Rural versus urban academic hospital mortality following stroke in Canada

Abstract

IntroductionStroke is one of the leading causes of death in Canada. While stroke care has improved dramatically over the last decade, outcomes following stroke among patients treated in rural hospitals have not yet been reported in Canada.ObjectivesTo describe variation in 30-day post-stroke in-hospital mortality rates between rural and urban academic hospitals in Canada. We also examined 24/7 in-hospital access to CT scanners and selected services in rural hospitals.Materials and methodsWe included Canadian Institute for Health Information (CIHI) data on adjusted 30-day in-hospital mortality following stroke from 2007 to 2011 for all acute care hospitals in Canada excluding Quebec and the Territories. We categorized rural hospitals as those located in rural small towns providing 24/7 emergency physician coverage with inpatient beds. Urban hospitals were academic centres designated as Level 1 or 2 trauma centres. We computed descriptive data on local access to a CT scanner and other services and compared mean 30-day adjusted post-stroke mortality rates for rural and urban hospitals to the overall Canadian rate.ResultsA total of 286 rural hospitals (3.4 million emergency department (ED) visits/year) and 24 urban hospitals (1.5 million ED visits/year) met inclusion criteria. From 2007 to 2011, 30-day in-hospital mortality rates following stroke were significantly higher in rural than in urban hospitals and higher than the Canadian average for every year except 2008 (rural average range = 18.26 to 21.04 and urban average range = 14.11 to 16.78). Only 11% of rural hospitals had a CT-scanner, 1% had MRI, 21% had in-hospital ICU, 94% had laboratory and 92% had basic x-ray facilities.ConclusionRural hospitals in Canada had higher 30-day in-hospital mortality rates following stroke than urban academic hospitals and the Canadian average. Rural hospitals also have very limited local access to CT scanners and ICUs. These rural/urban discrepancies are cause for concern in the context of Canada’s universal health care system.

Potentially avoidable Inter-Facility transfer from Veterans Health Administration emergency departments: A cohort study

“…Over 2.4 million Veterans seek care from Veterans Health Administration (VHA) emergency departments (EDs) each year, and 40% of these Veterans live in rural America [1]. Providing high quality emergency care in low-volume centers is challenging, and several prior studies have suggested that clinical outcomes are worse in low-volume rural hospitals [2][3][4][5][6][7][8][9]. These volumeoutcome relationships could be attributable to provider training and experience, staffing, or resource allocation in low-volume facilities [10].…”

Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada

“…[1][2][3] Interventions such as thrombolysis, endovascular thrombectomy (EVT), stroke unit care, and rehabilitation are associated with improved outcomes after stroke, but require resources and expertise that are not available in all centers and are less likely to be located in rural areas. 1,[4][5][6][7] Poor geographic access to medical care has been associated with lower quality of care and with worse outcomes for a variety of medical conditions. 8,9 Although organized systems of stroke care in Ontario are designed to optimize care across the continuum for an entire region, it is not known whether current stroke systems provide adequate access for residents of rural areas.…”

Canadian in-hospital mortality for patients with emergency-sensitive conditions: a retrospective cohort study

“…(22) This finding echoes previous reports that highlighted significant disparities in access to high-quality emergency care in Canadian rural communities. (23,24) In the same way it was done for trauma care across the country, Canadian decision-and policy-makers could use the ED-HSMR to trigger in-depth performance assessment to help identify opportunities for improving emergency care structures and processes to improve patient outcomes. As worrisome as they are, wait times henceforth do not appear to be the only important risk factor impacting outcomes of ED patients with emergency sensitive conditions.…”