Rural Stroke Patients Have Higher Mortality: An Improvement Opportunity for Rural Emergency Medical Services Systems
Peter K. Georgakakos, Morgan B. Swanson, Azeemuddin Ahmed, Nicholas M. Mohr
Abstract
PURPOSE: Early recognition and prompt prehospital care is a cornerstone of acute stroke treatment. Residents of rural areas have worse access to stroke services than urban residents. The purpose of this study was to (1) describe US trends in rural-urban stroke mortality and (2) identify possible factors associated with rural-urban stroke case-fatality disparities. METHODS: This study was a nationwide retrospective cohort study of stroke admissions. The primary exposure was rurality of patient's residence. The primary outcome was death during hospital encounter. The secondary outcome was discharge to a care facility or home healthcare. Univariable and multivariable logistic regressions estimated the odds of mortality by subject rurality among stroke subjects. FINDINGS: Rural stroke subjects had higher mortality than nonrural counterparts (18.6% rural vs 16.9% nonrural). After adjustment for patient and hospital factors, patient rurality was associated with increased odds of mortality (aOR = 1.11; 95% CI: 1.06-1.15; P < .001). For the secondary outcome of discharge to home, rural stroke subjects were less likely to be discharged to a care facility than nonrural stroke visits (aOR 0.94; 95% CI: 0.91-0.97; P < .001). Results were similar after adjusting for thrombolytics administration and transfer status. CONCLUSIONS: Rural stroke patients have higher mortality than their urban counterparts likely due to their increased burden of chronic disease, lower health literacy, and reduced access to prompt prehospital care. There may be an opportunity for emergency medical services systems to assist in increasing stroke awareness for both patients and clinicians and to establish response patterns to expedite emergency care.