Rural-Urban Disparity in Postacute Care and 1-Year Outcomes After Ischemic Stroke

Rural residents have been experiencing higher stroke mortality than urban residents, and the gap has widened. Disparity in postacute care after stroke may increase the rural-urban gaps of mortality and disability. We aimed to examine whether rural patients with stroke receive the same postacute care and achieve comparable outcomes to urban patients.

We conducted a cohort study of Medicare beneficiaries aged ≥65 years treated in the Get With The Guidelines-Stroke participating hospitals for acute ischemic stroke during 2017 to 2022. We used restricted mean home-time to compare 1-year home-time among patients discharged from rural versus urban hospitals and the Cox proportional hazards model for all-cause mortality and readmission, adjusting for patient and hospital characteristics.

The analysis included 29 734 patients treated in rural hospitals and 478 122 in urban hospitals, with a mean age of 79 years, and 55.5% were women. Compared with patients in urban hospitals, patients in rural hospitals were less commonly discharged to inpatient rehabilitation facilities (20.1% versus 25.1%; adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]) and more frequently to skilled nursing facilities (24.5% versus 20.9%; adjusted odds ratio, 1.21 [95% CI, 1.11-1.32]). Compared with urban patients, rural patients had 1.8 fewer days of home-time (95% CI, -3.2 to -0.3) overall; rural patients discharged to skilled nursing facilities had 5.7 fewer days of home-time (95% CI, -9.0 to -2.3), and those discharged home had 2.2 fewer days of home-time (95% CI, -3.7 to -0.7). Rural patients overall had comparable all-cause mortality with urban patients (adjusted hazard ratio, 1.01 [95% CI, 0.98-1.05]) and lower all-cause readmission (adjusted hazard ratio, 0.92 [95% CI, 0.90-0.95]). However, rural patients who were discharged home had higher all-cause mortality than urban patients (adjusted hazard ratio, 1.11 [95% CI, 1.05-1.17]).

Compared with urban patients, rural patients with stroke had less inpatient rehabilitation facility and more skilled nursing facility utilization, less home-time, but similar mortality. Further efforts are needed to ensure equitable postacute care in rural areas.