SAN DIEGO—The city life and country living each has its own set of advantages and disadvantages, and that may include certain aspects of acute stroke care. According to Wayne Clark, MD, and colleagues, the elapsed time from dispatch of emergency personnel to a patient’s arrival at a rural hospital was shorter than it was for a patient to be admitted to an urban hospital. In addition, patients who arrived at a rural emergency department were evaluated by a physician more rapidly than were those at an urban emergency department. However, stroke evaluations at urban hospitals were more resource-intensive than were those at rural hospitals.

Overall, despite the differences, the end results for stroke patients were comparable regardless of in which setting they received acute stroke care. “Patient outcomes are similar for urban and rural stroke patients, even after stratifying by stroke severity,” Dr. Clark commented. Dr. Clark is Director of the Oregon Stroke Center and Professor of Neurology at the Oregon Health and Science University in Portland. He presented his group’s findings at the American Stroke Association’s 29th International Stroke Conference.

HEALTH CARE AND HABITAT

The health services infrastructure in rural communities often faces geographic and financial challenges unlike those in larger urban areas, noted Dr. Clark. So he and his group wanted to determine the impact that rural living in Oregon had on prehospital and acute stroke care. Oregon consists of a few urban areas primarily in the western part of the state and a large, sparsely populated area covering the central and eastern areas. Sixteen hospitals in the state were recruited to participate in a prototype stroke registry. The registry collects more than 100 variables and represents approximately 60% of the strokes in Oregon. As of January 2004, the registry contained 3,669 stroke records.

Although many of the 16 hospitals serve rural residents, four are located in rural communities and thus qualified as rural hospitals. Rural was defined as all geographic areas 10 or more miles from the centroid of a population center of 30,000 or more.

STROKE AND THE CITY

The researchers found that urban patients had a mean length of stay of 4.7 days, compared with 3.2 days for rural patients. “The length of stay is significantly longer for stroke patients at urban hospitals,” said Dr. Clark. Both groups were similar in terms of being discharged to home/self-care (46% rural, 43% urban) and being able to walk or walk with assistance at discharge (82% rural, 83% urban). The two groups had an identical in-hospital mortality rate of 11.1%.

The mean elapsed time from emergency management services (EMS) dispatch to scene arrival in an urban setting was 8.4 minutes versus 7.5 minutes for that in a rural setting. For EMS dispatch to emergency department arrival, the mean was 41.4 minutes in the urban environment compared with 37.2 minutes in the rural area. Once a patient arrived at the hospital, living in an urban area had its advantages. Among urban patients, 3.4% received acute thrombolysis, compared with 2.7% of rural dwellers. About 17% of urban patients were assessed using the NIH Stroke Scale, compared with 2% of rural patients, and 23% of urban patients had a brain image taken within 25 minutes versus 11% of rural patients. In addition, 57% of urban patients had a consultation with a neurologist compared with 16% of rural patients. On the positive side for rural patients, 41% were observed by an emergency department physician within 10 minutes versus 32% of urban patients.

INPATIENT STROKE EVALUATION

The investigators found that 61% of urban patients had a dysphagia evaluation performed within 48 hours, compared with 45% of rural patients, and 58% of urban patients had a carotid ultrasound or magnetic resonance angiography, versus 43% of rural patients. Both groups had a nearly identical rate of CT (96% rural, 94% urban), and 40% of urban patients had an MRI, compared with 14% of rural patients.

Dr. Clark pointed out that additional severity-adjusted analysis, greater rural representation, and more sensitive outcome measures are necessary before results can be generalized beyond their pilot study sample.

NR

—Colby Stong

Suggested Reading
Burgin WS, Staub L, Chan W, et al. Acute stroke care in non-urban emergency departments. Neurology. 2001;57:2006-2012.

Return to table of contents