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Background:Approximately 14% of the US population resides in rural areas, which have higher rates of chronic disease and are often medically underserved. We compared 1-year outcomes after ischemic stroke for Medicare beneficiaries living in urban vs rural areas.Methods:We identified all Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US acute-care hospitals with ischemic stroke in 2015 to 2017. Patients were followed up to 1 year through 2018 for death or ischemic stroke recurrence and categorized according to geographic remoteness of their residence using the Rural-Urban Community Area codes. We balanced patient characteristics between the rural/urban categories using stabilized inverse probability weights (IPW) based on patient demographic and clinical characteristics. We created adjusted Kaplan-Meier curves based on the IPW and fit Cox models to assess differences in 1-year all-cause mortality and recurrent stroke weighted by the IPW and accounting for competing risks.Results:There were 536,930 stroke patients (32,635 isolated rural, 40,240 small rural, 66,320 large rural, 397,735 urban; mean age 79.0 years, 54.7% women, 82.5% White). For isolated rural, small rural, large rural, and urban residents, 1-year adjusted mortality rates were 24.1%, 24.6%, 24.7%, and 22.9%, and 1-year stroke recurrence rates were 8.0%, 7.8%, 7.9%, and 8.1%, respectively. Compared with urban residents, isolated rural (HR 1.07, 95% CI 1.04-1.09), small rural (1.09, 1.07-1.12), and large rural (1.10, 1.08-1.12) residents had greater risk of death within 1 year after stroke, but there was little difference in recurrence (Fig. A). Urban residents had the lowest mortality across regions, but there was variation among the rural subcategories and for recurrence in region-stratified analyses (Fig. B).Conclusions:Ischemic stroke patients living in urban areas had a lower risk of mortality within 1 year compared with those living in more rural areas.

Background:Whether stroke patients treated at hospitals with better short-term quality performance metrics have better long-term outcomes is unknown. We determined if ischemic stroke patients treated at US hospitals with better past performance on the Centers for Medicare & Medicaid Services (CMS) 30-day mortality and readmission outcome measures for stroke had better 1-year outcomes compared to those treated at other hospitals.Methods:We included all Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US hospitals with a principal diagnosis of ischemic stroke from 07/01/2015 to 12/31/2018. We categorized patients by the treating hospital’s performance on the CMS hospital-specific 30-day risk-standardized all-cause mortality and readmission rate measures for stroke from 07/01/2012 to 06/30/2015: Low-Low (both CMS mortality and readmission rates for the hospital were <25thpercentile of national rates), High-High (both >75thpercentile), and Intermediate (all others). We balanced characteristics between hospital performance categories using stabilized inverse probability weights (IPW) based on patient demographic and clinical factors. We fit Cox models to assess patient risks of 1-year mortality and recurrent stroke across hospital performance categories, weighted by the IPW and accounting for competing risks.Results:There were 595,929 stroke patients (mean age 78.9y, 54.4% women, 82.2% White) discharged from 134 Low-Low, 2288 Intermediate, and 141 High-High hospitals. For patients treated at Low-Low, Intermediate, and High-High hospitals, respectively, 1-year mortality rates were 23.8% (95% CI 23.3-24.3%), 25.2% (25.1-25.3%), and 26.5% (26.1-26.9%), and recurrence rates were 8.0% (7.6-8.3%), 7.9% (7.8-8.0%), and 8.0% (7.7-8.3%). Compared with patients at High-High hospitals, those at Low-Low and Intermediate hospitals, respectively, had 15% (hazard ratio 0.85; 95% CI 0.82-0.87) and 9% (0.91; 0.89-0.93) lower risks of 1-year mortality but no difference in 1-year recurrence.Conclusions:Ischemic stroke patients treated at better-performing hospitals had lower risks of post-discharge 1-year mortality but similar risks of recurrent stroke compared with patients treated at other hospitals.

Objective:There are known associations between long-term air pollution exposure and greater stroke incidence, morbidity, and mortality; however, there is little research on the association of pollutant exposure with poststroke hospital readmission.Methods:We assessed associations of average annual CO, NO2, O3, PM2.5, and SO2exposure with 30-day all-cause hospital readmission in US fee-for-service Medicare beneficiaries age ≥65 years hospitalized for ischemic stroke in 2014-2015. We fit Cox models to assess 30-day readmission as a function of these pollutants, adjusted for patient and hospital factors and temperature. We repeated the models stratified by performance of the treating hospital on the Centers for Medicare & Medicaid Services (CMS) risk-standardized 30-day all-cause readmission for stroke measure to determine if the results were independent of performance: Low (CMS rate for hospital <25th percentile of national rate), High (>75thpercentile), and Middle (all others).Results:There were 448148 patients discharged with stroke in 2014-2015 of whom 12.5% were readmitted. Average 2-year CO, O3, PM2.5, and SO2values during the study were below national standards. In adjusted analyses, each 1 standard deviation increase in average annual NO2and SO2exposure was associated with a 3.6% (95% CI 2.9%-4.4%) and a 2.0% (95% CI 1.1%-3.0%) increased readmission risk within 30-days, respectively (Table). Associations between long-term air pollution exposure and increased readmissions persisted across performance categories.Conclusion:Long-term air pollution exposure was associated with increased 30-day readmissions after stroke at pollutant levels below national standards across hospital performance categories. Additional research is needed to determine whether improvements in air quality lead to reductions in poststroke hospital readmissions.

Supplemental Digital Content is available in the text.Despite evidence-based guidelines,1stroke rehabilitation remains underutilized, particularly among women and minorities.2Telerehabilitation is a promising alternative to traditional in-person rehabilitation and offers a novel strategy to overcome access barriers,3which intensified during the COVID-19 pandemic.4A broadband connection is a prerequisite for its wide adoption but its availability varies across the United States (https://broadbandnow.com/national-broadband-map). Little is known about demographic and geographic variation in internet use among stroke survivors. In this study, we sought to compare internet use in a nationally representative sample of individuals with and without stroke.

The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation.

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.

The Centers for Medicare and Medicaid Services proposes to use 30-day hospital readmissions after ischemic stroke as part of the Hospital Inpatient Quality Reporting Program for payment determination beginning in 2016. The proportion of poststroke readmissions that is potentially preventable is unknown.

Background:Critical access hospitals (CAHs) provide emergency and inpatient care in rural communities. CAHs have higher 30-day mortality after stroke, but little is known about long-term outcomes. We compared 1-year outcomes after ischemic stroke for patients treated at CAHs versus other hospitals.Methods:We identified all Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US hospitals with a principal diagnosis of ischemic stroke in 2015. Patients were followed 1 year for death or stroke recurrence, accounting for competing risks. We balanced characteristics between CAH and non-CAH patients using stabilized inverse probability weights (IPW) based on patient demographic and clinical characteristics. We created adjusted Kaplan-Meier curves based on the IPW and fit Cox models to assess differences in 1-year mortality and recurrent stroke weighted by the IPW.Results:There were 4,487 patients discharged with stroke from CAHs and 202,502 from non-CAHs. CAH vs non-CAH patients were older (mean age 82.8y vs 78.6y) and more often women (61.8% vs 53.9%), white (94.3% vs 83.7%), and dual Medicare-Medicaid eligible (21.6% vs 17.1%). Discharge to home (29.6% vs 36.8%) and inpatient rehabilitation (4.2% vs 18.9%) was less common for CAH patients, whereas discharge to an intermediate care/skilled nursing facility was more common (26.7% vs 23.9%). For CAHs and non-CAHs, respectively, 1-year mortality rates were 27.8% (95% CI 26.5-29.0) and 22.2% (22.0-22.4), and 1-year recurrence rates were 4.3% (3.6-4.9) and 4.6% (4.5-4.7) (Figure). In IPW-adjusted analyses, stroke patients treated at CAHs vs non-CAHs had higher risk of 1-year mortality (HR 1.29, 95% CI 1.22-1.37) but not recurrent stroke (0.91, 0.78-1.06).Conclusions:Stroke patients discharged from CAHs vs non-CAHs had greater risk of 1-year mortality but not recurrence. Further work is needed to understand the observed disparity, potentially with a focus on post-acute care services.

Background:Stroke rehabilitation (SR) has been outlined in ASA/AHA guidelines as a critical component of post-acute care. US studies from the 2000s have found associations between rural residence and lower SR attendance, but contemporary information about SR attendance across geographic areas and patient subgroups is limited.Methods:Using the most recent 2011, 2013, 2015, and 2017 self-reported Behavioral Risk Factor Surveillance System (BRFSS) Surveys with SR data, we identified US adult stroke patients in 20 states. Rural/urban residence was classified by the Metropolitan Statistical Area codes. We compared SR attendance (Yes/No) among rural and urban stroke patients by sex and age groups (18-44y, 45-64y, 65+y). Logistic regression was used to examine the association between rural/urban residence and SR while controlling for key sociodemographic factors. Survey weighting was applied to all analyses.Results:Among 7878 stroke patients (40.8% rural, 62.2% women), slightly less rural residents attended SR compared to urban ones (30.8% vs 32.6%, p=0.357) (Figure). Rural/urban residence was not associated with SR prior to and after adjustment for sex, age, race, education, income, insurance status, and having a personal doctor (OR: 0.96, 95% CI: 0.80-1.15). In stratified analyses, women, patients 18-44y, and 45-64y who live in rural areas were less likely to attend SR than their urban counterparts. Women also had lower SR than men, irrespective of rural/urban residence.Conclusions:On average, a third of US stroke patients went to SR with no association found between rural/urban residence and SR attendance. However, a pattern of lower SR rates was observed across some sex and age subgroups in rural areas and in women regardless of residence status. Targeted interventions are needed to address rural/urban disparities and optimize secondary stroke prevention utilization, especially among women and young to middle aged patients in US rural areas.

Background:Prior studies have identified sex, age, and geographic differences in post-stroke rehabilitation use in certain US areas. Internet use is an important prerequisite to the adoption of telerehabilitation, which has shown promise in equalizing access to follow-up care among stroke patients. We aimed to assess 30-day internet use disparities between male and female stroke patients by age and within each US state.Methods:We identified US adults 18y and older with a self-reported history of stroke from the Behavioral Risk Factor Surveillance System surveys, a nationally representative dataset (2015-2017). Internet users were identified as those who responded “Yes” to the question, “Have you used the internet in the past 30 days?” Prevalence of internet use was compared between sex and age groups and by state. Survey weights were applied in all analyses.Results:Among 55260 individuals with stroke (57.5% women), 57.8% reported using the internet in the preceding 30 days. The overall prevalence of internet use was similar between women (58.2%, 95% CI: 57.0-59.4%) and men (57.4%, 95% CI: 56.1-58.8%). Female stroke patients had higher internet use than their male counterparts until age 65+y (all p<0.0001, Figure 1a). Substantial differences in internet use by state were found for women and men with stroke, with stroke survivors in Louisiana reporting the greatest difference (women 51% vs. men 36%) (Figure 1b).Conclusions:Overall, less than 60% of US stroke survivors reported recent internet use, with marked variation by sex, age, and across states. Study findings may inform individual state’s actions to improve internet use among women 65+y who bear a greater stroke burden yet have lower internet use than men. Efforts to increase internet use in specific stroke patient subgroups may facilitate future telerehabilitation expansion and help to reduce sex- and age-based disparities currently present in post-stroke care.

Stroke is a leading cause of disability, cognitive impairment, and death in the United States and accounts for 1.7 of national health expenditures. Because the population is aging and the risk of stroke more than doubles for each successive decade after the age of 55 years, these costs are anticipated to rise dramatically. The objective of this report was to project future annual costs of care for stroke from 2012 to 2030 and discuss potential cost reduction strategies.

The critical access hospital (CAH) designation was established to provide rural residents with local access to emergency and inpatient care. CAHs, however, have poorer short-term outcomes for pneumonia, heart failure, and myocardial infarction compared with other hospitals. We assessed whether 30-day risk-standardized mortality rates (RSMRs) and risk-standardized readmission rates (RSRRs) after ischemic stroke differ between CAHs and non-CAHs.

Secondary stroke prevention treatments vary in different regions of the US. We determined the degree to which guideline-recommended stroke treatments vary by region for patients treated at hospitals participating in a voluntary national quality improvement program, Get With The Guidelines-Stroke.

Ischemic stroke patients treated at Joint Commission Primary Stroke Center (JC-PSC)-certified hospitals have better outcomes. Data reflecting the impact of JC-PSC status on outcomes after hemorrhagic stroke are limited. We determined whether 30-day mortality and readmission rates after hemorrhagic stroke differed for patients treated at JC-PSC–certified versus noncertified hospitals.

Risk-standardized hospital readmission rates are used as publicly reported measures reflecting quality of care. Valid risk-standardized models adjust for differences in patient-level factors across hospitals. We conducted a systematic review of peer-reviewed literature to identify models that compare hospital-level poststroke readmission rates, evaluate patient-level risk scores predicting readmission, or describe patient and process-of-care predictors of readmission after stroke.

Prompt care-seeking behavior is a focus of US national public stroke educational campaigns. We determined whether the time between symptom onset and hospital arrival and the receipt of intravenous tissue-type plasminogen activator (IV t-PA) changed for ischemic stroke patients evaluated at US academic centers between 2001 and 2004.

The Joint Commission (JC) began certifying Primary Stroke Centers in November 2003. Cross-sectional studies assessing the impact of certification could be biased if these centers had better outcomes before the start of the program. We determined whether hospitals certified within the first years of the JC program had better outcomes than noncertified hospitals before the start of the certification program.

Patients with transient ischemic attack (TIA) are at increased risk for stroke, cardiovascular events, and death, yet little is known about whether these risks differ for men and women. We determined whether there are sex-based differences in these outcomes 30 days and 1 year after TIA using a national sample of elderly patients.

Background:Secondary prevention addressing cardiovascular risk factors is a key care component for reducing the risk of vascular events among those who had a stroke/TIA. We assessed cardiovascular risk factor (CVD-RF) profiles and their impact on hospitalizations and Emergency Department (ED) visits and whether the association differs for men and women with prior stroke/TIA.Methods:We used data from the nationally representative Medical Expenditure Panel Survey (2012-2015) for persons aged≥18 years with a prior stroke/TIA. CVD-RF score included 6 self-reported factors (hypertension, diabetes, high cholesterol, lack of exercise, smoking, obesity), categorized as low (0-1 factors), intermediate (2-3), or high (4-6). Outcomes included ≥1 hospitalization discharges or ED visits during the participant’s survey year. Multivariable logistic regression models assessed the association between CVD-RF scores and outcomes, stratified by sex. We tested for interaction by sex in a combined model with men and women.Results:The weighted sample represents 9.9 million individuals (mean age 65.1 years; 54.3% women). Overall, 16.7%, 59.3%, and 24.1% of men had low, intermediate, and high CVD-RF scores compared to 21.6%, 59.5%, and 18.9% of women. Among men, there was no significant association between CVD-RF score and the two outcomes (Table). Among women, even after adjustment for covariates, those with high scores had 1.89 and 2.06-fold increases in the odds of hospitalizations and ED visits, compared to those with low CVD-RF scores (P<0.05). Furthermore, women with intermediate CVD-RF scores had a 1.68-fold increase in the odds of ED visits compared to those with low scores (P<0.05). The combined model showed a significant interaction by sex.Conclusion:Women with increased CVD-RF scores had increased odds of ED visits and hospitalizations, which could be due to less effective secondary prevention. Further research is needed to explore reasons for this sex disparity.

Background:There is known geographic variation in recurrent stroke rates in the US; however, the contributions of socioeconomic status (SES), healthcare access/utilization, and community resources to these disparities are uncertain. We assessed community characteristics in counties having persistently higher recurrent stroke rates over a 16-year period.Methods:We included 3,485,618 fee-for-service Medicare beneficiaries aged ≥65y discharged with ischemic stroke from 2001-2016, grouped into four 4-year periods. We categorized 3221 US counties or equivalents into 6 groups based on the % of stroke patients with a recurrent stroke within 1 year. Persistently high-recurrence counties were those in the highest sextile for each 4-year period. We integrated county-specific demographic, geographic, SES, general health, care availability, health behavior, and environmental data from the US Census Bureau, USDA Economic Research Service, and Dartmouth Atlas. We calculated mean standardized differences in county characteristics between high-recurrence and other counties and used logistic regression to model high-recurrence counties as a function of 12 potentially modifiable county characteristics.Results:There were 133 persistently high-recurrence counties that were concentrated in the South Central US and included 140,144 stroke patients during the study (A; mean age 78.3y, 57% women, 82% White, 11.5% stroke recurrence vs 79.0 y, 55% women, 86% White, 10.5% stroke recurrence in other counties). Compared with the rest of the US, these counties had populations with lower SES, poorer health, more limited access to care providers and recreation/fitness, and reduced rates of preventive testing (B). The model including 12 potentially actionable characteristics had a c statistic of 0.84.Conclusions:Our findings highlight the value of identifying potentially modifiable community characteristics that, if improved, might reduce recurrent stroke rates.

Background:There have been important advances in secondary stroke prevention and a focus on healthcare delivery in the US over the past two decades. Yet, little is known about temporal patterns of recurrent stroke in the US. We examined temporal trends in recurrent stroke by sociodemographic characteristics and geographic areas using national Medicare data.Methods:We included fee-for-service Medicare beneficiaries aged ≥65y with a primary discharge diagnosis of ischemic stroke from 2001 to 2016. We fit a Cox proportional hazards model that censored for change in Medicare enrollment and accounted for death to evaluate the temporal trend in 1-year recurrent stroke, adjusting for demographic and clinical factors. Models were repeated for subgroups defined by age, sex, race, and state. We mapped smoothed rates of 1-year recurrent stroke by county to assess geographic variation over time.Results:There were 3,485,618 unique beneficiaries discharged with stroke during the study period. Demographic and clinical characteristics remained relatively stable over time, but the proportions discharged with home health services and inpatient rehabilitation increased. The observed 1-year recurrent stroke rate decreased from 11.2% in 2001-2004 to 9.3% in 2013-2016, with an adjusted annual reduction in recurrence from 2001-2016 of 1.49% (95% CI 1.40%-1.58%). There were significant reductions for all age, sex, and race groups (A). Geographic areas with persistently high rates were identified over time (B). In state-stratified analysis, the annual percentage reduction in recurrence ranged from -1.2% to 2.5% and was significant for all but 12 states.Conclusions:Recurrent strokes decreased over time overall and by sociodemographic subgroups; however, we identified geographic areas with persistently high recurrence rates. Such findings can target secondary prevention intervention opportunities for high-risk populations and communities.

Background:Few studies report 10-year mortality outcomes after stroke in the US by race. We assessed long-term survivorship by race among elderly ischemic stroke patients.Methods:We identified fee-for-service Medicare beneficiaries aged ≥65 years discharged alive from US acute-care hospitals with a principal diagnosis of ischemic stroke from 2005 to 2007. Patients were followed through 2016 to calculate 10-year all-cause mortality, censoring for change in Medicare enrollment. Inverse probability weighting (IPW) was used to assess race differences in mortality. We used logistic regression to calculate the probability of a patient being Black as a function of age, Medicaid eligibility, comorbidities, in-hospital complications, discharge disposition, length of stay, and Medicare payment. We then fit a Cox regression model for the relationship between race and 10-year mortality that adjusted for sex and the inverse probability of being Black.Results:There were 744,044 patients discharged alive with stroke (mean age 78.7y, 54.7% women, 85.6% White, 9.9% Black, and 4.5% other race). Black patients tended to be younger and were more often women. There were race differences in comorbidities, with renal failure, dementia, and diabetes more common in Blacks; atherosclerosis and COPD were more common in Whites. The 10-year mortality rate was 75.3% (95% CI 75.2–75.4%) for the overall population, with Blacks having the highest mortality (76.4%, 76.1–76.7%), followed by Whites (75.4%, 75.3–75.5%) and those of other race (70.3%, 69.8–70.8%; Figure). In the IPW analysis, the risk of death within 10 years of stroke was higher for Blacks (RR 1.04, 95% CI 1.03–1.04) but lower for other races (RR 0.92, 95% CI 0.90–0.93) when compared with Whites.Conclusions:More than 75% of stroke patients died within 10 years. The 10-year stroke mortality risk was higher for Black stroke patients even after accounting for sociodemographic and index hospitalization factors.

Background:Daily average temperature is associated with increased hospitalizations and mortality for vascular conditions, but it is unclear if daily temperature variation is also associated with these outcomes. We assessed the relationship of daily temperature fluctuations with stroke and AMI hospitalizations and mortality in the elderly.Methods:We identified fee-for-service Medicare beneficiaries aged ≥65 y with a primary discharge diagnosis of ischemic stroke or AMI in 2014-2015. Daily temperature data from the National Centers for Environmental Information were linked with Medicare beneficiary data by county and admission date. We fit a Poisson model for the relationship between daily temperature range (county daily maximum minus minimum) and 30-day hospitalizations, adjusted for season and patient demographics. Logistic regression assessed 30-day mortality, adjusted for season, patient demographics, and clinical characteristics. Overall and NOAA climate region-stratified relationships were assessed.Results:There were 311,213 unique stroke hospitalizations (mean age 78.8 y, 53% women, 84% White) and 274,703 for AMI (mean age 77.6 y, 45.4% women, 86% White). The national hospitalization rate per 100,000 beneficiary-years was 735 for stroke and 639 for AMI. Thirty-day mortality was 12.0% for stroke and 12.8% for AMI. Each 1oF increase in daily temperature range was associated with a 1.26 percentage point (95% CI 1.09-1.44) increase in stroke and a 1.48 percentage point (95% CI 1.43-1.53%) increase in AMI hospitalizations and varied by climate region (figure). Daily temperature range had little influence on stroke or AMI mortality (both OR 1.00, 95% CI 1.00-1.00).Conclusions:Daily temperature fluctuations were associated with increased hospitalizations for stroke and AMI. Additional research is needed to understand meteorological effects on vascular events to inform prevention efforts for vulnerable populations.

A systematic review found an association between the July start of internships and residencies and higher mortality rates for hospitalized patients, but data related to stroke are limited. We assessed seasonal variations in 30-day risk-adjusted mortality rates (RAMRs) after ischemic stroke by hospital teaching status.