Abstract Body: Background: Structural racism and disparities between rural and urban healthcare systems significantly impact stroke care delivery in the United States. This study explores the interaction between structural racism, urbanity, and the administration of acute ischemic stroke (AIS) interventions—specifically, intravenous thrombolysis (TPA) and endovascular thrombectomy (ET).
Methods: This retrospective analysis utilized complete, de-identified inpatient Medicare data from January 1, 2016, to December 31, 2019. We included Medicare beneficiaries aged ≥65 years with incident AIS admissions in large metropolitan and non-urban settings. Structural racism was assessed using county-level validated metrics, including segregation, housing, employment, education, and income indices, and a composite structural racism score. We used multilevel logistic models adjusted for age, sex, and race (Black vs. White) to estimate the odds ratios (ORs) for TPA and ET receipt, with data clustered at the county level.
Results: Among 951,914 AIS patients, those treated in rural hospitals had lower ICU capacity (27.5% vs. 88.6%), stroke certification (5.3% vs. 38.4%), and lower rates of TPA (1.6% vs. 12.3%) and ET (<1% vs. 3.8%) compared to urban hospitals. Structural racism metrics, particularly higher dissimilarity (OR: 1.06 for TPA, 1.27 for ET) and isolation indices (OR: 1.10 for TPA, 1.33 for ET), as well as a composite structural racism score (OR: 1.47 for TPA, 4.15 for ET), were associated with increased odds of receiving these interventions in urban areas. Despite better access to care in urban settings, Black patients were significantly less likely to receive TPA (OR: 0.70) and ET (OR: 0.63) compared to White patients.
Conclusions: This analysis underscores the persistent disparities in stroke care access and outcomes influenced by structural racism and the rural-urban divide. These findings suggest a need for targeted interventions to address these inequities in stroke treatment