People living in rural areas who suffer strokes are less likely to receive advanced care than those living in urban areas, leading to higher mortality risk among rural stroke patients than among their urban counterparts, according to a study released Thursday.
Gmerice Hammond, MD, MPH, of the Washington University School of Medicine, St. Louis, and colleagues, reported these findings in a manuscript published online Thursday in Stroke.
The authors sought to provide a better understanding for the increasingly widening rural-urban life-expectancy gap. They noted that previous studies suggested stroke care might be worse for people living in rural areas and that they may not have the same access to technological advancements in the treatment of strokes.
The authors conducted a retrospective cohort study using National Inpatient Sample data from 2012 to 2017. Each patient’s county of residence was classified by the National Center for Health Statistics’ Urban-Rural Classification Scheme, ranging from large central metropolitan to “noncore,” the least densely populated.
The study consisted of 792,054 hospitalizations for acute stroke. Rural patients were more often white (78% vs. 49%), older than 75 (44% vs. 40%), and in the lowest quartile of income (59% vs. 32%) in comparison with urban patients.
Among patients with acute ischemic stroke, intravenous thrombolysis and endovascular therapy use were lower for rural patients (intravenous thrombolysis: 4.2% vs. 9.2%, adjusted odds ratio [OR], 0.55; 95% confidence interval [CI], 0.51-0.59; p<0.001; endovascular therapy: 1.63% vs. 2.41%, adjusted OR, 0.64; 95% CI, 0.57-0.73; p<0.001). These gaps persisted throughout the study period.
Overall, stroke mortality was higher in rural than urban areas (6.87% vs. 5.82%; p<0.001). Adjusted in-patient mortality rates increased as patients’ counties of residence became increasingly rural. The gap in mortality did not improve from 2012 (adjusted OR, 1.12; 95% CI, ,1.00-1.26; p<0.001) to 2017 (adjusted OR, 1.27; 95% CI, 1.13-1.42; p<0.001).
The authors noted several limitations to their analysis, including that they did not have access to variables that may have affected patients’ eligibility for intravenous thrombolysis or endovascular therapy for acute ischemic stroke. Use of International Classification of Diseases, Ninth and Tenth revisions, introduces the opportunity for misclassification of stroke type, and these misclassifications could be greater in urban than rural hospitals.
“There are so many challenges facing rural America right now – higher rates of chronic disease, poverty and joblessness – and cardiovascular and other health outcomes are much worse in rural areas,” Karen E. Joynt Maddox, MD, MPH, senior author of the study and assistant professor of medicine at the Washington University School of Medicine, said in a news release announcing the study. “This study shines light on one area where changes in care, such as the introduction of telehealth or other programs, could really make a difference.”
Hammond G, Luke AA, Elson L. et al. Urban-Rural Inequities in Acute Stroke Care and In-Hospital Mortality. Stroke 2020 Jun 17. https://doi.org/10.1161/STROKEAHA.120.029318