Urban-Rural Inequities in Acute Stroke Care and In-Hospital Mortality

Abstract

Background and Purpose: The rural-urban life-expectancy gap is widening, but underlying causes are incompletely understood. Prior studies suggest stroke care may be worse for individuals in more rural areas, and technological advancements in stroke care may disproportionately impact individuals in more rural areas. We sought to examine differences and 5-year trends in the care and outcomes of patients hospitalized for stroke across rural-urban strata. Methods: Retrospective cohort study using National Inpatient Sample data from 2012 to 2017. Rurality was classified by county of residence according to the 6-strata National Center for Health Statistics classification scheme. Results: There were 792 054 hospitalizations for acute stroke in our sample. Rural patients were more often white (78% versus 49%), older than 75 (44% versus 40%), and in the lowest quartile of income (59% versus 32%) compared with urban patients. Among patients with acute ischemic stroke, intravenous thrombolysis and endovascular therapy use were lower for rural compared with urban patients (intravenous thrombolysis: 4.2% versus 9.2%, adjusted odds ratio, 0.55 [95% CI, 0.51–0.59], P <0.001; endovascular therapy: 1.63% versus 2.41%, adjusted odds ratio, 0.64 [0.57–0.73], P <0.001). Urban-rural gaps in both therapies persisted from 2012 to 2017. Overall, stroke mortality was higher in rural than urban areas (6.87% versus 5.82%, P <0.001). Adjusted in-patient mortality rates increased across categories of increasing rurality (suburban, 0.97 [0.94–1.0], P =0.086; large towns, 1.05 [1.01–1.09], P =0.009; small towns, 1.10 [1.06–1.15], P <0.001; micropolitan rural, 1.16 [1.11–1.21], P <0.001; and remote rural 1.21 [1.15–1.27], P <0.001 compared with urban patients. Mortality for rural patients compared with urban patients did not improve from 2012 (adjusted odds ratio, 1.12 [1.00–1.26], P <0.001) to 2017 (adjusted odds ratio, 1.27 [1.13–1.42], P <0.001). Conclusions: Rural patients with stroke were less likely to receive intravenous thrombolysis or endovascular therapy and had higher in-hospital mortality than their urban counterparts. These gaps did not improve over time. Enhancing access to evidence-based stroke care may be a target for reducing rural-urban disparities.

Demographic and institutional predictors of stroke hospitalization mortality among adults in the United States

“…In urban and teaching hospitals, hospitalizations for stroke were significantly associated with higher mortality even after controlling for age, gender, location, and comorbidities. This observation contrasts with previously published work that suggested rural settings and non-teaching hospitals have higher odds of stroke mortality [ 45 , 46 ]. Patient transfers from rural to urban settings could have contributed to these results, as rural facilities may not be well equipped to handle sicker patients [ 47 ].…”

Analysis of Thrombolysis Process for Acute Ischemic Stroke in Urban and Rural Hospitals in Nova Scotia Canada

“…Additionally, this study shows that access to rapid imaging interpretation from radiology is also a barrier. This urban-rural disparity in stroke treatment is consistent with previous quantitative studies that showed that rural AIS patients are less likely to receive thrombolysis (27) and have longer DTN times (14) than their urban counterparts. This disparity is apparent despite the use of tPA in AIS patients being reported as successful in rural settings, or in areas where access to a neurologist and imaging expertise is limited (28).…”

Maintaining Quality of Care among Dialysis Patients in Affected Areas after Typhoon Morakot

“…Social demographics such as socioeconomic status, sex, geographic location, income, and education are still important factors affecting the accessibility of health services, especially in rural areas [46]. Previous studies in Canada have suggested that rural residents have reduced access to basic stroke care, such as computed tomography, thrombolysis, a stroke unit, a stroke prevention clinic, or inpatient rehabilitation once they have had a stroke, and therefore experience relatively more severe outcomes, including disability [47,48]. Our study also found that dialysis patients living in severely affected areas had a higher risk of mortality than patients in moderately affected areas.…”