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.
