title: Rural-urban differences in inpatient quality of care in US Veterans with ischemic stroke.
abstract: OBJECTIVE
  Differences in stroke care quality for patients in rural and urban locations have been suggested, but whether differences exist across Veteran Administration Medical Centers (VAMCs) is unknown. This study examines whether rural-urban disparities exist in inpatient quality among veterans with acute ischemic stroke.
  
  
  METHODS
  In this retrospective study, inpatient stroke care quality was assessed in a national sample of veterans with acute ischemic stroke using 14 quality indicators (QIs). Rural-Urban Commuting Areas codes defined each VAMC's rural-urban status. A hierarchical linear model assessed the rural-urban differences across the 14 QIs, adjusting for patient and facility characteristics, and clustering within VAMCs.
  
  
  RESULTS
  Among 128 VAMCs, 18 (14.1%) were classified as rural VAMCs and admitted 284 (7.3%) of the 3,889 ischemic stroke patients. Rural VAMCs had statistically significantly lower unadjusted rates on 6 QIs: Deep vein thrombosis (DVT) prophylaxis, antithrombotic at discharge, antithrombotic at day 2, lipid management, smoking cessation counseling, and National Institutes of Health Stroke Scale completion, but they had higher rates of stroke education, functional assessment, and fall risk assessment. After adjustment, differences in 2 QIs remained significant-patients treated in rural VAMCs were less likely to receive DVT prophylaxis, but more likely to have documented functional assessment.
  
  
  CONCLUSIONS
  After adjustment for key demographic, clinical, and facility-level characteristics, there does not appear to be a systematic difference in inpatient stroke quality between rural and urban VAMCs. Future research should seek to understand the few differences in care found that could serve as targets for future quality improvement interventions.
authors.affiliation: Department of Neurology, University of Connecticut/Hartford Hospital, Hartford, Connecticut; Medical Informatics, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Connecticut; VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI) Program, Indianapolis, Indiana.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Phipps
authors.forename: Huanguang
authors.initials: H
authors.lastname: Jia
authors.forename: Neale R
authors.initials: NR
authors.lastname: Chumbler
authors.forename: Xinli
authors.initials: X
authors.lastname: Li
authors.forename: Jaime G
authors.initials: JG
authors.lastname: Castro
authors.forename: Jennifer
authors.initials: J
authors.lastname: Myers
authors.forename: Linda S
authors.initials: LS
authors.lastname: Williams
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Bravata
mesh_terms: D000368:Aged; D005260:Female; D006780:Hospitals, Rural / Q000592:standards; D006786:Hospitals, Urban / Q000592:standards; D006787:Hospitals, Veterans / Q000592:standards*; D006801:Humans; D007297:Inpatients; D008297:Male; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D020521:Stroke / Q000453:epidemiology / Q000628:therapy*; D014481:United States / Q000453:epidemiology; D014728:Veterans
keywords: geography; health disparities; health services research; quality; veterans