Strategic interventions and investments are needed to improve stroke care in rural areas, according to a scientific statement from the American Heart Association (AHA) published in Stroke.

The AHA statement addresses potential solutions for monitoring and improving the performance and delivery of prehospital, acute, and postacute rural stroke care(NOT RECOVERY!).

In the prehospital setting, the patients’ distance from stroke-capable hospitals may delay reperfusion and definitive care(NOT RECOVERY!), and effective strategies may include supporting the hospitals’ transition to certified Acute Stroke Ready Hospital (ASRH) and stroke centers and use of air transport. Individuals in rural areas are less likely to arrive by emergency medical services (EMS) for stroke, and improved ambulance availability is needed in rural settings.

The use of prehospital telemedicine and smartphone applications and artificial intelligence also may enhance stroke detection. Challenges in the emergency department for stroke care(NOT RECOVERY!) in lower-resource rural settings may lead to decreased use of thrombolysis, and some rural areas are lacking board-certified emergency medicine physicians. Telestroke use may support improved educational and communication efforts, according to the AHA writing group.

Related efforts and policy interventions should be directed to enhance public awareness, impart staff training, build stroke infrastructure…and implement quality assessment and improvement programs taking into account the challenges and needs of the rural setting.

Rural and under-resourced settings are associated with challenges to timely access to high-quality mechanical thrombectomy. Developing a live map for EMS and hospitals with the location of available thrombectomy-capable centers, including traffic and weather conditions and operator availability, may be beneficial, noted the AHA group. Early identification of large vessel occlusion stroke should be combined with tertiary sites, including the transfer process, according to the researchers.

Improving door-in-door-out times for transferred patients to ensure timely thrombectomy includes strategies such as transfer agreements with receiving hospitals and transferring ambulances. In addition, centralized image sharing with the receiving hospital also may enhance workflow, and air transportation should be considered in remote settings with longer distances.

Performance gaps exist between rural and urban hospitals regarding stroke quality measures such as stroke education. Telestroke can improve access to neurologic expertise and is associated with an increase in thrombolytic therapy and improved patient outcomes. Rural hospitals also may invest in annual comprehensive stroke education programs, partner with certified stroke centers, and use stroke care(NOT RECOVERY!) coordinators and nurse navigators.

Postacute care(NOT RECOVERY!) is challenging for rural, lower-resourced areas. For patients discharged to home, transitional stroke clinics could help bridge the gap between acute hospitalization and discharge, but would need to account for accessibility and travel distances, the AHA group noted. Home-based interventions, such as blood pressure monitoring and telerehabilitation, virtual support groups, and additional online support, may be beneficial for stroke survivors in rural settings. Expansion of ASRH or Primary Stroke Centers in rural areas needs to be geographically efficient, considering population density and proximity of resources and incentivizing strategies to optimize population coverage.

Overall, patients in rural areas are an underserved population vulnerable to inefficient care(NOT RECOVERY!) and poor outcomes, and policies must address specific workforce shortages. In addition, many barriers regarding health and outcomes in rural communities are associated with social determinants of health, economic opportunity, and community. Integrating rural care(NOT RECOVERY!) systems among various disciplines may lead to more effective advocacy for systematic investments in shared resources, the group noted.

“Related efforts and policy interventions should be directed to enhance public awareness, impart staff training, build stroke infrastructure, enhance access to clinical expertise, streamline data management, and implement quality assessment and improvement programs taking into account the challenges and needs of the rural setting,” the AHA writing group wrote.