Division of Cardiology (G.H., K.E.J.M.).
Washington University School of Medicine, St Louis, MO (A.A.L., L.E.).
Stroke. 2020 Jul;51(7):2131-2138. doi: 10.1161/STROKEAHA.120.029318. Epub 2020 Jun 17.
The rural-urban life-expectancy gap is widening, but underlying causes are incompletely understood. Prior studies suggest stroke care may be worse for individuals in more rural areas, and technological advancements in stroke care may disproportionately impact individuals in more rural areas. We sought to examine differences and 5-year trends in the care and outcomes of patients hospitalized for stroke across rural-urban strata.
Retrospective cohort study using National Inpatient Sample data from 2012 to 2017. Rurality was classified by county of residence according to the 6-strata National Center for Health Statistics classification scheme.
There were 792 054 hospitalizations for acute stroke in our sample. Rural patients were more often white (78% versus 49%), older than 75 (44% versus 40%), and in the lowest quartile of income (59% versus 32%) compared with urban patients. Among patients with acute ischemic stroke, intravenous thrombolysis and endovascular therapy use were lower for rural compared with urban patients (intravenous thrombolysis: 4.2% versus 9.2%, adjusted odds ratio, 0.55 [95% CI, 0.51-0.59], <0.001; endovascular therapy: 1.63% versus 2.41%, adjusted odds ratio, 0.64 [0.57-0.73], <0.001). Urban-rural gaps in both therapies persisted from 2012 to 2017. Overall, stroke mortality was higher in rural than urban areas (6.87% versus 5.82%, <0.001). Adjusted in-patient mortality rates increased across categories of increasing rurality (suburban, 0.97 [0.94-1.0], =0.086; large towns, 1.05 [1.01-1.09], =0.009; small towns, 1.10 [1.06-1.15], <0.001; micropolitan rural, 1.16 [1.11-1.21], <0.001; and remote rural 1.21 [1.15-1.27], <0.001 compared with urban patients. Mortality for rural patients compared with urban patients did not improve from 2012 (adjusted odds ratio, 1.12 [1.00-1.26], <0.001) to 2017 (adjusted odds ratio, 1.27 [1.13-1.42], <0.001).
Rural patients with stroke were less likely to receive intravenous thrombolysis or endovascular therapy and had higher in-hospital mortality than their urban counterparts. These gaps did not improve over time. Enhancing access to evidence-based stroke care may be a target for reducing rural-urban disparities.
城乡预期寿命差距正在扩大，但根本原因尚不完全清楚。先前的研究表明，农村地区的卒中护理可能更差，卒中护理技术的进步可能会对更多农村地区的个体产生不成比例的影响。我们旨在研究不同城乡地区卒中患者的治疗和预后差异及 5 年变化趋势。
这是一项利用 2012 年至 2017 年全国住院患者样本的回顾性队列研究。根据国家卫生统计中心的 6 层分类方案，根据居住地的县来划分农村和城市。
在我们的样本中，有 792054 例急性卒中住院患者。与城市患者相比，农村患者更常为白人（78%对 49%），年龄超过 75 岁（44%对 40%），收入处于最低四分位数（59%对 32%）。在急性缺血性卒中患者中，农村患者接受静脉溶栓和血管内治疗的比例低于城市患者（静脉溶栓：4.2%对 9.2%，调整后比值比为 0.55[95%CI，0.51-0.59]，<0.001；血管内治疗：1.63%对 2.41%，调整后比值比为 0.64[0.57-0.73]，<0.001）。2012 年至 2017 年，这两种治疗方法的城乡差距持续存在。总的来说，农村地区的卒中死亡率高于城市地区（6.87%对 5.82%，<0.001）。农村地区的住院死亡率随着农村程度的增加而增加（郊区：0.97[0.94-1.0]，=0.086；大城镇：1.05[1.01-1.09]，=0.009；小城镇：1.10[1.06-1.15]，<0.001；中等城市农村：1.16[1.11-1.21]，<0.001；偏远农村地区：1.21[1.15-1.27]，<0.001），与城市患者相比。与城市患者相比，农村患者的死亡率在 2012 年（调整后比值比为 1.12[1.00-1.26]，<0.001）至 2017 年（调整后比值比为 1.27[1.13-1.42]，<0.001）并未改善。
与城市患者相比，农村卒中患者更不可能接受静脉溶栓或血管内治疗，且住院死亡率更高。这些差距并没有随着时间的推移而改善。提高循证卒中治疗的可及性可能是减少城乡差异的目标。
