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Rural-Urban Disparities Arise for Stroke Patient Access to Care

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By Sara Heath

– Mounting evidence outlines the rural-urban divide in patient access to care, with new research showing health disparities in stroke care for patients living in rural regions.

The data, published in the American Heart Association’s journal Stroke, found that individuals living in rural areas are less likely to receive life-saving stroke treatments and are more likely to die of stroke in the hospital.

“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, an assistant professor of medicine at Washington University School of Medicine, said in a statement.

“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.”

Using data about over 790,000 stroke patients receiving care between 2012 and 2017, Joynt Maddox and colleagues found that stroke care disparities fall along geographic lines. Patients living in rural areas were half as likely to receive medication to break up clots, one-third less likely to undergo a thrombectomy to remove a stroke-causing clot, and more likely to die of a stroke in the hospital compared to their urban-dwelling counterparts.

More specifically, 6.9 percent of rural patients and 5.8 percent of urban patients died in the hospital from a stroke.

Although the study did not look into the reason why rural patients did not receive the same level of care as their urban-dwelling peers, Joynt Maddox and colleagues did have some ideas. For one, rural patients are less likely to have timely access to care than urban patients largely due to geography. In 2018, Pew Research Center reported that patients living in rural areas face hospital travel distances up to 17-times those of patients living in urban areas.

And in a time-sensitive emergency like stroke care, those longer travel differences could be making a key difference.

Nonetheless, Joynt Maddox said the study’s results were surprising, in large part because of the emphasis rural health experts have placed on telehealth access. Telehealth has lent itself especially well for early stroke intervention because clinical experts are able to use the video component of the tool to assess early symptoms.

“The magnitude of the differences in risk of death and the lack of improvement over time were striking,” said Joynt Maddox. “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.”

Patients living in rural areas also have limited access to specialty care. In the case of a stroke, that would mean limited access to a neurologist at the onset of symptoms, an interventional neurologist or radiologist to do an interventional procedure, and a neurosurgeon as backup.

Healthcare leaders may consider different care coordination partnerships to address that lapse in care access.

“That means partnerships between hospitals for rapid transfer, as well as telehealth when appropriate,” said study author Dr. Gmerice Hammond, a cardiology fellow at Washington University School of Medicine.

These partnerships and a push for a broader rural health workforce are hard to pivot, the researchers acknowledged. To that end, strong patient education tactics will be essential to help drive engagement and self-management should stroke symptoms occur.

“Be aware of signs and symptoms of stroke and seek care urgently if any symptoms develop,” Hammond advised. “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.”

Going forward, the researchers plan to look into the different clinical factors that have also led to care disparities between urban and rural patients. Although adequate and timely access to care likely play a large role in outcomes for both cohorts, Joynt Maddox said it is essential to also look at the clinical differences that could sway outcomes.

“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 concluded. “Those questions can’t be answered with administrative data, but they’re very important to look into so that we can develop effective solutions.”

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