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Original Investigation
May 4, 2020

Trends Among Rural and Urban Medicare Beneficiaries in Care Delivery and Outcomes for Acute Stroke and Transient Ischemic Attacks, 2008-2017

Author Affiliations
  • 1Center for Health Services Research, Department of Family Medicine, The Larner College of Medicine, University of Vermont, Burlington
  • 2Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
  • 3Massachusetts General Hospital, Boston
  • 4Department of Neurology, Harvard Medical School, Boston, Massachusetts
  • 5Rand Corporation, Arlington, Virginia
  • 6Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 7Beth Israel Deaconess Medical Center, Boston, Massachusetts
JAMA Neurol. Published online May 4, 2020. doi:10.1001/jamaneurol.2020.0770
Key Points

Question  Did disparities between rural vs urban residents following an acute stroke or transient ischemic attack in care and patient outcomes change from 2008 to 2017?

Findings  In this cohort study, rural vs urban disparities in use of certified stroke centers and neurologist consultations narrowed over the past decade. In contrast, disparities in outcomes, such as mortality or morbidity, have not changed or have worsened over the same period.

Meaning  More focus is needed on reducing long-standing rural-urban disparities in high-quality stroke care and patient outcomes.


Importance  Over the last decade or so, there have been substantial investments in the development of stroke systems of care to improve access and quality of care in rural communities. Whether these have narrowed rural-urban disparities in care is unclear.

Objective  To describe trends among rural and urban patients with acute ischemic stroke or transient ischemic attack in the type of health care centers to which patients were admitted, what care was provided, and the outcomes patients experienced.

Design, Setting, and Participants  This descriptive observational study included 100% claims for beneficiaries of traditional fee-for-service Medicare from 2008 through 2017. All rural and urban areas in the US were included, defined by whether a beneficiary’s residential zip code was in a metropolitan or nonmetropolitan area. All admissions in the US among patients with traditional Medicare who had a transient ischemic attack or acute stroke (N = 4.01 million) were eligible to be included in this study. Admissions for beneficiaries with end-stage kidney disease (n = 85 927 [2.14%]), beneficiaries with unidentified Rural-Urban Commuting Area codes (n = 12 797 [0.32%]), and beneficiaries not continuously enrolled in traditional Medicare in the 12 months before and 3 months after their admission (n = 442 963 [11.0%]) were excluded.

Exposures  Residence in an urban or rural area; admission to a hospital with a transient ischemic attack or acute stroke.

Main Outcomes and Measures  Discharge from a certified stroke center, receiving a neurology consultation during admission, treatment with alteplase, days institutionalized, and 90-day mortality.

Results  The final sample included 3.47 million admissions from 2008 through 2017. In this sample, 2.01 million patients (58.0%) were female, and the mean (SD) age was 78.6 (10.5) years. In 2008, 24 681 patients (25.2%) and 161 217 patients (60.6%) in rural and urban areas, respectively, were cared for at a certified stroke center (disparity, −35.4%). By 2017, this disparity was −26.6%, having narrowed by 8.7 percentage points (95% CI, 6.6-10.8 percentage points). There was also narrowing in the rural-urban disparity in neurologist evaluation during admission (6.3% [95% CI, 4.2%-8.4%]). However, the rural-urban disparity widened or was similar with regard to receiving alteplase (0.5% [95% CI, 0.1%-0.8%]), mean days in an institution from admission (0.5 [95% CI, 0.2-0.8] days), and mortality at 90 days (0.3% [95% CI, −0.02% to 0.6%]), respectively.

Conclusions and Relevance  In the last decade, care for rural residents with acute ischemic stroke and transient ischemic attack has shifted to certified stroke centers and now more likely includes neurologist input. 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.

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