Identifying Best Practices for Improving the Evaluation and Management of Stroke in Rural Lower Resourced Settings

In the last 10 years, we have made great strides in acute stroke treatment. Significant advances in thrombolytic and interventional technologies¹ associated with organizational improvements in stroke care² have allowed clinicians to offer treatment to a larger number of patients and obtain improved clinical outcomes. Unfortunately, most of these advances are disproportionately concentrated in urban high-volume centers³. As a result, many stroke patients in rural areas arrive at hospitals with limited stroke resources, creating a potential gap between urban and rural populations⁴.

The American Heart Association Scientific Statement on Identifying Best Practices for Improving the Evaluation and Management of Stroke in Rural Lower Resourced Settings⁵ provides an excellent insight into the background of these disparities. This document examines the current challenges in rural stroke care, and proposes possible avenues for improvement including telemedicine, expanding stroke care certifications and mentorship from comprehensive stroke centers.

In this document, the authors highlight several important issues:

Rural stroke patients face unique challenges. These patients often have a higher prevalence of traditional stroke risk factors, many of which remain uncontrolled. Many are uninsured or underinsured, which further restricts their access to care. Additionally, they must travel longer distances to receive acute treatment and typically arrive at community emergency rooms with fewer resources. These challenges highlight the importance of investing in rural community emergency rooms. This can be achieved by encouraging their involvement in national quality improvement initiatives such as Get With The Guidelines (GWTG) for stroke care. Additionally, joining a tele-stroke network and connecting with a comprehensive stroke center can provide continuous mentoring and training.

Stroke care systems are generally less organized in rural areas. Access to pre-hospital emergency services is often limited, as many communities rely on voluntary EMS, which may not be available around the clock. Additionally, rural emergency rooms face a shortage of board-certified Emergency Medicine physicians, along with general staffing shortages, making it more difficult to obtain necessary tests and provide timely treatment. To improve these conditions, the authors suggest that rural centers seek certification and establish partnerships with comprehensive stroke centers to receive guidance throughout the certification process. They also recommend that local and state authorities assist with funding for both the certification process and stroke coordinators.

Access to mechanical thrombectomy is significantly limited in rural areas. The authors outline the unique challenges in providing timely access to this treatment, which include the prompt identification of patients with large vessel occlusion, delays in interhospital transfers, and the difficulty of locating suitable receiving centers. To address these issues, the authors propose innovative solutions, such as standardizing clinical and imaging protocols and creating a live map that displays available EMS crews and hospitals equipped for mechanical thrombectomy.

Post-acute care and rehabilitation services are significantly limited in rural areas. Stroke patients in these regions are less likely to receive the rehabilitation they need, which raises the risk of suboptimal health outcomes. The authors propose several novel solutions to address this issue, such as the establishment of transitional clinics and the use of telemedicine to facilitate at-home rehabilitation.

The American Heart Association's Scientific Statement on Identifying Best Practices for Improving the Evaluation and Management of Stroke in Rural, Lower-Resource Settings addresses the significant challenges of acute stroke care in rural areas. This important document not only highlights the extent of the problem but also outlines potential actions for local, state, and national authorities to improve stroke outcomes in these regions. One effective first step toward improvement is to encourage and assist rural hospitals in obtaining stroke certification. Achieving this goal requires the support of local and state authorities who are committed to developing policy solutions. Priorities should include policies that tackle staffing shortages and enhance access to telehealth services and infrastructure support.

Hopefully, this document will act as a guide for improving care in a population that appears to be unjustly subjected to suboptimal treatment and clinical outcomes.