Geographic Disparities in Stroke Outcomes and Service Access

Abstract

Background and ObjectivesInternational evidence shows that patients treated at nonurban hospitals experience poorer access to key stroke interventions. Evidence for whether this results in poorer outcomes is conflicting and generally based on administrative or voluntary registry data. The aim of this study was to use prospective high-quality comprehensive nationwide patient-level data to investigate the association between hospital geography and outcomes of patients with stroke and access to best-practice stroke care in New Zealand.MethodsThis is a prospective, multicenter, nationally representative observational study involving all 28 New Zealand acute stroke hospitals (18 nonurban) and affiliated rehabilitation and community services. Consecutive adults admitted to the hospital with acute stroke between May 1 and October 31, 2018, were captured. Outcomes included functional outcome (modified Rankin Scale [mRS] score shift analysis), functional independence (mRS score 0–2), quality of life (EuroQol 5-dimension, 3-level health-related quality of life questionnaire), stroke/vascular events, and death at 3, 6, and 12 months and proportion accessing thrombolysis, thrombectomy, stroke units, key investigations, secondary prevention, and inpatient/community rehabilitation. Results were adjusted for age, sex, ethnicity, stroke severity/type, comorbid conditions, baseline function, and differences in baseline characteristics.ResultsOverall, 2,379 patients were eligible (mean [SD] age 75 [13.7] years; 51.2% male; 1,430 urban, 949 nonurban). Patients treated at nonurban hospitals were more likely to score in a higher mRS score category (greater disability) at 3 (adjusted odds ratio [aOR] 1.28, 95% CI 1.07–1.53), 6 (aOR 1.33, 95% CI 1.07–1.65), and 12 (aOR 1.31, 95% CI 1.06–1.62) months and were more likely to have died (aOR 1.57, 95% CI 1.17–2.12) or experienced recurrent stroke and vascular events at 12 months (aOR 1.94, 95% CI 1.14–3.29 and aOR 1.65, 95% CI 1.09–2.52). Fewer nonurban patients received recommended stroke interventions, including endovascular thrombectomy (aOR 0.25, 95% CI 0.13–0.49), acute stroke unit care (aOR 0.60, 95% CI 0.49–0.73), antiplatelet prescriptions (aOR 0.72, 95% CI 0.58–0.88), ≥60 minutes of daily physical therapy (aOR 0.55, 95% CI 0.40–0.77), and community rehabilitation (aOR 0.69, 95% CI 0.56–0.84).DiscussionPatients managed at nonurban hospitals experience poorer stroke outcomes and reduced access to key stroke interventions across the entire care continuum. Efforts to improve access to high quality stroke care in nonurban hospitals should be a priority.

Ethnic differences in stroke outcomes in Aotearoa New Zealand: A national linkage study

“…Median (interquartile range) age for Māori, Pacific Peoples, Asians, and NZ Europeans was 65 (20), 65 (22), 71 (19), and 79 (16), respectively (Table 1). Ever smoking was the highest among Māori (55%), followed by NZ Europeans (40%), Pacific Peoples (28%), and Asians (16%).…”

“…21 Also, overall stroke service improvements may have been implemented more rapidly in urban areas (more Pacific Peoples attended urban hospitals compared with Māori (91% vs 51%)), and we have recently shown that patients presenting to non-urban hospitals experience worse outcomes. 22 However, this cannot fully explain poorer outcomes for Māori as the proportion attending urban area hospitals is similar to that of NZ Europeans (51% and 61%, respectively), and we controlled for hospital location. There were differences in medication dispensing following discharge.…”

Evaluating remote facilitation intensity for multi-national translation of nurse-initiated stroke protocols (QASC Australasia): a protocol for a cluster randomised controlled trial

“…In New Zealand, the most recent nationwide stroke audit in 2018 was conducted as part of the Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care) Study. The findings showed that only 34.7% of ischemic stroke patients in urban hospitals and 32.5% of those in non-urban hospitals received a swallow assessment within 6 h of hospital arrival, with no significant difference between both groups (adjusted odds ratio 0.94, 95% confidence interval 0.74–1.18) [ 6 ]. Management of the other two FeSS Protocol elements (fever and hyperglycaemia) were not included in the audit hence it remains unclear whether or not these physiological parameters are being monitored and treated appropriately in New Zealand.…”

Comparison of Stroke Care Costs in Urban and Nonurban Hospitals and Its Association With Outcomes in New Zealand: A Nationwide Economic Evaluation

“…For example, smaller hospitals may not have stroke units or strokespecific rehabilitation services, with patients often cared for by general physicians, nurses, and allied health teams without stroke-specific training or ongoing professional development. 6 Recent studies confirmed significant service gaps in nonurban hospitals in New Zealand, 7 disparity in outcomes by hospital location, 8 and geographic disparities in access to reperfusion therapies in some New Zealand hospitals. [9][10][11][12][13] This situation generally mirrors observations in other countries.…”