Improving utilization of guideline directed medical therapy and structured exercise interventions in individuals with intermittent claudication in a rural setting

Dartmouth-Hitchcock Clinic, Lebanon NH

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Abstract

This research aims to improve utilization of guideline-directed medical therapy (GDMT) and structured exercise therapy (SET) for individuals with intermittent claudication due to peripheral artery disease (PAD) in rural settings. Despite strong evidence supporting comprehensive care including pharmacotherapy, risk factor modification, and exercise interventions, these treatments remain critically underutilized, with fewer than 50% of patients receiving GDMT and less than 10% participating in SET. While barriers to implementation have been identified in urban settings, little is known about the unique challenges facing rural patients with PAD. The project employs a multi-method approach with three specific aims: (1) identify the population of PAD patients in northern New England who are or are not receiving comprehensive evidence-based claudication management through electronic health record data analysis; (2) assess facilitators and barriers to GDMT and SET through semi-structured qualitative interviews with both patients and providers; and (3) evaluate the feasibility and acceptability of a commercially available mobile appbased structured exercise program among individuals with claudication in rural communities. The research will utilize expertise from the Center for Rural Health Care Delivery Science, the Dartmouth Center for Program Design and Evaluation, and the Dartmouth Center for Implementation Science to ensure methodological rigor and contextual relevance. The project introduces several innovative elements to address rural healthcare challenges, including development of a computable phenotype to consistently identify patients with claudication from electronic health record data, creation of a novel interview guide to explore the unique barriers and facilitators in rural settings, and systematic evaluation of mobile health interventions in this population. Implementation science frameworks and methodologies are central to this work, particularly the use of the Consolidated Framework for Implementation Research (CFIR) to guide the evaluation of the mobile health intervention. The project will assess implementation outcomes including acceptability, adoption, feasibility, and fidelity of the intervention, providing valuable insights into the contextual factors that influence implementation success in rural settings. Through rigorous implementation science methods, the findings will bridge the gap between evidence-based practices and their real-world application in rural healthcare delivery systems, addressing one of the most persistent challenges in cardiovascular care.