Improving Access to Cardiovascular Care in Rural New Mexico

Dr. Amanda Ryan, an interventional cardiologist and owner of Advanced ASC of Carlsbad, New Mexico, shares her experience creating an ambulatory surgery center (ASC). Dr. Ryan's work as a cardiologist is driven by her desire to address health equity concerns and access to care in her community, which has a rural population. She notes, "There's an area out here that probably should be served by six to seven interventional cardiologists and we have two to three." 

Learn more about Dr. Ryan's experience building Advanced ASC and serving patients in New Mexico:

A lightly edited transcript is below.

I am Rebecca Kapur, managing editor with Cath Lab Digest. Today on our Cardiovascular Ambulatory Surgery Center channel, we are going to talk with Amanda Ryan, DO, an interventional cardiologist and owner of Advanced ASC of Carlsbad, New Mexico. Dr. Ryan's work as a cardiologist is driven by her desire to address health equity concerns and access to care in her community, which has a rural population. The New Mexico Department of Health categorizes some of the health challenges that are specific to the state, which include 25% of new Mexicans live at or below the federal poverty level; one in three new Mexicans live in rural areas; and obesity and diabetes among New Mexico youth are disproportionately higher in native and Hispanic populations.

New Mexico is also one of the most rural states in America, where geography plays a huge role. It impacts healthcare and outcomes by influencing when people access care, and how often their choice of provider and the type of care is available, due to New Mexico’s size and lack of population centers. Many residents of New Mexico are living in rural parts of the state and find it very difficult to access health centers and hospitals.

Dr. Ryan's rural community in Carlsbad, New Mexico didn't have convenient access to cardiovascular care. So by expanding quality care through a cardiovascular hybrid office-based lab / ambulatory surgery center (or OBL / ASC), she hopes to overcome this gap in care.

Dr. Ryan, welcome. Can you tell us about your new lab and your role?

[Dr. Amanda Ryan] We have a 8,500 square foot, two-room state-of-the-art Philips cath lab here in Carlsbad, New Mexico, serving a relatively rural three-county area. I'm a physician owner and CEO of the ambulatory surgery center.

What type of procedures do you perform?

We perform peripheral interventions, diagnostic peripheral studies, venous studies, cardiac catheterizations, cardiac catheterization with intervention, as well as deep venous stenting.

Tell me about your patients. What are the demographics? What type of patients do you see?

We have a very rural area, again, southeast New Mexico, and I would say our average age of patient is about 65 to 70, so actually a very high prevalence of diabetes here, even in our younger patients. I remember when I came to the area first was about 10 years ago. I remember being quite shocked. The first 10 acute heart attack patients actually had an average age of 42, and I came from Florida where the average age was quite a bit older. I had practiced for six years and our average age there of our acute heart attacks was probably 80. So that was quite a change. So a relatively rural, a little bit younger population.

Why did you pick this particular area? Clearly there's a huge need.

My grandfather was a cardiac patient, had an ejection fraction about 5% to 7% years ago in the eighties. Underwent bypass surgery, had recurrent heart failure for many years and I told him I would be a cardiologist practicing in a small town to bring advanced access to care for our rural areas. And when this opportunity came up, I really felt that was the opportunity to do so.

Can you talk about how your lab has affected your community and your patients?

Yes. So it's the first new medical facility in probably 25 years in our area. The community has definitely had a lot to do with the development of it. We really worked well with local government. We're involved in local rotary clubs, Lions Club, Masons, different things to really get out there in the community and make sure that everyone is on board with what we need, as well as helping us accomplish it. That's really the community where we started with one lab and when we really expanded to the three- to four-county surrounding areas over the last few years, we realized that probably two labs was more appropriate given our overall volume.

Can you give me a sense of travel times? Before your center was in place, how far were patients having to travel and then how are they accessing you now?

Three or four hours for even a basic stress test oftentimes, which, just having come from the Florida area, being around Orlando, thinking that that would be like going to Miami for a stress test, a basic heart catheterization. It's very interesting to think how far these patients were going. And I think I had the view even when I first was evaluating coming here, that most of our patients were going to Lubbock [Texas], or Albuquerque, traveling three to four hours. But the truth is the higher socioeconomic patients who weren't at work were doing that, but a lot of our hardworking middle class and our lower socioeconomic patients were not getting care at all.

You tend to see younger patients. Can you talk a bit more about that? Do you feel like you've had an impact on the local population in terms of awareness and timeliness of care?

I do. I think care navigation is very important. I've long focused on that approach to healthcare, really getting our patients in the right cardiac rehab program. We have a diabetic education program, we have a chronic care management program that's really trying to reach particularly our heart failure patients, and is where we really started that program. We do have a referral coordinator that when we send referrals out, we check within one or two weeks. If the patient actually got an appointment, we make sure we get the records back. I have direct communication with the outgoing physicians. So I think we definitely have made a difference. And that's really in having key staff in place and knowing what community resources you do have and really partnering with those

So you have more availability for treatment. Can you talk a bit more about the education that you're doing and how patients are affected in terms of ease of access?

There's a large gap in the healthcare in our rural area in cardiovascular and stroke awareness and peripheral arterial disease (PAD) awareness. Heart health month is in February, and then PAD awareness is September. We definitely are out there doing a lot of screenings in those months in particular, but in any month, we take every opportunity we can to speak to our local groups and really getting to that underserved population, too. It's interesting, Carlsbad serves somewhat as a hub for many people that work in the oil field here or live in even more rural areas than Carlsbad. So we are really trying to reach that most vulnerable population. We've expanded our telehealth services; sometimes that can be a way to reach people. We also go to the local senior centers and often to our churches in our more socioeconomic repressed areas, trying to make sure we reach those patients as well.

With the younger and more complex patient population that you're seeing in your community with those longer lifetime needs, more complexity of care, do you feel that you're able to address that both from a clinical standpoint and an educational standpoint, maintaining that connection?

Definitely. I think we really do try to get people in within two weeks, which has been a definite change. It wasn't uncommon for people to wait several months prior to the development of our program as well as our cardiac ASC. And again, like I said, we do serve three counties, probably a 200-mile radius. There's an area out here that probably should be served by six to seven interventional cardiologists and we have two to three. So really trying to, we utilize our mid-level practitioners and have a very organized stepwise approach to getting knowledge to the patients so they understand when they are at risk and getting them in as appropriate for any procedures, but also focusing on prevention. It's understanding sometimes, I've had patients say, What if I really did stop smoking and control my sugars?! Dr. Ryan, what would you do? And I was like, well, I could do hair and makeup. I have a lot of other talents if I stomp out all cardiovascular disease, but I'm not looking for the same patient to come back over and over again. I do have a passion for prevention. We set up 5K walks, we have aggressive walking, we have a walking group for our patients. I mean, you can treat end-stage disease when that's what's in front of you, but also have a focus on prevention and that really is the goal we have in our practice.

How are you working with hospitals that are in the area to better patient care?

Collaboration is definitely the key, and there's a large amount of procedures that are safe in an ASC /OBL situation from a cardiovascular standpoint, but there are also cases that are more appropriate at your higher level hospitals. So we really work hard to collaborate with our local areas on patient care, deciding where our best options are.

Do you have advice for others on improving access to care in their communities?

I think it's involvement. It's building a team. I have a team of people that have been with me for many years, hand-selected with really the same mission. You really have to remain true to your mission and sometimes when you're working 60 and 80 hours a week, sometimes you're like, now you can get a little bit off track at times. You really have to focus on why we're doing this and how to do it in an organized manner. We're very organized and I think that's how we're able to improve access to care for so many patients is by being organized.

You're obviously a woman physician and you're a business owner. This is a very male-dominated space, traditionally. Do you have advice specifically for women who might be looking to enter this same sort of space?

Yes. I think you can't have complete risk aversion if you're going to do something that's somewhat entrepreneurial. I think if you have a desire and you have some good consultants, a good team, Philips has definitely provided a great team. We've had several good consultants along the way that can really help guide you. But I think again, if you really listen to your patient population, you get to know your area and you figure out what the needs are, then you can really help steer your practice towards meeting those needs.

Can you give a timeline from start to open? Just curious how long that took you.

It's been about a five-year process, honestly.

Do you have plans to continue expanding to other areas that might lack convenient care sites for cardiovascular procedures?

Yes, I do. Again, I think in our urban areas, for example, New Mexico, this is the second cardiac ASC in New Mexico versus our counterparts in Texas and Arizona, who in the more urban and suburban areas have many surgical centers available to them. I think our rural areas are really a market where we can expand advanced access to care. So I think there's a lot of room in our rural areas to do so.

Is there anything that I didn't ask about that you wanted to bring up or highlight about your patients, the types of procedures you do, or about creating your lab?

I think one other thing is how we've really been successful out here is partnering with our large tertiary referral centers, as well in Lubbock, Albuquerque, and El Paso are kind of our main areas. When I first came out or I really went to those towns, a large hospital systems, I got to know all of the physicians in person so they could really put in a face with a name and really help serve our patients, because there are times when you do need to get your patients to the larger centers. So really having that relationship solidified has made a big difference for our patients.

Thank you very much for your time. I appreciate your talking with me and this has been wonderful!

Thank you. Great! Thank you so much.

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