Stroke in Rural Areas Means Higher Mortality Rate, Less Advanced Treatments

Karen Joynt Maddox, MD, MPH

New research suggests disparities in stroke care seen at urban compared with rural settings are having a legitimate impact on the quality of care and survival of stroke patients.

Results of the study, which examined the issue using nationwide data from 2012-2017, found stroke patients in rural areas were less likely to receive advanced stroke treatments and more likely to die before leaving the hospital than those treated in urban areas. Additionally, results indicated no progress has been made at narrowing these gaps during the study period.

"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. 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," said lead investigator Karen Joynt Maddox, MD, MPH, assistant professor of medicine at Washington University School of Medicine in St. Louis, Missouri, in a statement from the American Heart Association.

With the rural-urban life expectancy gap continuing to widen and little understanding related to the underlying causes, investigators sought to evaluate differences and 5-year trends in the care and outcomes of patients hospitalized for stroke in rural vs urban areas. For the purpose of analysis, investigators designed their study using the National Inpatient Sample (NIS) data from 2012-2017, which allowed them to identify 792,054 hospitalizations for acute stroke for inclusion.

Investigators used the National Center for Health Statistics classification scheme to identify a patient’s county of residence according to 6 possible variations of rural and urban classifications—this was used as the primary predictor in the study. Additionally, investigators used the Elixhauser approach to define comorbidities, which included zip code median income, insurance status, hospital size, hospital ownership, hospital teaching status, and region. 



The primary outcomes of the study were revascularization rates among those with acute ischemic stroke and all-cause in-hospital mortality among all patients with stroke. Of note, investigators sought to calculate specific rates of intravenous thrombolysis (IVT) or endovascular therapy (EVT) as part of their analyses. Secondary outcomes of the study included length of stay, discharge to home, and total hospital charges.

Of the 792,054 patients identified for inclusion, 28% were from urban areas, 24% were from suburban areas, 21% were from large towns, 10% were from small towns, 10% were from micropolitan areas, and 7.4% were from rural areas. Patients from rural areas were more likely to be white (78% vs 49%), be older than 75 years of age (44% vs 40%), and be in the lowest quartile of income (59% vs 32%) when compared against their urban counterparts. Overall, stroke mortality was greater among patients in rural areas than those in urban areas.

Among 540,359 patients who were identified as having an acute ischemic stroke, rates of both IVT (4.2% versus 9.2%; adjusted OR, 0.55; 95% CI, 0.51-0.59; P <.001) and EVT (1.63% vs 2.41%; aOR, 0.64; 95% CI, 0.57-0.73; P <.001) were lower among patients classified as rural compared to those classified as urban. Additionally, results of the investigators' analyses indicated the rural-urban disparities in IVT and EVT remained relatively similar when compared rates in 2012 and 2017. &#8232;

When examining adjusted in-patient mortality rates for all stroke patients, investigators observed an increase in across categories of increasing rurality—specific odds ratios were 0.97 (0.94—1.0; P=.086) for suburban patients, 1.05 (1.01-1.09; P=0.009) for patients from large towns, 1.10 (1.06—1.15; P <.001) for patients from small towns, 1.16 (1.11-1.21; P <.001) for those residing in micropolitan rural areas, and 1.21 (1.15-1.27; P <.001) for those in remote rural areas when compared with urban patients. &#8232;&#8232;

Investigators also highlighted the mortality for rural patients compared with urban patients did not improve from 2012-2017 (aOR, 1.12; 95% CI, 1.00-1.23; P <.001 for 2012; aOR 1.27; 95% CI, 1.13-1.42; P <.001 for 2017).

This study, titled “Urban-Rural Inequities in Acute Stroke Care and In-Hospital Mortality,” was published in Stroke. &#8232;