Background: Rural-urban disparities in access to acute stroke care exist and have widened over time. We sought to quantify the rural-urban disparities that may exist in access to endovascular thrombectomy (EVT) for patients experiencing strokes with large vessel occlusions in Colorado.
Methods: This was a retrospective cohort study looking at all Colorado residents aged ≥18 years with large vessel occlusions undergoing EVT, between January 1, 2015, and November 30, 2022. Eleven sites performed EVTs in Colorado during the study period, and each site submitted data independently to the coordinating center. Rural designation at the patient level was defined as either (1) the patient first presented to a rural hospital or (2) the patient lived in a rural area based on their 5-digit residential zip code. Primary outcomes include time from last known normal to groin puncture and unfavorable outcome, defined as a modified Rankin Scale score >2 at discharge. Secondary outcomes include the length of stay and whether the patient was discharged home.
Results: A total of 3100 patients were included in the study: 346 (11%) rural and 2754 (89%) urban patients. The adjusted geometric mean time from last known normal to EVT in rural patients was 6.0 (95% CI, 4.6-7.9) hours compared with 4.5 (95% CI, 3.5-5.8) hours for urban patients. Rural patients took 33.3% (P=0.001) longer than urban patients to undergo EVT. Rural patients had a 10% higher risk of unfavorable outcomes (P=0.016). The lengths of stay for rural patients were 14% longer than urban patients (P<0.01). Rural patients were 11% more likely not to be discharged home after a stroke than urban patients (P=0.007).
Conclusions: Rural patients experienced longer time to intervention and had worse outcomes after a stroke with large vessel occlusions. Each rural patient with large vessel occlusions lost ≈1.7 years of disability-free life compared with an urban patient with the same severity stroke. More work needs to be done to identify and quantify the sources of delay for rural patients.
Keywords: cardiovascular diseases; delivery of health care; heart disease risk factors; ischemic stroke; thrombectomy.