Stroke patients more likely to die in rural hospitals than in urban ones

People living in rural areas of the United States are less likely to get the most advanced treatments for stroke and more likely to die in the hospital than their urban counterparts, according to a new study.

Compared with stroke patients living in cities, researchers found those treated at rural hospitals were about half as likely to receive clot-busting medication; about one-third less likely to undergo a thrombectomy procedure to remove a stroke-causing clot; and more likely to die of any type of stroke before leaving the hospital (6.9% versus 5.8%).

"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," senior study author Dr. Karen E. Joynt Maddox said in a news release. "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."

Joynt Maddox and her colleagues, who published their findings Wednesday in the American Heart Association's journal Stroke, used data on more than 790,000 adults hospitalized with stroke between 2012-2017. It was from the National Inpatient Sample database, the nation's largest publicly available, all-payer inpatient health care database.

"The magnitude of the differences in risk of death and the lack of improvement over time were striking," said Joynt Maddox, an assistant professor of medicine at Washington University School of Medicine in St. Louis, Missouri. "One would think that recent improvements in technology and in telehealth would mean that we could, as a system, deliver optimal care no matter where people live. That turns out to not yet be the case for stroke care."

As well as lack of access to advanced therapies, rural patients also had significantly lower rates of access to specialists. That could mean a neurologist to guide the initial care, an interventional neurologist or radiologist to do a procedure and a neurosurgeon as backup, study author Dr. Gmerice Hammond said in the news release.

Clinicians should work to improve access to care and outcomes for stroke in rural areas, said Hammond, a cardiology fellow at Washington University School of Medicine. "That means partnerships between hospitals for rapid transfer, as well as telehealth when appropriate."

Meanwhile, rural residents can help protect themselves.

"Be aware of signs and symptoms of stroke and seek care urgently if any symptoms develop," Hammond said. "To the extent possible, be as aggressive as you can with preventive efforts like blood pressure control. The best way to survive a stroke is to not have one in the first place."

The most common symptoms of stroke are face drooping, arm weakness and speech difficulty. Bystanders should call 911 even if the symptoms go away.

The researchers did not have information about the severity of stroke or factors that determine who is eligible for advanced therapies – such as the size of the clot, where it is, and the length of time between onset of symptoms and the patient's arrival at the hospital.

Joynt Maddox said future studies with more detailed clinical data will help figure out why rural patients aren't getting time-sensitive therapies.

"Is it because their stroke severity is different? Or because delays in getting to the hospital meant they weren't eligible by the time they arrived?" she said. "Those questions can't be answered with administrative data, but they're very important to look into so that we can develop effective solutions."

If you have questions or comments about this story, please email [email protected].