For many, quality and advocacy means an annual trip to Washington, DC, to share challenges of the day-to-day practice of medicine with policymakers, or a local project to improve quality metrics at their home hospital. However, when I moved to Portland, ME, for fellowship training, I learned in providing care to patients scattered over hundreds of square miles of countryside that quality and advocacy can assume another layer of complexity. Beyond the typical challenges of dealing with payors to ensure coverage for care and medication, rurality presents a series of complexities – and opportunities – that take on an outsized role.

For the urban and suburban patient populations served by many fellowship programs, running water and electricity are a given. Access to sidewalks, parks or walkways that enable outdoor exercise is ubiquitous. Catheterization laboratories are frequently located within a few miles and occasionally across the street from each other. Going to cardiac rehab might involve a few stops on the bus or train.

In contrast, Maine's cardiac patient population often present in extremis to the emergency department of a small critical access hospital. Access to acute cardiovascular care often involves an ambulance ride of several hours or a flight of up to several hundred miles. The nearest cardiac rehabilitation program might require a full morning's drive from their home. Services we often take for granted – such as transvenous pacemaker insertion – are frequently unavailable at outlying hospitals. Thrombolysis remains a mainstay for the treatment of STEMI, an approach which is largely of historical interest to those practicing in a more urban environment.

To provide high-quality and reliable cardiovascular care throughout the state, it is imperative to consider aspects of care that extend beyond acute hospitalization – from the initial onset of symptoms to the ultimate transition to home. Moreover, it is essential to effectively coordinate among the entire system of care, which extends well beyond emergency medical services (EMS) and the hospital to frequently include several EMS crews and at least two hospitals.

As a part of this effort to effectively deliver care to a widely distributed population, Thomas J. Ryan, Jr., MD, FACC, director of the MaineHealth STEMI network, runs an ongoing outreach effort for emergency medical technicians and emergency physicians within the catchment area. Out of this effort, one of the programs we are most excited about is the possibility of direct helicopter transfer for primary PCI. In this program, patients with a qualifying electrocardiography are brought directly to a waiting helicopter rather than stopping at the closest hospital, effectively expanding the territory covered by primary PCI to a much larger part of the population. Another initiative that Ryan pursued involves keeping the initial ambulance that delivers a patient with chest pain to an outside hospital on site while the emergency physicians conduct their first assessment. This would enable the expeditious transfer of the patient if the decision is made to give thrombolysis or escalate to a higher level of care.

These programs require cardiologists to think about a wide array of logistical variables that they are not necessarily accustomed to considering, such as weather, aircraft availability and helipad occupancy. However, in this environment, they are essential to delivering patients the best opportunity to achieve optimal outcomes and can make the difference between a primary PCI approach and thrombolytics.

Additionally, challenges associated with delivering high-quality care to a rural population manifest outside of the acute setting. For example, we have recently confronted decisions about the implantation of a left ventricular assist device in a patient living "in the woods" without running water and electricity. Despite challenges with deploying such complex devices so far from the hospital, we continue to find success managing patients several hours away using a combination of frequent phone calls and close collaboration with the primary care physicians. Someday, these efforts may also be supported by advanced telecommunications that support "e-visits."

After an acute episode, we strive to ensure access to a formal cardiac rehabilitation program for every patient, no matter how far they live from Portland. This is achieved in part through a rehabilitation nurse, who is able to bridge the geographic gaps from the tertiary care they receive in Portland to the small outlying hospitals where the nearest rehabilitation programs are located.

Rurality certainly presents many challenges to delivering high-quality care across the continuum – from the initial presentation to a small outside hospital to the patient's return home. However, in Maine, a close consideration of these barriers have created opportunities to improve access to proven therapies, no matter the geographic distance from Portland.

This article was authored by Morgan Kellogg, MD, cardiology Fellow in Training (FIT) at Maine Medical Center in Portland, ME.