Case Study: Rural Healthcare Inequities

The theme of this edition of LipidSpin addresses disparities in healthcare affecting our rural communities, with a focus on  access to specialists treating lipid disorders. These inequities are not new, but amplified by the current COVID-19 pandemic.

The state of Oklahoma is a good example of these disparities, as the patients in rural communities are often provided medical care by overburdened medical providers who have little time to learn about the diagnosis and treatment of lipid disorders. In rural Oklahoma healthcare, it is typical to see the “urgent care only” concept of medical delivery for “sick care” rather than preventive healthcare. 

Advancing healthcare equity throughout the medical profession will involve a coordinated and dedicated approach. This edition of LipidSpin can bring awareness to the difficulties that patients living in rural communities face, and also provide healthcare workers in rural areas the resources to educate patients.

This case demonstrates one of many examples showing how patients in rural settings are often treated differently, and also have different interests and capabilities regarding access and interest in healthcare opportunities. 

CASE STUDY:
The patient is a 44-year-old white male. He is a law-enforcement officer from a community with a population of 50,000, approximately 85 miles from a large metropolitan city in Oklahoma. He
was referred to the Central Oklahoma Early Detection Center (COED) by his physician assistant. The patient has a history of diabetes, hypertension, obesity,  obstructive sleep apnea, and had a coronary artery calcium score of 77. This score indicates a mild coronary calcific plaque burden. In view of developing plaque at the patient’s young age, risk factor modification was strongly advised.(1,2) He did not have a significant family history of premature coronary artery disease. A paternal grandfather had a myocardial infarction, age unknown.

He had recurrent pancreatitis, thought to be associated with high triglycerides.

When first evaluated in clinic, his medications included atorvastatin 80 mg daily, fenofibrate 48 mg daily, lisinopril 5 mg daily, metformin 1000 mg twice daily, over-the-counter omega-3 fatty acids 4000 mg daily. 

He presented with his most recent lab results showing a hemoglobin A1c of 9.7% and stated this was an improvement. He was unconcerned about his diet. His presenting triglyceride level was 3,452 mg/dL, total cholesterol was 258 mg/dL, HDL-C was 26 mg/dL, and lipoprotein(a) [Lp(a)] was 309 nmol/L. Less than 75 nmol/L is optimal for lipoprotein(a), 75-125 nmol/L is moderately elevated, and greater than 125 nmol/L is high.

His Apolipoprotein B (ApoB) was only slightly elevated at 101 mg/dL (optimal is less than 90 mg/dL), suggesting that most of his ApoB containing lipoproteins were ApoB48 containing chylomicrons. Most of his ApoB 100 lipoproteins were contained on his Lp(a). Glucose drawn in our clinic upon his presentation was 419 mg/dL, and hemoglobin A1c was 10.4%.

The genetic studies were done by Phosphorous Genetics lab. This testing was far less expensive than the other laboratory studies done. The patient had agreed to a cash pay option with the lab which made this testing affordable.

The following genotypes were identified:

KIF6 variant is well known to the lipid community. The clinical response is unknown; however, patients with this gene type are thought in some studies to be at higher risk for ASCVD. They may require a particularly high dose of statin treatment.(3)

The APOA5 gene encodes the apolipoprotein A-V which is involved in determination of plasma triglycerides levels. Mutations in APOA5 are associated with autosomal dominant hyperchylomicronemia (MM:144650) and familial hypertriglyceridemia (MM145750).(4) APOA5 was considered to be autosomal dominant, and this patient was heterozygous.

clinic. The author and clinic staff provided him with extensive dietary information from the Familial Chylomicronemia Syndrome (FCS) organization. They provide a book which includes information about diet and resources.(5) He declined seeing a dietitian in his local community due to time constraints. He was started on an SGLT2 inhibitor and pioglitazone. Continuous glucose monitoring was made available but he failed to acknowledge. He was contacted five times by the clinical pharmacist employed by the clinic who offered to work with him on his blood sugars at no cost to him. He had a very restrictive medical insurance program which did not cover our clinic services. He was started on a GLP 1 receptor agonist and was scheduled for close follow-up recognizing there is controversy regarding use GLP1RA in patients with a history of pancreatitis.

His physician assistant started him on basal-bolus insulin regimen prior to his return visit. Numerous services involving his diabetes care, nutrition, lifestyle and medications were offered and the patient declined, claiming the clinic was too far away, the medication too costly, and lifestyle changes too challenging. Further he worked night shifts as a law enforcement officer which limited his daytime availability.

Several cardiologists practice in his community. These cardiologists would not consider the patient a candidate for their clinical practice as he did not yet have clinically significant coronary artery disease. Consequently, the COED clinic staff communicated with the astute and caring physician assistant who referred him initially to COED.

This case is an example of the structural, financial, and social drivers of health inequities. In our patient specifically, cost, time, and access to the specialized care were identified barriers. The obstacles
to patient care and prevention of chronic disease are great in rural communities.
To address these inequities, the COED Center, as described, has developed a partnership with the providers in these distant communities and involves the patient’s primary care provider by sending educational materials, via a mass email messaging service. These are short documents, usually two paragraphs, with the intent to keep health care providers succinctly abreast of information regarding treatment strategies in clinical lipidology.

As leaders in clinical lipidology, the members of the National Lipid Association have an opportunity to play a prominent role in healthcare equity. NLA members are encouraged to foster relationships with rural healthcare providers, share educational materials from the NLA, as well as offer training programs using venues such as Zoom, Lipid Journal Clubs, and other communication tools, with the goal of optimizing patient care for cardiovascular risk reduction amidst the significant challenges.

Disclosure statement: Dr. Dimick has received honoraria from Amgen.
References are listed in the 2021-2022 Winter LipidSpin .pdf on www.lipid.org