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The association between rural residence and stroke care and outcomes

  • Author Footnotes
    1 Contributed to the study concept and design, interpretation of the data, as well as drafting and revisions to the manuscript. Dr. Koifman reports no disclosures.
    Julius Koifman
    Footnotes
    1 Contributed to the study concept and design, interpretation of the data, as well as drafting and revisions to the manuscript. Dr. Koifman reports no disclosures.
    Affiliations
    Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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  • Author Footnotes
    2 Contributed to study design, interpretation of the data and revisions to the manuscript. Dr. Hall reports no disclosures.
    Ruth Hall
    Footnotes
    2 Contributed to study design, interpretation of the data and revisions to the manuscript. Dr. Hall reports no disclosures.
    Affiliations
    Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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  • Author Footnotes
    3 Performed data analyses. Mr Li reports no disclosures.
    Shudong Li
    Footnotes
    3 Performed data analyses. Mr Li reports no disclosures.
    Affiliations
    Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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  • Author Footnotes
    4 Contributed to study design and revising the manuscript. Ms Stamplecoski reports no disclosures.
    Melissa Stamplecoski
    Footnotes
    4 Contributed to study design and revising the manuscript. Ms Stamplecoski reports no disclosures.
    Affiliations
    Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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  • Author Footnotes
    5 Performed data analyses and contributed to interpretation of the data and revisions to the manuscript. Dr. Fang reports no disclosures.
    Jiming Fang
    Footnotes
    5 Performed data analyses and contributed to interpretation of the data and revisions to the manuscript. Dr. Fang reports no disclosures.
    Affiliations
    Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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  • Author Footnotes
    6 Contributed to study concept and revisions to the manuscript.
    Alexandra P. Saltman
    Footnotes
    6 Contributed to study concept and revisions to the manuscript.
    Affiliations
    Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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  • Author Footnotes
    7 Contributed to the study concept and design, interpretation of the data, as well as drafting and revisions to the manuscript. Dr Kapral reports no disclosures.
    Moira K. Kapral
    Correspondence
    Corresponding author at: Toronto General Hospital, 14EN 215 - 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
    Footnotes
    7 Contributed to the study concept and design, interpretation of the data, as well as drafting and revisions to the manuscript. Dr Kapral reports no disclosures.
    Affiliations
    Department of Medicine, University of Toronto, Toronto, Ontario, Canada

    Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada

    Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
    Search for articles by this author
  • Author Footnotes
    1 Contributed to the study concept and design, interpretation of the data, as well as drafting and revisions to the manuscript. Dr. Koifman reports no disclosures.
    2 Contributed to study design, interpretation of the data and revisions to the manuscript. Dr. Hall reports no disclosures.
    3 Performed data analyses. Mr Li reports no disclosures.
    4 Contributed to study design and revising the manuscript. Ms Stamplecoski reports no disclosures.
    5 Performed data analyses and contributed to interpretation of the data and revisions to the manuscript. Dr. Fang reports no disclosures.
    6 Contributed to study concept and revisions to the manuscript.
    7 Contributed to the study concept and design, interpretation of the data, as well as drafting and revisions to the manuscript. Dr Kapral reports no disclosures.
Published:February 09, 2016DOI:https://doi.org/10.1016/j.jns.2016.02.019

      Highlights

      • Rural residence was associated with lower use of brain/vascular imaging after stroke.
      • Rural residents were less likely than urban ones to receive stroke unit care.
      • Rural residents were less likely than urban ones to receive post-stroke rehabilitation.
      • There was a trend toward higher 30-day stroke mortality for rural vs urban residents.

      Abstract

      Background

      Little is known about stroke care and outcomes in those residing in rural compared to urban areas.

      Methods

      We conducted a cohort study on a population-based sample of patients with stroke or transient ischemic attack seen at 153 acute care hospitals in the province of Ontario, Canada, between April 1, 2008 and March 31, 2011. Based on their primary residence, patients were categorized as residing in a rural (population < 10,000), medium urban (population 10,000–99,999) or large urban (population ≥ 100,000) area. In the study sample of 15,713, we compared processes of stroke care (use of thrombolysis, stroke unit care, investigations, consultations and treatments) and outcomes (30-day mortality, disability at discharge) in those from rural and urban areas, with multivariable models constructed to evaluate the association between rural residence and outcomes after adjustment for potential confounders.

      Results

      Patients from rural areas were less likely than those from urban areas to receive stroke unit care, brain imaging within 24 h, carotid imaging, and consultations from neurologists, physiotherapists, occupational therapists and speech language pathologists, and were less likely to be transferred to inpatient rehabilitation facilities. Use of antithrombotic agents and lipid lowering therapy was similar in rural and urban residents, as was disability at discharge. There was a trend toward higher 30-day mortality in rural compared to urban residents (adjusted hazard ratio 1.14; 95% confidence interval 0.99–1.32).

      Conclusion

      Rural residence is associated with lower use of key stroke care interventions after stroke. Future work should focus on developing interventions to address gaps in stroke care in rural areas.

      Keywords

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      References

        • Donnan G.A.
        • Fisher M.
        • Macleod M.
        • Davis S.M.
        Stroke.
        Lancet. 2008; 371: 1612-1623
        • Kondo N.
        • Sembajwe G.
        • Kawachi I.
        • van Dam R.M.
        • Subramanian S.V.
        • Yamagata Z.
        Income inequality, mortality and self-rated health: meta-analysis of multilevel studies.
        BMJ. 2009; 339: b4471
        • Cox A.M.
        • McKevitt C.
        • Rudd A.G.
        • Wolfe C.D.
        Socioeconomic status and stroke.
        Lancet Neurol. 2006; 5: 181-188
        • Kapral M.K.
        • Fang J.
        • Chan C.
        • et al.
        Neighbourhood income and stroke care and outcomes.
        Neurology. 2012; 79: 1200-1207
        • Howard G.
        Adventures (and misadventures) in understanding (and reducing) disparities in stroke mortality.
        Stroke. 2013; 44: 3254-3259
        • Sergeev A.V.
        Racial and rural–urban disparities in stroke mortality outside the stroke belt.
        Ethn. Dis. 2011; 21: 307-313
        • Yiannakoulias N.
        • Svenson L.W.
        • Hill M.D.
        • et al.
        Incident cerebrovascular disease in rural and urban Alberta.
        Cerebrovasc. Dis. 2004; 17: 72-78
        • Pohar S.
        • Majumdar S.
        • Johnson J.A.
        Health care costs and mortality for Canadian urban and rural patients with diabetes: population-based trends from 1993 to 2001.
        Clin. Ther. 2007; 29: 1316-1324
        • Bermejo F.
        • Vega S.
        • Morales J.M.
        • et al.
        Prevalence of stroke in two samples (rural and urban) of old people in Spain. A pilot door-to-door study carried out by health professionals.
        Neurologia. 1997; 12: 157-161
        • Correia M.
        • Silva M.R.
        • et al.
        Prospective community-based study of stroke in Northern Portugal. Incidence and case fatality in rural and urban populations.
        Stroke. 2004; 35: 2048-2053
        • Lemesle M.
        • Giroud M.
        • Matos I.
        • et al.
        Incidence and case-fatality rates of stroke in Burgundy (France). Comparison between a rural (Avallon) and an urban (Dijon) population between 1989 and 1993.
        Eur. J. Neurol. 1996; 3: 109-115
        • Powles J.
        • Kirov P.
        • Feschieva N.
        • Stanoev M.
        • Atanasova V.
        Stroke in urban and rural populations in north-east Bulgaria: incidence and case fatality findings from a ‘hot pursuit’ study.
        BMC Public Health. 2002; 2 (Epub 2002 Sep 2)
        • Scott P.A.
        • Temovsky C.J.
        • Lawrence K.
        • Gudaitis E.
        • Lowell M.J.
        Analysis of Canadian population with potential access to intravenous thrombolysis for acute ischemic stroke.
        Stroke. 1998; 29: 2304-2310
        • Liu L.
        • Reeder B.
        • Shuaib A.
        • Mazagri R.
        Validity of stroke diagnosis on hospital discharge records in Saskatchewan, Canada: implications for stroke surveillance.
        Cerebrovasc. Dis. 1999; 9: 224-230
        • Juurlink D.N.
        • Preyra C.
        • Croxford R.
        • et al.
        Canadian Institute for Health Information Discharge Abstract Database: A Validation Study.
        Institute for Clinical Evaluative Sciences, Toronto (ON)2006
      1. Statistics Canada. Upper income limits and income shares of adjusted after-tax income quintiles, by economic family type, 2011 constant dollar. http://www.statcan.gc.ca/pub/75-202-x/2009000/analysis-analyses-eng.htm. Date modified: 2013-02-19.

        • du Plessis V.
        • Beshiri R.
        • Bollman R.D.
        • Clemenson H.
        Definitions of Rural.
        Statistics Canada Agriculture Division, Ottawa (ON)2002 (Agriculture and rural working paper series working paper no.61). Available at: http://ageconsearch.umn.edu/bitstream/28031/1/wp020061.pdf (Accessed January 4, 2016)
      2. Cochrane Database Syst. Rev. 2013; 11 (Stroke Unit Trialists' Collaboration)
        • Stavem K.
        • Rønning O.M.
        Survival of unselected stroke patients in a stroke unit compared with conventional care.
        Q. J. Med. 2002; 95: 143-152
        • Glader E.L.
        • Stegmar B.
        • Johansson L.
        • et al.
        Differences in long term outcome between patients treated in stroke units and in general ward.
        Stroke. 2001; 32: 2124-2130
        • Krespi Y.
        • Gurol M.E.
        • Coban O.
        • Tuncay R.
        • Bahar S.
        Stroke unit versus neurology ward. A before and after study.
        J. Neurol. 2003; 250: 1363-1369
        • Alberts M.J.
        • Hademenos G.
        • Latchaw R.E.
        • et al.
        Recommendations for the establishment of primary stroke centers.
        JAMA. 2000; 283: 3102-3109
        • Bluhmki E.
        • Chamorro A.
        • Davalos A.
        • et al.
        Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis.
        Lancet. 2012; 379: 2364-2372
        • Jauch E.C.
        • Saver J.L.
        • Adams H.P.
        • et al.
        Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2013; 44: 870-947
        • Coutts S.B.
        • Wein T.H.
        • Lindsay M.P.
        • et al.
        Canadian Stroke Best Practice Recommendations: secondary prevention of stroke guidelines, update 2014.
        Int. J. Stroke. 2015; 10: 282-291
        • European Stroke Organization (ESO) Executive Committee, ESO Writing Committee
        Guidelines for the management of ischaemic stroke and transient ischaemic attack 2008.
        Cerebrovasc. Dis. 2008; 25: 457-507
        • National Collaborating Centre for Chronic Conditions
        Stroke: Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack (TIA).
        National Institute for Health and Clinical Excellence, London (UK)2008 (Available: www.nice.org.uk/nicemedia/pdf/CG68NICEGuideline.pdf (accessed 2014, Oct 26))
      3. U.S. Census Bureau. 2010 Census Urban and Rural Classification and Urban Area Criteria. Available online: https://www.census.gov/geo/reference/ua/urban-rural-2010.html. Last Revised: February 9, 2015.

      4. Statistics Canada. Canada's rural population since 1851. Population and dwelling counts, 2011 Census. http://www12.statcan.gc.ca/census-recensement/2011/as-sa/98-310-x/98-310-x2011003_2-eng.pdf. Date modified: April 4, 2015.

      5. Hall, R, Khan, F, O'Callaghan, C, et al. Ontario Stroke Evaluation Report 2014. Available Online: http://ontariostrokenetwork.ca/wp-content/uploads/2014/06/Full-Report2.pdf. Date visited: Dec 21, 2014.

        • Cadilhac D.A.
        • Purvis T.
        • Kilkenny M.F.
        • et al.
        Evaluation of rural stroke services: does implementation of coordinators and pathways improve care in rural hospitals?.
        Stroke. 2013 Oct; 44: 2848-2853
        • Mullen M.T.
        • Judd S.
        • Howard V.J.
        • et al.
        Disparities in evaluation at certified primary stroke centers: reasons for geographic and racial differences in stroke.
        Stroke. 2013 Jul; 44: 1930-1935
        • Rucker D.
        • Hemmelgarn B.R.
        • Lin M.
        • et al.
        Quality of care and mortality are worse in chronic kidney disease patients living in remote areas.
        Kidney Int. 2011; 79: 210-217
        • Rodriguez D.
        • Cox M.
        • Zimmer L.O.
        • et al.
        Similar secondary stroke prevention and medication persistence rates among rural and urban patients.
        J. Rural. Health. 2011; 27: 401-408
        • Rubin M.N.
        • Demaerschalk B.M.
        The use of telemedicine in the management of acute stroke.
        Neurosurg. Focus. 2014 Jan; 36E4
        • Joubert J.
        • Prentice L.F.
        • Moulin T.
        • Liaw S.T.
        • Joubert L.B.
        • Preux P.M.
        • et al.
        Stroke in rural areas and small communities.
        Stroke. 2008; 39: 1920-1928
        • Schwamm L.H.
        • Pancioli A.
        • Acker J.E.
        • et al.
        Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association's Task Force on the Development of Stroke Systems.
        Stroke. 2005; 36: 690-703
        • Norrving B.
        • Adams R.J.
        Organized stroke care.
        Stroke. 2006; 37: 326-328
        • Leira E.C.
        • Hess D.C.
        • Torner J.C.
        • Adams Jr., H.P.
        Rural-urban differences in acute stroke management practices: a modifiable disparity.
        Arch. Neurol. 2008; 65: 887-889
        • Waite K.
        • Silver F.
        • Jaigobin C.
        • Black S.
        • Lee L.
        • Murray B.
        • et al.
        Telestroke: a multi-site, emergency-based telemedicine service in Ontario.
        J. Telemed. Telecare. 2006; 12: 141-145
        • Kapral M.K.
        • Fang J.
        • Silver F.L.
        • Hall R.
        • Stamplecoski M.
        • O'Callahan C.
        • Tu J.V.
        Effect of a provincial system of stroke care delivery on stroke care and outcomes.
        CMAJ. 2013; 185: E483-E491
        • Ekundayo O.J.
        • Saver J.L.
        • Fonarow G.C.
        • et al.
        Patterns of emergency medical services use and its association with timely stroke treatment: findings from get with the guidelines-stroke.
        Circ. Cardiovasc. Qual. Outcomes. 2013; 6: 262-269
        • Quinn T.J.
        • Dawson J.
        • Walters M.R.
        • Lees K.R.
        Functional outcome measures in contemporary stroke trials.
        Int. J. Stroke. 2009; 4: 200-206