Inequities in acute stroke care and outcomes among rural versus urban populations in Canada: a literature review

Abstract

In acute stroke evaluation, rapid intervention and rehabilitation is critical. Canada’s vast geography innately creates barriers for efficient transport to stroke centres, thus delaying treatment. The purpose of this literature review is to investigate potential inequities in acute stroke care and outcomes, and to understand the causes and consequences of inequities in access to diagnostic investigations, acute stroke care management, and overall post stroke mortality in rural versus urban populations in Canada. A literature search using PubMed database was performed using keywords ischemic stroke, hemorrhagic stroke, Canada, and rural or urban. Three articles met the inclusion criteria and were included in the review. One additional related report was included by consulting primary sources in reference lists of relevant articles. Literature suggests that rural residence is associated with limited access to stroke centres and rehabilitation services, decreased acquisition of neuroimaging, increased hesitancy to treat with tPA, and impeded access to timely revascularization intervention via EVT. These disparities may in part be explained by time required to access appropriate healthcare facilities, variations in resource allocation and level of expertise of treating health care providers. There is contrasting findings regarding usage of tPA and 30-day post stroke mortality rates. Acute stroke care management is substandard in rural compared to urban populations in Canada. This gap in care may be addressed by focusing on minimizing existing barriers including access to stroke centres and rehabilitation services, neuroimaging, comfort administering tPA and timely revascularization intervention. Implementing telestroke and regionalization of stroke care may be of value.