Abstract
Background: Nearly one fifth of the US population resides in rural areas. Although endovascular therapy can substantially improve clinical outcomes in patients treated with large vessel occlusion acute ischemic stroke, the penetration and outcomes of this therapy in rural US populations remain incompletely characterized. Methods: From the nationwide Get With The Guidelines Stroke registry, incorporating select social determinants of health (SDOH) by the Institute for Health Metrics and Evaluation registry (2016-2019), we identified patients with acute ischemic stroke and transient ischemic attack who were transferred from their presenting hospitals to other hospitals with the intention of thrombectomy evaluation, for patients residing in rural and nonrural areas. The primary outcome was the likelihood of undergoing intra-arterial catheter-based therapy after transfer, adjusted for stroke severity, age, baseline ambulatory status, and select SDOH, by multivariable logistic regression. Results: Among 24 620 patients meeting inclusion criteria, 5.1% resided in rural areas. Patients residing in rural areas transferred for endovascular therapy evaluation experienced less favorable SDOH than patients residing in nonrural areas (P<0.01, each, for education, income, homeownership, poverty, and unemployment). Patients in both groups presented with moderate/severe stroke and similar vascular risk factors. Patients residing in rural areas were 15% less likely to undergo endovascular therapy, when adjusting for stroke severity, age, baseline ambulatory status, and select SDOH (40.8% versus 49.4%; adjusted odds ratio [aOR], 0.85 [95% CI, 0.74-0.99]). Patients residing in rural areas experienced similar incidence of reported transfer delays as patients residing in non-rural areas (0.1%, each; aOR, 1.36 [95% CI, 0.56-6.84]). Conclusion: In this nationwide cohort study, patients living in rural areas with acute ischemic stroke or transient ischemicattack who were transferred to other hospitals for endovascular therapy evaluation were less likely to undergo intra-arterial catheter-based therapy, despite similar incidence of transfer delays, and when adjusting for select SDOH commonly associated with rurality.