Background: Rural residence is associated with stroke incidence and mortality, but little is known about potential rural/urban differences in ambulatory stroke care. Methods and Results: We used the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) cohort, created from linked administrative databases from the province of Ontario, Canada, and divided into primary (N=6 207 032) and secondary (N=75 823) prevention cohorts based on the absence or presence of prior stroke. We defined rural communities as those with a population size of ≤10 000 and within each of the primary and secondary prevention cohorts, compared cardiovascular risk factors and care between rural and urban areas. We then calculated sex-/age-standardized rates of stroke incidence and mortality per 1000 person-years between January 1, 2008 and December 31, 2012 and used cause-specific hazard models to compare outcomes in rural versus urban areas adjusting for age, sex, income, ethnicity, smoking, physical activity and comorbid conditions, and accounting for the competing risk of death in the model for the occurrence of stroke incidence. In the primary prevention cohort, rural residents were less likely than urban ones to be screened for diabetes mellitus (70.9% versus 81.3%) and hyperlipidemia (66.2% versus 78.4%) and less likely to achieve diabetes mellitus control (hemoglobin A1c ≤7% in 51.3% versus 54.3%; P <0.001 for all comparisons). In the secondary prevention cohort, the prevalence and treatment of risk factors were similar in rural and urban residents. After adjustment for sociodemographic and comorbid conditions, rural residence was associated with higher rates of stroke and all-cause mortality in both the primary prevention (adjusted hazard ratio [aHR] for stroke, 1.06; 95% CI, 1.04–1.09; aHR for mortality, 1.09; 95% CI, 1.08–1.10) and the secondary prevention cohort (aHR for stroke, 1.11; 95% CI, 1.02–1.19; aHR for mortality, 1.07; 95% CI, 1.03–1.11). Conclusions: In this population-based study of over 6 million people with universal access to physician and hospital services, risk factors were more prevalent but less likely to be controlled in rural than in urban residents without prior stroke, whereas in those with prior stroke, risk factor prevalence and treatment were similar. Rural residence was associated with the rate of stroke and death even after adjustment for risk factors. Future efforts should focus not only on control of known vascular risk factors but also on addressing other determinants of health in rural communities.

Introduction: Residents of rural areas may have limited access to certain health care services. However, little is known about rural-urban differences in stroke secondary prevention care, or in the risk of recurrent stroke and death. We used linked population-based administrative databases from the province of Ontario, Canada, to assess the association between rural residence and ambulatory processes of care for secondary stroke prevention, as well as the incidence of recurrent stroke. Methods: We studied a sub-population of the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort, comprised of individuals between ages 40 to 105 years with a history of stroke prior to January 1, 2008. We defined rural communities as those with a population size of ≤ 10, 000, and compared screening and treatment for hypertension, hyperlipidemia, diabetes mellitus and smoking in rural and urban areas, as well as the incidence of recurrent stroke, adjusting for age, sex and baseline risk factors. Results: In our study sample of 86,811 individuals with prior stroke, the prevalence of vascular risk factors was similar in both rural and urban residents. Rural residents (n=10,988) had fewer mean annual visits to family physicians (5.2 vs. 6.7; p<0.001) and specialist physicians (2.5 vs. 3.5; p<0.001) and were less likely to be screened for hyperlipidemia (67.9% vs. 81.5%; p <0.05) compared to their urban counterparts. There were no rural-urban differences in prescription of medications for hypertension, diabetes and hyperlipidemia, and no differences in control of diabetes. The incidence of recurrent stroke was slightly higher in rural compared to urban areas (12.0 vs. 11.5 per 1000 person years, adjusted hazard ratio 1.09; 95% confidence interval 1.01 to 1.18). Conclusions: Rural and urban residents with prior stroke had similar prevalence and treatment of vascular risk factors, however, rural residence was associated with fewer physician visits, less screening for hyperlipidemia, and a slight increase in the risk of recurrent stroke. Ongoing efforts are needed to maintain equitable access to recommended ambulatory care services for secondary stroke prevention, and to address other social determinants of health in rural communities.

Introduction: Little is known about stroke incidence, mortality and risk factor prevalence in rural versus urban regions. We used linked population-based administrative databases to compare cardiovascular risk factors, stroke incidence and stroke-related death in residents of rural and urban Ontario, Canada. Methods: We used a sub-population of the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort, consisting of individuals aged 40 to 105 in Ontario with no known hospitalization for stroke in the 20 years prior to January 1, 2008. We defined rural regions as those with a population size ≤ 30, 000. We compared the age- and sex- standardized prevalence of risk factors, as well as 5-year stroke incidence and stroke-related mortality rates, in people residing in rural versus urban areas. Results: The study sample consisted of 6,207,032 individuals. Compared to residents of urban regions, rural residents were more likely to smoke (25.3% versus 19.3%), be obese (25.1% versus 19.3%) and live in a low-income area (43.5% versus 38.3%) (P<0.001 for all comparisons). However, there were no differences in the proportion of residents with hypertension, diabetes and atrial fibrillation. Age- and sex-standardized stroke incidence was higher in rural compared to urban areas (2.18 versus 1.99 events/1000 person-years; p<0.001), as was stroke-related mortality (0.79 versus 0.65 events/1000 person-years; p<0.001). Conclusions: Certain cardiovascular risk factors have increased prevalence in rural areas compared to urban areas. Furthermore, stroke incidence and mortality rates were greater in rural areas in Ontario. Future efforts should focus on reducing regional discrepancies in social determinants of health and addressing risk factor prevalence, particularly smoking and obesity, in rural regions.