to take a back burner to their primary job. So they don’t have the resources that they need to successfully implement this.” – Pharmacist.

“We do have a small research department of a handful of people, and actually they’re quite helpful when we get them [to help with an intervention]” – Cardiologist.

Organization and provider buy-in

Health care workers identified how organization and provider buy-in influenced the implementation of new interventions. To approve and start an intervention, organizations’ administrators might want to assess its feasibility and financial viability. Once an intervention had begun, organizations’ administrators might need time to work out issues such as billing. Beyond the logistics of finances, our participant rural clinics faced financial pressures such as heavier reliance on lower-reimbursing public payors including Medicare and Medicaid, which may have impacted their ability to take on new projects. Since study clinics also were typically part of larger health systems, our participants noted, multiple layers of decision-making around uptake of new interventions sometimes impacted the speed of implementation. At the same time, not only organizational leadership but also providers might need to be convinced or incentivized to participate in an intervention. For example, for a project focused on team-based care to address workforce shortages, some health care workers wanted to be shown the value of realigning their roles around shared responsibilities.

“Usually the falter is getting the approval for that financial burden that … [the larger organization of which the clinic is part], they ultimately say yay or nay, where for us, we are all on board, but we have to get the okay financially from it. So, that’s what usually slows the process down.” – Advanced practice provider.

“And then I think giving up control for some providers is also I think a little bit hard. So a provider saying, ‘Okay, I’m going to let this nurse manage the hypertension part of my panel to a certain extent,’ some providers have a little bit of hard time giving up medication management. So I think that would be a barrier.” – Primary care physician.

Education for staff and patients on the intervention protocol

The participants discussed education for staff and patients on the intervention protocol. Participants believed that, for an intervention to work, staff and patients needed to be educated on the intervention protocol. Staff might need multiple educational sessions over time, and they might benefit from having short, easy-to-follow algorithms for intervention protocols, in part because there could be a learning curve as colleagues adjusted to using a new workflow consistently. However, given the busyness of our participant clinics, health care workers faced the organizational challenge of finding time to do this training. In addition, participants reported that intervention leaders should consider how various individuals in a given clinic communicated so that everyone would learn about new protocols (e.g., some staff might not check e-mail very often, others might not learn about an intervention unless an effort was made to reach them).

“I think the biggest issue that we have dealt with is it is more work to take an accurate blood pressure in our clinic now and every six to 12 months, some of our staff kind of get … busy or preoccupied by other things and don’t follow what they should to get accurate blood pressures.” – Primary care physician.

“I’m a huge fan of simple, one-page algorithms … especially if there are new changes from what [providers are] used to, new medications or new procedures.” – Pharmacist.

Establishing workflows and acquiring or committing needed resources

To begin a new intervention, participants believed that a necessary step was establishing workflows and acquiring or committing needed resources. Participants observed that shifts in workflows were common and expected, as knowledge of best practices was always being updated. However, the logistics of changes could still be challenging, including how the efforts of clinicians and other staff members would be allocated, needs and services would be documented in the electronic medical record, billing would occur, and other services would be affected. For cardiovascular interventions, participants wanted home blood pressure monitoring tools such as cuffs to give to low-income patients, particularly as their patient populations frequently faced resource constraints and chronic heart conditions. Participants also reported the need to commit space in the clinic for tools.

For a hypertension intervention, “…getting [patients] access to the right [blood pressure] cuff that we know is in good functional shape and they record twice per day and send their readings in to us [is very important].” – Advanced practice provider.

For a new intervention to work, it is important to know “how this change is going to be implemented in the electronic medical record, and who’s going to be responsible for that, and how is it going to affect workflow” –Primary care physician.

Considering patients’ perspectives and needs to ensure their access to care

Participants spoke of considering patients’ perspectives and needs to ensure their access to care. As safety net providers for vulnerable populations, the participants believed in addressing access-related issues, including attending to specific cardiovascular issues, co-morbidities, or social determinants of health present in the local patient population. These issues included, for example, patients having to travel long distances to reach the clinic, being older, or having cultural values of accepting care from known, trusted providers, and therefore preferring local providers to referrals to unknown providers. Past interventions had been successful in meeting these ends when they had involved helping patients monitor their conditions as well as making services more geographically accessible to patients, for example, by co-locating services to reduce patients’ travel burden. Another means of providing patient-centered care had included employing a care coordinator who developed relationships with patients over time and could act as a central connection between patients, insurers, and local and referring providers.

“I think what went well [with that intervention] is we had the ability to have, particularly my girls, seen by a therapist in the same clinic where they got their primary care.” – Social worker.

“My patients are older, many of them are kind of hearing impaired, right? So it [a new intervention’s technology] needs to be a fairly simple technology that doesn’t require exceptional auditory acuity.” – Cardiologist.

Partnering with other organizations

To implement new interventions, partnering with other organizations was often necessary, as collaborations addressed rural clinic workforce shortages, financial challenges, and technology gaps. Foundation and corporate partners offered funding and program support. Other health care organizations, such as university partners and a health care consulting firm, offered opportunities for translational and other research, connections for patient referrals and specialty care by telemedicine, and education on cardiovascular care and other topics. A Project Extension for Community Healthcare Outcomes (ECHO) educational series, for instance, provided tele-mentoring that connected urban specialist teams to rural primary care providers to empower local primary care providers to address specific health issues such as opioid use [30]. Most often participants viewed these connections positively.

“We’re working in a collaboration …, and so that’s been huge. It was like [the other organization] set up the entire structure of the program. We’re working with multiple clinics to learn from each other’s experiences, and we meet, someone meets with them once or twice a month and at the start of the program and then a little less frequently as that’s been ongoing.” – Advanced practice provider.

“And part of what made that successful was that it had an ECHO component to it . [A partnering university’s physician faculty member] did case reviews with us and he was just a really approachable person but kept leading us to what we needed to do.” –Primary care physician.

Discussion

Understanding the context in which an intervention will be implemented is important for achieving equitable outcomes for people living in that context [31, 32]. To better understand the context of rural primary care practice and promote equitable translation of cardiovascular research to that practice, we investigated health care workers’ and patients’ priorities for cardiovascular research and health care workers’ prior experiences of intervention implementation.

When rating rural cardiovascular health services research priorities via survey, participants on average rated all priorities higher than 6.0, suggesting that all topics were at least moderately important to participants. Research priorities addressing a range of known implementation barriers and facilitators (e.g., economics), workforce shortage and care structuring (e.g., in teams) were the highest rated in our study, including “developing data sharing systems for rural health clinics and the hospitals where patients are referred,” “developing regional connections between organizations to support cardiovascular care,” and “studying funding models for rural-serving hospitals and clinics.” Write-in rural cardiovascular health services topics addressed technology, resources, and patient perspectives and needs.

Patient-focused research was important to participants as evidenced by the write-in rural cardiovascular health services research topic responses. Both patients and health care workers highlighted an interest in research on education for patients. One possible way to increase trust is to meaningfully engage patients in the research process [20]. Patient engagement in the research process also helps produce research that is compatible with both patients’ and health care workers’ needs [33], and many frameworks are available that encourage patient involvement in research [34]. In rural communities, community engagement throughout the research process has been associated with improved recruitment, participation, and trust [35]. Such engagement may also help ensure that technology-related and other interventions are aligned with the priorities of rural communities.

Although telemedicine and technology-related research topics were the most frequent write-in responses, studying the use of telemedicine and digital tools for health care was the lowest rated research priority. This suggests that there could be a disconnect between the types of telemedicine and digital health research currently being conducted and the telemedicine and digital health priorities of rural primary care clinics. This point was underscored by the respondent (exemplar quote in Fig. 1), who wrote about making use of available technology instead of “thinking too big and failing to ever start.” Additionally, these findings could indicate that participants interpreted the survey question on studying the use of telemedicine and digital tools as separate from their own ideas on researching how to increase access to telemedicine, researching the effectiveness of telemedicine, using technology that is available in the rural context, and using technology to deliver cardiac rehabilitation. This underscores the importance of rural patients and health care workers as part of the research agenda-setting process to clarify what is important to people living and working in rural communities [36]. Furthermore, understanding past implementation experiences could guide the development of telemedicine and digital health innovations to ensure equitable implementation in rural settings [21, 22].

When asked in semi-structured interviews about past experiences with implementing research, quality improvement, or other new interventions, health care workers discussed the need for time, money, and dedicated staff to run interventions; the importance of organization and provider buy-in; the value of partnering with other organizations; and the importance of considering patients’ perspectives and needs. Health care workers also emphasized that introducing new interventions necessitated education for staff and patients to implement protocols adequately and the need to establish workflows and documentation, as well as acquire and commit needed technology and space [37].

Ensuring availability of funding and health care workers for rural clinics was important to our survey and interview respondents not only as a subject for further research but also as a means of ensuring that research and quality improvement projects would be implemented in rural clinics. Relatedly, participants prioritized research into increasing the number of people with insurance coverage. Acute shortages of funding, health care workers, and insurance are well-known barriers to rural health care [2]; our results point to the need for action-oriented, sustainable funding supporting infrastructure and workforce retention that aligns research with rural health services’ financial and workforce realities. These conclusions are consistent with those of other scholars [38, 39] who highlight the need for funding models supporting service delivery alongside research activity. In addition, a novel finding of the present study was that limited funding and a lack of health care workers also may have slowed or prevented organizational change and improvement. Funding for infrastructure and workforce would provide necessary “organizational slack,” a safety margin of resources beyond the minimum that allows organizations to respond effectively to environmental pressures [40]. Implementing innovative projects aimed at addressing financing and workforce issues are key means of responding to rural environments.

Survey and interview responses highlighted developing partnerships with other organizations as priorities for research and necessary for successful research implementation. Interviewees noted past important collaborations as means to address barriers to change, including foundation, corporation, university, and health care consulting firm linkages. Support through these connections included referrals, telemedicine, education, research, and funding [14, 31, 41]. In rural environments where there are funding, workforce, and resource limitations, networks provide essential support at many levels of implementation. This finding corresponds to existing literature arguing that rural health communities of practice, practice networks, and embedded research facilitate mentorship, shared learning, and funding support [42–45]. Building on this existing qualitative work and commentary, we suggest that organizational partnerships’ impact on rural health infrastructure and rural health equity are topics that merit further research, particularly with quantitative methods.

Though our qualitative analysis used inductive codes to attend to the meanings that participants assigned to their experience, it aligns with constructs from the Consolidated Framework for Implementation Research (CFIR 2.0) [37]. The CFIR is an evidence-based framework using five domains and more than 70 constructs to outline barriers and facilitators known to influence implementation. For example, the inductive theme of time, money, and dedicated staff to implement an intervention mapped to CFIR constructs related to the availability of funding and an adequate workforce (i.e., innovation cost, local conditions, financing, work infrastructure, and available resources), as well as the prioritization of an intervention within an organization. These constructs spanned the CFIR’s Inner Setting, Outer Setting, and Innovation domains, which characterize levels of context influencing implementation. The alignment of inductive themes with CFIR constructs in multiple domains reinforces the credibility of our findings. It also points to the importance of support for implementation at multiple levels of context within the organization and outside of it, as other researchers also have found [14, 15, 32].

Limitations

We note the following limitations. First, because our research was led by a team including a PBRN whose study participants were members, participants’ responses describing experiences with that PBRN may have been more positive in tone than they would have been otherwise. Second, our study sample consisted primarily of white participants. Although this lack of diversity tracks with the population of the counties in which participant clinics were located, a more diverse sample might have provided a wider range of responses and further supported our aim to promote health equity. To address these issues, we are expanding this research to include rural minoritized patients and the clinics serving them. We also note our relatively small survey sample size (n = 45 total respondents; 31 health care workers and 14 patients) as a limitation as it limits generalizability of these findings. Rather than representing broader rural patient or health care worker populations, these data provide insight into the cardiovascular research priorities of patient and health care workers within participating clinics and should be interpreted as exploratory.

Conclusion

Rural‒urban cardiovascular health inequities will not be solved without an understanding of the impact of the rural context on research conduct and intervention implementation. Rural patients and rural-serving health care workers prioritize cardiovascular research areas that are patient-focused, focused on technology that is feasible in the rural context, and aim to increase resources in rural communities. Improving funding to rural clinics and increasing access to insurance to patients, as well as increasing the supply of health care workers, remain key concerns. Improving connections between organizations shows promise to promote change.

Abbreviations

AHA

American Heart Association

CFIR

Consolidated Framework for Implementation Research

PBRN

Practice-Based Research Network

RUCC

Rural-Urban Continuum Code

WWAMI WPRN

Washington, Wyoming, Alaska, Montana, and Idaho region Practice and Research Network

Authors’ contributions

SB and SGM contributed equally to this manuscript. SB analyzed and interpreted quantitative and qualitative data and was a major contributor in writing the manuscript. SGM analyzed and interpreted qualitative data and was a major contributor in writing the manuscript. AC, MZS, SE, RG, MAG, CGJ and KM contributed to acquisition of data. CTL was a major contributor to design and contributed to revisions. KBS, AGS, BS, EW, AJ, MZS, CTL, and RTB contributed to qualitative analysis and revisions to the work.

Funding

This publication was supported by the American Heart Association / https://doi.org/10.58275/AHA.23HERNPRH1150364.pc.gr.173735 / University of Washington School of Medicine / 2026. Support for the WPRN is provided by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1 TR002319. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or American Heart Association.

Data availability

The questionnaire and quantitative data tables are available from the authors upon reasonable request. To preserve the confidentiality of participants, qualitative data cannot be shared.

Declarations

Ethics approval and consent to participate

The research was conducted in accordance with the standards of the Belmont Report, U.S. Common Rule (45 Code of Federal Regulations 46, Subpart A), and the Helskinki Declaration. Informed consent to participate was obtained from all participants. The University of Washington Institutional Review Board (IRB) reviewed the study and certified that it was exempt from full IRB review (reference ID STUDY00018300). All the participants received an explanation of the purpose of the research and the research process.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.