Disclosures: One author reports she receives research support from the NHLBI and National Institute on Aging, and did contract work for HHS. Hammond and the other authors report no relevant financial disclosures.
June 18, 2020
2 min read

Stroke care, survival in rural areas unimproved

Disclosures: One author reports she receives research support from the NHLBI and National Institute on Aging, and did contract work for HHS. Hammond and the other authors report no relevant financial disclosures.
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From 2012 to 2017, there was little observable improvement in stroke survival or administration of stroke treatment among rural patients compared with those living in urban areas, researchers reported.

“There is a significant inequity both in the treatment and in outcomes after having a stroke for rural patients,” Gmerice Hammond, MD, MPH, cardiologist and health policy research fellow at Washington University School of Medicine, St. Louis, told Healio. “We have to begin to appreciate rurality as an independent risk factor for stroke treatment and outcomes, and clinicians need to be aware of this in their practice, but also as clinician scientists, we need to pursue solutions to this in research.”

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A retrospective cohort study published in Stroke assessed National Inpatient Sample data to determine the 5-year trends in stroke care and outcomes in rural and urban areas. Rurality was defined by county according to the 6-strata National Center for Health Statistics classification scheme.

Researchers observed that compared with urban patients, rural patients with acute ischemic stroke were more likely to be white (78% vs. 49%), older than 75 years (44% vs. 40%) and of the lowest quartile of income (59% vs. 32%).

The prevalence of IV thrombolysis and endovascular therapy for stroke treatment was lower among rural patients compared with urban patients (adjusted OR for IV thrombolysis = 0.55; 95% CI, 0.51-0.59; aOR for endovascular therapy = 0.64; 95% CI, 0.57-0.73). The frequency of IV thrombolysis for stroke increased from 2012 (6.1%) to 2017 (9%), but researchers noted that trends varied by rurality.

Mortality from stroke

Moreover, stroke mortality was higher in rural areas compared with urban areas (6.87% vs. 5.82%; P < .001), and the trend did not improve from 2012 (aOR = 1.12; 95% CI, 1-1.26) to 2017 (aOR = 1.27; 95% CI, 1.13-1.42).

Gmerice Hammond

“Unfortunately, [the results] didn't surprise me. The reason why is because prior to 2009, there had been some epidemiologic data suggesting that inequities have been worsening for rural areas. This was despite Telestroke, which had started in 1999 and the Centers for Excellence which had started in 2003 with the aim to reduce these disparities,” Hammond said in an interview. “We’ve known for some time that they hadn't had the impact that we had hoped. Then in 2014 with Medicaid being differentially expanded in urban and northern areas, I was worried that the inequities were going to be worsening. If you look at our data the deficit between rural and urban outcomes and treatment did widen. When we looked statistically, the significance of the widening wasn't there but it actually worsened over the study period.”

Mortality with increasing rurality

In other findings, as rurality increased, so did adjusted mortality rates, compared with urban areas:

  • suburban (OR = 0.97; 95% CI, 0.94-1);
  • large towns (OR = 1.05; 95% CI, 1.01-1.09);
  • small towns (OR = 1.1; 95% CI, 1.06-1.15);
  • micropolitan rural (OR = 1.16; 95% CI, 1.11-1.21); and
  • remote rural (OR = 1.21; 95% CI, 1.15-1.27).

Improving awareness, policy and telehealth

“Stroke starts in a patient's home and context, ie, the social determinants of health and increasing prevention. Then the goal is in the patient's understanding and awareness of the symptoms of stroke, so that as soon as they feel the symptoms, they are able to recognize them right away,” Hammond told Healio. “But beyond the patient, policy comes into play. Emergency medical services in rural areas are unfortunately often suboptimally set up. There can be significant delays between calling 9-1-1 and having relief arrive in an urban area.
“We could try to expand telehealth. Why aren't we doing telehealth in the ambulance? We're waiting until the patient gets to the emergency room or into the hospital before we're telehealthing-in the neurologist, which sometimes creates massive delays in diagnosis. If you expanded telehealth beyond the walls of the hospital, it could have significant impacts,” Hammond said in an interview. “Across all of those steps, any intervention that's taken on a policy level or on the physician level, any of those interventions need to be studied in terms of how they're being implemented.