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Rural Stroke Patients Are Getting More Neurology Consults, but Mortality Outcomes Have Not Improved Over Time

Article In Brief

Over the past 10 years, more rural stroke patients have gained access to certified stroke centers, but their mortality outcomes have not improved.

Stroke patients in rural areas are receiving more treatment in certified stroke centers and are being seen by neurologists than they were 10 years ago, closing historic disparities in access to care with similar patients in urban centers, according to a JAMA Neurology cohort study published online on May 4.

But disparities in outcomes—such as mortality and morbidity—have remained the same or worsened over the last decade, the study reported.

“In the last decade, care for rural residents with acute ischemic stroke and transient ischemic attack [TIA] has shifted to certified stroke centers and now more likely includes neurologist input,” the study authors wrote. “However, disparities in access to treatments, such as alteplase, and outcomes persist, highlighting that work still is needed to extend improvements in stroke care to all US residents.”

“We see that when stroke patients [from rural areas] go to these [Joint Commission-certified] stroke centers, they are speaking to neurologists more often,” said Andrew D. Wilcock, PhD, assistant professor in the department of family medicine at the University of Vermont Larner College of Medicine in Burlington. “However, they may not be getting the same level of timely access to tissue plasminogen activator [tPA] or thrombectomy as stroke patients in urban settings.”

“We didn't see any narrowing in the disparity between rural and urban populations when it came to receiving treatment like tPA or thrombectomy,” noted Dr. Wilcock. “These disparities in care might explain why we didn't see narrowing in mortality or some of the other important outcomes that we looked at.”

Study Details

To understand existing urban-rural disparities among stroke patients, Dr. Wilcock and colleagues, reviewed data from Medicare beneficiaries who had TIA and acute ischemic strokes between 2008 and 2017. They factored in data on the patients' residences and all hospital stays, including observational stays.

The investigators were able to identify the presenting hospitals and determine whether the discharge hospital was a comprehensive stroke center or primary stroke center, which was a main outcome of the study. Other outcome measures of the study included treatment with alteplase, 90-day mortality, days institutionalized, and receiving a neurology consultation.

The researchers assessed 3.47 million admissions from 2008 to 2017. In 2008, there were 266,238 urban hospital admissions and 98,008 rural hospital admissions, while in 2017, there were 242,313 urban hospital admissions and 86,750 rural hospital admissions.

In 2008, 25.2 percent of patients in rural areas and 60.6 percent in urban areas were treated at a certified stroke center—a disparity of −35.4 percent. That disparity narrowed by 8.7 percent to -26.6 percent in 2017.

“A lot of it is timing,” Dr. Wilcock said. “There's an optimal time that you need to get to an emergency department to be evaluated and then get the recommendation to get tPA. Beyond a certain point, treatments such as tPA and thrombectomy are no longer beneficial,” he emphasized.

“Rural populations have to travel to an emergency department or speak to a health care provider about their situation, so that can account for disparities in care,” Dr. Wilcock continued. “In addition, rural populations are known to have more chronic and underlying conditions that predict a more severe stroke—which may account, in part, for the differences in patient outcomes that we are seeing.”

Likewise, in 2008, 63.9 percent of urban area residents and only 33.2 percent of rural residents with TIA and stroke were assessed by a neurologist during their admission. This represented an unadjusted disparity of 30.7 percentage points. However, by 2017, the rural-urban disparity in neurologist assessment during admission tapered off by 6.3 percentage points following adjustment.

Has telemedicine impacted the statistics? Somewhat, Dr. Wilcock noted, but a number of barriers remain to using telemedicine under the Medicare program.

“Historically, telemedicine for traditional Medicare patients has only been allowed in rural areas from clinics or hospitals,” Dr. Wilcock said. “You couldn't do it from home, and most likely you had to be a rural resident. “You had to be in a care setting like a clinic, which was located in a rural area, among other limitations.”

Until recently, many hospitals did not qualify for payment under Medicare's telemedicine rules, noted Dr. Wilcock. “It's an investment, and rural locations may have fewer resources for it than other hospitals. So, we are hoping that in the future, we can figure out ways to make telemedicine more widely available in these hospitals that serve rural populations,” he added.

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“Its hard to interpret any one finding in isolation. Higher mortality certainly looks like a big problem, however, thats not obviously the case. For example, if the answer is that patients in rural settings have different preferences for intensity of care resulting in higher mortality, but less survival with severe disability, then the slightly higher mortality rate might be a reflection of that preference-sensitive care.”—DR. JAMES BURKE

Some of these barriers have been addressed in the setting of COVID-19, Dr. Wilcock said.

Now patients can do visits from home, and you don't need to be in a rural area. “However, for telestroke these limitations had already been removed under the Balanced Budget Act of 2018 and have been allowed since January 2019. Urban locations, even mobile units are now allowed as sites for telestroke.”

“The current COVID-related changes to Medicare's telemedicine rules probably have not had a direct effect on telestroke use nationally as the rules for telestroke were already loosened last year. But telestroke use may still go up if under the new COVID rules regional health systems have decided to invest in and use telemedicine capabilities broadly,” Dr. Wilcock emphasized.

The study authors identified several study limitations: the results were limited to the Medicare populations, and they said administrative claims records and changes in patient comorbidities over time may be the result of changes in coding and clinician reporting. In addition, the study did not account for ambulance use from emergency medical services clinicians that don't use fees for service billing, they continued.

“More focus is needed on reducing long-standing rural-urban disparities in high-quality stroke care and patient outcomes,” the research team concluded.

Expert Commentary

“This work again proves what we have known for a long time now: What care patients receive depends a lot on where the patient is living. Geography is a big driver of disparity in care,” said Shreyansh Shah, MD, assistant professor at Duke University and medical director of the Durham VA Stroke Program.

“This work again proves what we have known for a long time now: What care patients receive depends a lot on where the patient is living. Geography is a big driver of disparity in care.”

—DR. SHREYANSH SHAH

“In comparison to urban stroke patients, rural stroke patients were less likely to be transferred for higher level of care and this disparity kept on increasing during the study period,” Dr. Shah continued. “This highlights the fact that a large number of rural hospitals are still not able to partner with comprehensive stroke centers, so rural stroke patients are not able to benefit from recently developed lifesaving stroke therapies like mechanical thrombectomy.”

“It's striking how rapid the improvement in tPA use has been in both rural and urban settings, noted James Burke, MD, MS, associate professor of neurology at the University of Michigan. “We went from having less than 1 percent of stroke patients treated with tPA in 2008 and now we are at 6 percent—more than a six-fold increase in less than a decade. That's really pretty impressive progress particularly given how complicated and difficult it is to deliver tPA in rural settings,” Dr. Burke told Neurology Today.

Determining what is driving the gap in mortality is important, Dr. Burke said. “It's hard to interpret any one finding in isolation. Higher mortality certainly looks like a big problem, however, that's not obviously the case. For example, if the answer is that patients in rural settings have different preferences for intensity of care resulting in higher mortality, but less survival with severe disability, then the slightly higher mortality rate might be a reflection of that preference-sensitive care,” he emphasized.

“Future work on stroke systems of care need to consider how to improve access to these lifesaving therapies for rural stroke patients by incorporating rural hospitals into large stroke networks that are developing across the country,” Dr. Shah said.

Disclosures

Drs. Burke, Wilcock, and Shah did not report any disclosures.

Link Up for More Information

• Wilcock AD, Zachrison KS, Schwamm LH, et al. Trends among rural and urban medicare beneficiaries in care delivery and outcomes for acute stroke and transient ischemic attacks, 2008-2017 https://jamanetwork.com/journals/jamaneurology/fullarticle/2765473. JAMA Neurol 2020; Epub 2020 May 4.