MedWire News: The quality of rural acute stroke care in the USA needs urgent attention, as it is not keeping pace with that of urban care, say reviewers.
Enrique Leira (University of Iowa College of Medicine, Iowa City, USA) and colleagues reviewed studies of urban and rural acute stroke care. They say that the topic proved too one-sided to be suitable for a systematic review.
"Acute stroke management practices in rural areas are suboptimal, which creates an unacceptable health disparity between urban stroke patients and their rural counterparts, who constitute 25% of the US population," they write in the Archives of Neurology.
Stroke patients in rural USA often receive acute care from primary care physicians in small hospitals.
"This environment is not reproduced by current stroke trials, which are conducted by academic vascular neurologists in large urban medical centers," note Leira et al.
They say that inferior rural stroke care begins with the paramedics, who tend to be older and less educated than urban paramedics, and are often volunteers. "They have, in general, less training, less experience, and fewer learning opportunities to achieve the proficiency of their urban counterparts," says the team.
"This problem needs to be overcome through federal and state initiatives to reduce quality gaps in rural emergency medical services, including incentives to recruit professional, well-trained individuals."
Emergency physicians in rural hospitals are likely to see far fewer stroke patients than those in urban settings, and are reputedly less willing to use recombinant tissue plasminogen activator (rtPA).
"These reservations are not surprising because the rtPA trial was conducted using expert vascular neurologists in large urban academic centers," say Leira and team.
They add: "This urban-rural gap is likely to worsen in the future as more complex interventions that require more sophisticated diagnostic capabilities and physician expertise, such as intra-arterial or mechanical thrombolysis, are tested and implemented in urban academic centers."
To improve acute stroke care in rural hospitals, the team recommends a "hub-and-spoke" system, whereby several small rural hospitals are supported by a large comprehensive stroke center. This system allows for support ranging from simple telephone consultations to sophisticated telemedicine.
A "hub-and-spoke" approach also allows for "drip and ship," where patients are administered rtPA at their local hospital and then rushed to the comprehensive center for further care.
Given the long distances involved in rural America, it is vital to optimize the transfer process in "drip and ship," stress Leira and colleagues. This includes maintaining contact with the patients' relatives, who may need to give consent for procedures such as intra-arterial thrombolysis.
"Family members typically arrive by ground later than the patient and helicopter crew, and the unavailability of consenting family members often impedes the tertiary care team's efforts to consider invasive therapies," says the team.
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