Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years

Abstract

Background: There are glaring racial and rural-urban inequities in stroke outcomes. The objective of this study was to determine whether there were recent changes to trends in racial inequities in stroke treatment and in-hospital mortality, and whether racial inequities differed across rural strata. Methods: Retrospective analysis of Black and White patients >18 years old admitted to US acute care hospitals with a primary discharge diagnosis of stroke (unweighted N=652 836) from the National Inpatient Sample from 2012 to 2017. Rural residence was classified by county as urban, town, or rural. The primary outcomes were intravenous thrombolysis and endovascular therapy use among patients with acute ischemic stroke, and in-hospital mortality for all stroke patients. Logistic regression models were run for each outcome adjusting for age, comorbidities, primary payer, and ZIP code median income. Results: The sample was 53% female, 81% White, and 19% Black. Black patients from rural areas had the lowest odds of receiving intravenous thrombolysis (adjusted odds ratio [aOR], 0.43 [95% CI, 0.37–0.50]) and endovascular therapy (aOR, 0.60 [0.46–0.78]), compared with White urban patients. Black rural patients were the least likely to be discharged home after a stroke compared with White/urban patients (aOR, 0.79 [0.75–0.83]), this was true for Black patients across the urban-rural spectrum when compared with Whites. Black patients from urban areas had lower mortality than White patients from urban areas (aOR, 0.87 [0.84–0.91]), while White patients from rural areas (aOR, 1.14 [1.10–1.19]) had the highest mortality of all groups. Conclusions: Black patients living in rural areas represent a particularly high-risk group for poor access to advanced stroke care and impaired poststroke functional status. Rural White patients have the highest in-hospital mortality. Clinical and policy interventions are needed to improve access and reduce inequities in stroke care and outcomes.