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

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.