Key Rural-Urban Differences Revealed in U.S. Post-Acute Stroke Care

Compared with stroke patients discharged from urban hospitals, rural stroke patients are sent less often to an inpatient rehabilitation facility and more often to a skilled nursing facility, indicating that rural patients likely have poorer access to important rehabilitation services. Tellingly, patients discharged to a skilled nursing facility spend substantially fewer days at home over the subsequent year — a validated outcome that reflects functional status — than those discharged to a rehab facility.

These findings, from a large U.S. cohort study, were recently published online ahead of print in Stroke. It was the second in a series of analyses focused on rural versus urban stroke care. The earlier study (Stroke. 2024;55[10]:2472-2481) evaluated acute stroke care and found that rural hospitals tend to provide less thrombolytic therapy, slower treatment times and less secondary stroke prevention treatment than urban hospitals do.

“Our team of experts from major North American institutions and the American Heart Association are shedding light on rural-urban differences in stroke care and subsequent outcomes,” says Cleveland Clinic neurologist Shumei Man, MD, PhD, first and corresponding author of both studies. “Our goal is to identify actionable causes to enable further intervention to improve the health of rural residents in the U.S., who have been experiencing a 30% higher stroke mortality than their urban counterparts.”

Study design

The cohort used for the current study consisted of Medicare beneficiaries aged 65 or older treated for acute ischemic stroke in hospitals participating in the American Heart Association’s Get With The Guidelines^® (GWTG)-Stroke program between 2017 and 2022. The analysis consisted of 29,734 patients from rural hospitals and 478,122 from urban hospitals (overall mean age of 79 years, 55.5% women), from a total of 2,345 sites.

Discharge destinations differed

Key findings related to discharge destination were as follows:

• Rural patients were less likely than urban patients to be discharged to an inpatient rehabilitation facility (20.1% vs. 25.1%; adjusted odds ratio [aOR] = 0.76; 95% CI, 0.69-0.84).
• Rural patients were more likely than urban patients to be discharged to a skilled nursing facility (24.5% vs. 20.9%; aOR = 1.21; 95% CI, 1.11-1.32).
• Rural patients were more likely than urban patients to be discharged home (48.0% vs. 45.7%; aOR = 1.06; 95% CI, 1.04-1.09).

“Rehabilitation services tend to be more intensive in an inpatient rehab facility than in a skilled nursing facility,” Dr. Man notes. “Consequently, studies have shown that patients discharged to an inpatient rehabilitation facility following a stroke tend to have better functional progress than those placed in a skilled nursing facility, as well as more time at home rather than in a care facility and lower one-year mortality in the year following the stroke.” She adds that rural patients’ increased nursing home discharge rate is unlikely due to poor function because more rural patients discharged to a skilled nursing facility were able to walk independently compared with their urban counterparts. She says this suggests that some rural patients discharged to a nursing home may medically meet the criteria for inpatient rehabilitation.

Differences in home-time

“Home-time” — defined as time a patient is not in a healthcare institution — has been identified as the most relevant and meaningful outcome associated with patient health following stroke. Increased home time represents better functional status and is a priority for patients with stroke.

In the current study, patients discharged to an inpatient rehabilitation facility had a median of 76 more days of home-time over the year compared with those discharged to a skilled nursing facility.

An adjusted analysis also found rural-urban differences in home-time according to discharge destination. Compared with their urban counterparts:

• Rural patients discharged to skilled nursing facilities had 5.7 fewer days of home-time.
• Rural patients discharged home had 2.2. fewer days of home-time.

Rural and urban patients discharged to inpatient rehabilitation facilities had comparable amounts of home-time.

Overall outcomes show mixed picture

In some respects, rural hospitals participating in the GWTG-Stroke program demonstrated favorable or comparable outcomes to urban hospitals:

• Rural hospitals had lower one-year all-cause readmission rates.
• Rural hospitals had similar rates of all-cause mortality, ischemic stroke readmissions and a composite of all-cause mortality, readmission and emergency department visits.

However, Dr. Man points out, further scrutiny may reveal a different picture. First, this study did not include patients who were transferred to another hospital. “Patients with severe stroke in rural hospitals tend to be transferred to a larger urban hospital, which might have reduced the mortality in rural hospitals and increased mortality in large hospitals,” she explains. Additionally, lower readmission rates might be due to rural residents having less access to medical care or being less willing to seek it.

Strategies that could improve rural stroke care

Dr. Man suggests several ways to bring the quality of post-acute stroke care in rural areas closer to the level in urban settings:

• Increase the rural workforce. Shortages of stroke expertise and physical therapists in rural areas likely limit access to, and quality of, acute stroke treatment and rehabilitation.
• Enhance care-team awareness. Health professionals need to keep in mind the importance of prompt treatment and rehabilitation following stroke, and help patients and families make educated decisions.
• Foster innovative solutions such as telestroke, teleneurology and electronic rehabilitation to increase access to specialty care in rural areas. Modified outpatient cardiac rehabilitation programs, as well as technology-enhanced home-based rehabilitation, have shown promise in post-stroke recovery and may be especially useful for patients in rural areas with limited access to specialty stroke rehabilitation resources.
• Increase GWTG-Stroke participation in rural areas. Although this study only included patients from GWTG-Stroke participating hospitals, other studies have shown that such hospitals are associated with sustained improvement in evidence-based stroke care.

“Our research has identified modifiable processes in stroke hospitals from acute thrombolytic therapy to secondary stroke prevention treatment to rehabilitation utilization,” Dr. Man concludes. “These gaps in care access and quality are likely due mainly to shortages of stroke expertise and resources in rural areas. Addressing these gaps will likely require an integrated healthcare system and policy changes that extend beyond rural hospitals alone.”