American Indians and People in Rural Areas Travel Farther for Stroke Care

When someone is experiencing a stroke, quick emergency care can make all the difference. But a new study finds that not everyone can access emergency services at the same rate. Some people have to travel farther to reach the nearest hospital that can properly treat stroke.

In a recent study published by Stroke, an American Stroke Association journal, researchers analyzed U.S. census data and found that American Indians and people in rural areas traveled the farthest for certified stroke care.

“Stroke is one of the most time-sensitive diseases we have in medicine," study co-author Akash Kansagra, MD, associate professor of radiology, neurological surgery, and neurology at the Washington University School of Medicine, tells Verywell. "In patients who have a stroke, a portion of the brain is not receiving enough oxygen because they have a blockage in blood flow." He says that the longer a blockage exists, the greater the impact of irreversible damage. 

When blood flow is stopped or interrupted to the brain, the brain begins a process of cell death, according to study co-author Peter Panagos, MD, professor of emergency medicine in neurology at Washington University School of Medicine in St. Louis, Missouri. He tells Verywell that damage can include becoming paralyzed, blind, and losing the ability to speak. “Out of all the organs in the body, the brain is the most unforgiving organ for lack of blood flow,” Panagos says.

That's why the timeliness of treatment is so important. “When we talk about implementing stroke care rapidly, we want to do so before the damage has spread to affect larger parts of the brain,” Kansagra says. For every minute that a stroke is untreated, a patient loses millions of neurons and billions of synapses, aging the brain by weeks or months.

However, providing that treatment on time remains “one of the issues that is the biggest barrier to providing good stroke care and getting good outcomes at a patient level,” Panagos says. 

Who Lived Farthest From Care?

Using a public mapping service, researchers were able to compare the road distance to the nearest certified stroke center for treatment of ischemic stroke—a blockage to an artery that supplies blood to the brain.

The data included 316 million people and more than 2,300 stroke-certified hospitals across 48 states and the District of Columbia.

Researchers found that in rural places, census areas with more elderly residents were farther from stroke centers. Each 1% increase in people ages 65 or older represented a 0.31-mile longer distance to travel.

But in both urban and rural areas, American Indian residents lived farther away from certified stroke centers. For each 1% increase in the concentration of American Indian residents, there was a 0.06-mile longer distance to travel for stroke care in urban areas and a 0.66-mile longer distance in rural areas.

For a center or hospital to become certified in stroke care, Kansagra says they must meet recognized standards of performance such as timeliness of administering treatment for stroke or seeing enough patients with stroke.

“Our study focuses on certified stroke care because looking at these hospitals provides a pretty consistent view of what is recognized as high-quality stroke care where this kind of stroke care will deliver the best possible outcomes for patients,” Kansagra explains. 

There were also disparities among uninsured communities. Uninsured people were located 0.01-mile further from stroke care in urban areas and 0.17-mile further in rural areas where there was a 1% increase in the proportion of patients who were uninsured.

“The fact that uninsured people were further away from stroke care in both urban and rural areas is pretty alarming,” Kansagra says. Research shows that people with lower socioeconomic status are less likely to receive evidence-based stroke services.

How Are Strokes Treated?

In order to treat ischemic stroke, blood flow must be reestablished through the administering of a clot-busting medication. The medication must be delivered with 4.5 hours after the onset of stroke symptoms, but ideally within one hour of hospital arrival.

Panagos says that symptoms of stroke include:

• Severe headache
• Nausea
• Vomiting
• Weakness or numbness on one side of the body 
• Difficulty with speech or slurred speech 
• Inability to understand 

Panagos says that stroke patients or people nearby may use the mnemonic “FAST” to determine whether to call 911. There is now a similar mnemonic available, “RAPIDO,” in Spanish.

FAST stands for:

• Face drooping
• Arm weakness
• Speech difficulty
• Time to call 911

“It’s an easy mnemonic that says, if I have an abnormality in my face, something is wrong with my speech, or I can’t use my arm or my leg, I think I could be having a stroke and I need to call 911,” Panagos says.

The 2019 American Heart Association and American Stroke Association guidelines recommend that stroke patients be transported by emergency medical services to the nearest stroke-capable hospital.

Coupled with in-person care, they also recommended centers utilize telestroke, videoconferencing for stroke care for people located in remote areas.

Increasing Access to Care for Strokes

To increase access to stroke care, Panagos says there needs to be an increase in the number of hospitals that provide certified stroke care located in urban and suburban areas.

In addition, he says by creating access to education, people can learn about the signs and symptoms of a stroke. “The largest investment is providing education to people across the United States,” Panagos says. 

Panagos stresses that in order to create equitable stroke care access in rural areas, hospitals need to leverage telemedicine to bring experts from stroke centers to rural populations. 

“As physicians, we spend our lives trying to help these patients, and part of our mission has to be to ensure that we deliver the maximum benefit to the maximum number of patients," Kansagra says. "And this study is just part of a larger conversation of how we can ensure that all Americans have equitable access to life-saving stroke treatments."