UCSF Fresno Vascular and Cardiology Physicians Screen Patients in Central Valley “Cardiovascular Deserts”

Heart and vascular screening team including UCSF Fresno's Leigh Ann O'Banion, MD, (left, first row) and Teresa Daniele, MD (second from right, first row).

Leigh Ann O’Banion, MD, a UCSF Fresno vascular surgeon, and Teresa Daniele, MD, a UCSF Fresno cardiologist and division chief of cardiology, have developed an innovative outreach program to bring cardiovascular education, screenings, testing and care to rural Central San Joaquin Valley residents.

Rural patients have factors that put them at risk for peripheral artery and heart disease, such as diabetes, obesity and high blood pressure. These characteristics, along with high rates of poverty, limited access to health care and insurance, are obstacles to good health. Screening for cardiovascular risk factors can help prevent disease, and testing for early signs of disease can improve health literacy and aid in early intervention. But rural residents are at a disadvantage – they have few sources of preventative care – and even scarcer opportunities for specialty follow-up.

“The Central Valley is extremely devoid of primary care, in addition to multi-specialty care, so just getting the patients plugged into primary care is a challenge,” says Dr. O’Banion. And Dr. Daniele adds: “It’s kind of overwhelming how much care these patients need and how devoid of services they are.”

Drs. Daniele and O’Banion, professor of Clinical Medicine and associate professor of Surgery at UCSF Fresno, respectively and Central California Faculty Medical Group (CCFMG) physicians share an interest in community outreach. The pair teamed last year to develop a cardiovascular health outreach “toolkit” with funding help from CCFMG and with an educational grant Dr. O’Banion received from Abbott, a global health care company that manufactures medical devices for cardiovascular conditions. Dr. Daniele has brought her outreach experience from 10 years of organizing a free UCSF Fresno Women’s Health Fair, and together they designed an outreach model to address health literacy, health education and health access for rural patients who live within what the physicians refer to as “cardiovascular deserts.”

Their rural outreach model is drawing attention outside the Central Valley.

“What Leigh Ann (Dr. O’Banion) is doing is not very common,” says Clara Gomez-Sanchez, MD, a UCSF assistant professor of surgery and vascular surgeon in San Francisco. “There have been some (heart health) outreach things like this before, but not for vascular care; vascular screening has not been a part of that,” she says. “This is something Leigh Ann is making from scratch.”

For cardiovascular outreach to be meaningful, Drs. O’Banion and Daniele say it must go beyond free screenings and testing but include enrollment in health insurance and connection to a primary care provider. Health education is particularly important for patients; and there must be continuing cardiovascular medical education for rural primary care physicians to foster their interest in cardiovascular screenings and testing.

“It’s not, ‘let’s just give you your risk,’” Dr. Daniele says of the services provided at outreach events. “This is start-to-finish, it’s full circle.”

Drs. O’Banion and Daniele say partnering with community organizations has been instrumental in reaching patients and tailoring outreach services to them. Community organizations know where the outreach event should be held to reach the most residents with the most needs. One of their events, for example, was held at a food bank on a day when the food insecure came to receive groceries.

“Teresa (Dr. Daniele) and I have learned so much in doing outreach in these communities, not only understanding that they need cardiovascular care, but just how disadvantaged as a whole they are,” Dr. O’Banion says.

At their first outreach event at the Raisin Day festival in Dinuba last September, most of the patients (51.1%), were Hispanic, as compared to 36% in statewide vascular deserts and 37.1 in non-deserts. Of all patients screened, 45.5% were 200% below poverty level as compared to 39.6% in statewide “vascular deserts” and compared to 35.2% in non-deserts, according to a report by UC Davis. Drs. O’Banion and Daniele are partnering with UC Davis to map out rural Central Valley communities in highest need of cardiovascular care.

UC Davis looked at eight social determinants of health in Dinuba – economy, education, health care access, housing, neighborhoods, clean environment, transportation and social environment – and Dinuba fell below in all eight factors that correspond to healthier community conditions as compared to statewide vascular deserts and non-deserts. And in Dinuba, 51.1% of the patients were Hispanic, as compared to 36% in statewide vascular deserts and 37.1 in non-deserts.

Dr. Daniele says 30% of their patients at the first outreach event were undiagnosed with diabetes. “And just being diabetic itself is a cardiovascular risk equivalent, meaning if you have diabetes, we already assume you’ve had a heart attack or will have one, if not, you have or will have blockage in the legs if left untreated.”

The physicians say they are learning and adapting their outreach model all the time to meet the needs of patients. For example, health literacy has become particularly important to consider. The physicians created an easy intake form to be filled out in English or Spanish – “but we didn’t appreciate a lot of patients are illiterate,” Dr. O’Banion said. “I really underestimated how disadvantaged this patient population was,” she said. “We had to rethink the way we approached these patients and had to kind of modify how we ran these outreach efforts to make them fit the patient population that we were reaching.”

Health education also is lacking in the communities. Many of the patients do not know that obesity puts you at risk for having a heart attack, or the importance of diet, the importance of knowing your blood pressure and knowing what your family history is in terms of risk factors, Dr. O’Banion says.

At their first outreach event, Drs. O’Banion and Daniele noted many of the patients had no insurance and no primary care provider. For their second event, they employed someone to be on site to help patients enroll in Medi-Cal, the state-federal government insurance program, and to help patients find primary care providers at a federally qualified health center.

This also involved educating patients who have only gone to an urgent care or the emergency room for serious illness of the importance of having a primary care physician. “It really is educating that prevention is key, and you need to see the doctor even if you are feeling fine,” Dr. Daniele says. “That is a whole new concept for some.”

Patients at outreach events have expressed gratitude for the health education and health screenings. At the Raisin Festival in Dinuba, people waited patiently in searing hot weather to be screened for diabetes, high blood pressure, cholesterol and to talk with the physicians. “They were just extremely receptive to anything they could get, which makes it all worthwhile,” Dr. Daniele says.

Providing cardiovascular education, screenings and testing for patients in rural Central Valley communities, has deepened Dr. O’Banion’s commitment to continuing, and hopefully expanding, cardiovascular outreach.

“Honestly, it’s been the most humbling experience of my life,” Dr. O’Banion says.