(605) Assessing Neurologic Outcome Disparities Between Urban and Rural Stroke Centers

Introduction: Endovascular thrombectomy (EVT) at an endovascular stroke center (ESC) is considered optimum care for patients with large vessel occlusion strokes (LVOS). However, there are fewer ESC in Rural than Urban settings. Decreased access may adversely affect treatment times and outcome of patients with LVOS.

Methods: We analyzed data from the Optimizing Prehospital Use of Stroke Systems of Care – Reacting to Changing Paradigms (OPUS-REACH) registry. All LVOS patient who underwent EVT at one of nine ESCs in the Northeast United States between 2015 and 2020 were included. We analyzed patients managed at Urban versus Rural designated hospitals and if the initial evaluation was at non-ESC centers prior to transfer to an ESC center. Data is presented as median and Interquartile Range (IQR). Univariate analysis was performed using Chi square or t-tests to obtain a p value. Chi square or ANOVA testing was used to evaluate ESC and non-ESC sites. A priori, we defined a p value of 0.05 as significant. We defined a good outcome as 0-2 on the modified Rankin Scale (mRS).

Results: 2091 patients were included in the final analysis. Median NIHHS were lower in patients treated at urban hospitals versus rural hospitals (16 vs 17). Both key metrics of LKW to Intravenous thrombolysis and LKW to EVT was significantly lower for patients evaluated at Urban ESCs [110(81,148) and 229(156,468)] and non-ESCs [114(89.3,173) and 386(252,657)] compared to Rural ESC [129(102,175) and 253(180,180,559)] and non-ESCs [127(100,155) and 395(275,714)] with p=0.004 and p=0.01 respectively. The percentage of patients with good 90-day mRS was greater for Urban ESC and non-ESC 40.8% and 38.8%, vs Rural ESCs and non-ESCs, 30.0% and 28.2%, respectively, p=0.010.

Conclusions: Median time to EVT was significantly lower when patients were transported directly to an ESC (either rural or urban). Outcomes after LVOS requiring EVT are better Urban ESC centers compared to Rural centers. This finding is partly explained by the lower NIHSS of patients who presented directly to an ESC as well as the shorter time from onset to EVT. The distance required to access a stroke center impacts neurologic outcome as they present with higher NIHSS and longer LKW to EVT, especially if the initial care is at a non-ESC.