ISC 2024 | Stroke in rural vs non-rural areas

We know that patients who live in rural areas undergo about two thirds as much mechanical thrombectomy than patients who reside in non-rural areas. And we also know that patients who reside in rural areas present less than half as much to a facility that actually is thrombectomy capable. So we really wanted to understand better what’s going on. Obviously, there’s a geographic disparity. There’s not a lot of mechanical thrombectomy centers in rural areas. But also to see what else is going on. Can we characterize the patient population and actually characterize the issue that we’re trying to face here? And then from there, you know, what can we try to do to mitigate some of these disparities? So with that, the American Heart Association/American Stroke Association had a Get With the Guidelines challenge, where they took the hospital reported data and linked it to social determinants of health, which were provided by the Institute for Health Metrics and Evaluation, and gave us an opportunity to delve deeper into this question. It was a data challenge, it was challenging, you know, learning how to use the data and so on, but it was a great experience and a great opportunity and a great resource.

Ultimately, we found that one of the issues that came up was that there are not a lot of rural patients in Get With the Guidelines at the moment and we can talk more about that later. But, for the time frame that we were able to look at, there are only about 3% of the patients had resided in rural areas overall in the whole registry. So we kind of had to refocus our efforts and sort of how to really understand this patient population. So we looked initially for the project that you are specifically referring to at patients who had LVO stroke, regardless of whether they went on to mechanical thrombectomy or not and we looked at their demographics, but also their social determinants of health. And in that project we found that there were a fair amount of demographic differences, but also that patients were less likely to own homes, were less likely to have a bachelor’s degree, and had lower median income. And then we also looked at metrics at the same time. So we found that patients who reside in rural areas actually presented to hospitals, whichever hospitals reporting to Get With the Guidelines, whether there were an initial hospital or hospital after transfer, we found that rural patients presented to the hospital probably about a little over an hour later than patients who resided in non-rural areas. We also found that patients receive less tPA. Initially there was a difference in tPA metrics, so the door to needle time was longer actually for patients in non-rural areas but when you accounted for patients who actually went on to mechanical thrombectomy, it was about comparable the door to needle time. So we found some sort of differences in metrics, some interesting things regarding tPA metrics and found ultimately that patients do experience less favorable social determinants of health.

To get back to the Get With the Guidelines and rural patients, Get With the Guidelines in the last about year or two, they have made a lot of initiatives to increase and include rural hospitals. I do telestroke and a lot of the hospitals I work with are actually now talking about working with Get With the Guidelines so it’s kind of cool to see that at the sort of face to face and granular level. From my perspective, I think that will be interesting once we have some of that data to really represent those patients in Get With the Guidelines and really understand that better. But until then, what are what are the best ways to understand? I think, you know, our kind of next goals are, are there other ways we can look at patient information, whether that’s with hospital reported outcomes or national inpatient samples or what other ways can we kind of characterize what’s going on? The other thing that’s interesting is, you know, is there a graded change regarding rurality? RUCA 10 is the most rural code, but there are other non-urban codes that are somewhere in between. So is there any way that this may change depending on the degree of rurality.? That’s something that we’re looking into. And then ultimately what can we do to mitigate these differences. We literally are treating patients differently because of geographic differences. It’s easy to kind of throw your hands up and say, oh, it’s because they live far away and we can’t just build hospitals everywhere and we can’t do mechanical thrombectomy everywhere. But, are there ways we can utilize the tools that we have? We have lots of cool things. We have telestroke, we have mobile stroke units, we have telestroke on mobile stroke units, we have care coordination applications. We have a lot of things that have been shown to help with access in non-rural settings, but these rural settings do not have access to a lot of the things, whether it’s, you know, because they don’t have a mobile stroke unit or because they don’t have bandwidth or less bandwidth, or it’s harder to implement telestroke or care coordination apps.

Additionally, I think one of the things that may help is that we look at a lot of door to needle times and that’s something that a lot of telestroke companies are really focusing on. But we really need to start holding telestroke companies accountable for transfer times as well. For these patients who are coming from really underserved areas. How can we explore that better? How can we make that work? And then hopefully, eventually, it would be awesome to get policy changed and so on to help support that. So a lot of systemic issues as well that need to be taken care of and addressed but those are sort of, I guess, future directions and long term goals for understanding rural patients’ experience.

Get With the Guidelines has this rural accelerator program where they’re really working on inclusivity for rural hospitals. And by providing the ability for rural hospitals to participate in Get With the Guidelines with without having to pay and also providing awards and other incentives for rural hospitals to participate and for having excellent quality goals and so on, this is something that the Get With the Guidelines has been doing to improve the issue of not having enough rural representation in the registry the way it is now.