title: The association between rural residence and stroke care and outcomes.
abstract: BACKGROUND
  Little is known about stroke care and outcomes in those residing in rural compared to urban areas.
  
  
  METHODS
  We conducted a cohort study on a population-based sample of patients with stroke or transient ischemic attack seen at 153 acute care hospitals in the province of Ontario, Canada, between April 1, 2008 and March 31, 2011. Based on their primary residence, patients were categorized as residing in a rural (population<10,000), medium urban (population 10,000-99,999) or large urban (population≥100,000) area. In the study sample of 15,713, we compared processes of stroke care (use of thrombolysis, stroke unit care, investigations, consultations and treatments) and outcomes (30-day mortality, disability at discharge) in those from rural and urban areas, with multivariable models constructed to evaluate the association between rural residence and outcomes after adjustment for potential confounders.
  
  
  RESULTS
  Patients from rural areas were less likely than those from urban areas to receive stroke unit care, brain imaging within 24 h, carotid imaging, and consultations from neurologists, physiotherapists, occupational therapists and speech language pathologists, and were less likely to be transferred to inpatient rehabilitation facilities. Use of antithrombotic agents and lipid lowering therapy was similar in rural and urban residents, as was disability at discharge. There was a trend toward higher 30-day mortality in rural compared to urban residents (adjusted hazard ratio 1.14; 95% confidence interval 0.99-1.32).
  
  
  CONCLUSIONS
  Rural residence is associated with lower use of key stroke care interventions after stroke. Future work should focus on developing interventions to address gaps in stroke care in rural areas.
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada. Electronic address: 8jyk@queensu.ca.
authors.forename: Julius
authors.initials: J
authors.lastname: Koifman
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. Electronic address: ruth.hall@ices.on.ca.
authors.forename: Ruth
authors.initials: R
authors.lastname: Hall
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. Electronic address: shudong.li@ices.on.ca.
authors.forename: Shudong
authors.initials: S
authors.lastname: Li
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. Electronic address: melissa.stamplecoski@ices.on.ca.
authors.forename: Melissa
authors.initials: M
authors.lastname: Stamplecoski
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. Electronic address: jiming.fang@ices.on.ca.
authors.forename: Jiming
authors.initials: J
authors.lastname: Fang
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada. Electronic address: alexandra.saltman@gmail.com.
authors.forename: Alexandra P
authors.initials: AP
authors.lastname: Saltman
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada. Electronic address: moira.kapral@uhn.ca.
authors.forename: Moira K
authors.initials: MK
authors.lastname: Kapral
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D009864:Ontario / Q000453:epidemiology; D005791:Patient Care / Q000379:methods* / Q000639:trends; D011159:Population Surveillance / Q000379:methods; D012424:Rural Population / Q000639:trends; D020521:Stroke / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D016896:Treatment Outcome; D014505:Urban Population; D055815:Young Adult
keywords: Geographic stroke differences; Healthcare delivery systems; Stroke; Urban rural differences