Rural US Hit Hardest by Recent Rise in Stroke Mortality

NEW ORLEANS, LA—Since 2013, the increase in cerebrovascular mortality occurring across the United States has been most pronounced in rural communities, a study shows.

That increase comes amid a longer-term phenomenon in which the gap in mortality between rural and urban areas has been widening steadily since at least 1999, Marek Čierny, MD (Medical College of Wisconsin, Milwaukee), reported here at the International Stroke Conference.

The trend has not deviated over that span, during which the acute treatment of ischemic stroke has changed dramatically with the introduction and evolution of mechanical thrombectomy and the expansion of IV thrombolysis to later time windows.

“Maybe if you want to reverse this, we should think about factors that have been present for the last 25 years . . . as we think about how we address this root cause,” Čierny said.

Commenting on the study for TCTMD, Mitchell Elkind, MD, chief science officer for brain health and stroke for the American Heart Association (AHA), said that “we know that only about 20% of healthcare outcomes are due to clinical encounters between doctors and patients. The other 80% is due to social or environmental factors, like access to healthy food and places to exercise, air pollution, and others.”

It’s possible that rural communities have felt the effects of these issues more than those in other parts of the country, said Elkind, a past AHA president. “We have seen other problems in rural communities, like deaths from substance abuse, that also support this potential mechanism.”

To explore the rural-urban disparity in cerebrovascular mortality, Čierny and his colleagues examined data from the Underlying Cause of Death database of the National Center for Health Statistics, part of the US Centers for Disease Control and Prevention. They assessed age-adjusted mortality rates in adults ages 25 to 64 from 1999 to 2023, stratified by urbanization and sex.

There were two distinct trends detected, with an initial decline in age-adjusted mortality rates between 1999 and 2013, followed by an upswing, with outcomes generally worse in rural versus urban communities. Between 1999 and 2013, the annual percentage change in mortality rate ranged from -1.4% among men in small/medium metropolitan areas to -3.2% among women living in large metropolitan areas. After 2013, the annual percentage change ranged from +0.8% among women living in large metropolitan areas to 2.2% among men living in rural counties.

Čierny described the increase in cerebrovascular mortality in recent years as a “very disturbing and surprising finding” because of the advancements that have been made in endovascular thrombectomy and in the speed and efficiency of treatment that have occurred during that time.

Making Sense of the Disparity

Asked about what might explain this uptick in mortality, he pointed to a 2023 study indicating that, among younger individuals, larger increases were observed in counties with higher proportions of non-Hispanic white residents, rural communities, and areas with higher rates of substance abuse, suicide mortality, and a lack of insurance coverage. Other possibilities include fallout from the financial crisis of 2008 and an increase in opioid-related stroke deaths, he indicated.

“We believe the major reason for the increase in stroke incidence and mortality is the increase in cardiometabolic disease—sedentary lifestyle, obesity, diabetes, hypertension,” Elkind said, noting that “rural counties have even greater increases in cardiometabolic conditions, as well as less access to care.”

The issues in rural areas have been apparent since long before 2013, however. The researchers showed that the ratios comparing mortality rates in rural areas with those in small-medium and large metropolitan areas have been getting larger—indicating a widening gap—since at least 1999. Between 1999 and 2023, for men, the mortality rate ratio increased from about 1.1 to 1.4 when comparing rural and large metropolitan areas and from about 1.0 to 1.2 when comparing rural and small/medium metropolitan areas. Similar trends were observed for women.

To help address the rural-urban divide, Elkind underscored the need “to educate the public and policymakers about the role that these social factors play in driving the burden of cerebrovascular disease, and advocate to increase access to care, quality of care, and other brain-positive resources—early childhood education, healthy diets, places to exercise, clean air—in rural communities.”

In addition, efforts are needed to educate individuals about how to care for themselves and to improve access to expert stroke care through virtual means, he said.

“Time is brain, and it can be difficult to provide the highest level of quality stroke care in communities where people live far from the hospital and are therefore unable to access acute stroke interventions, like thrombolysis or thrombectomy,” Elkind added, pointing to the use of mobile stroke units and telestroke as possible solutions.

Other ways to improve outcomes, Elkind said, include the use of allied health professionals like nurse practitioners and physician assistants trained in vascular risk factor control to guide secondary prevention efforts and collection of data on outcomes for continuous quality improvement.