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Rural-Urban Differences in Inpatient Quality of Care in US Veterans With Ischemic Stroke

Authors

  • Michael S. Phipps MD,

    Corresponding author
    1. Department of Neurology, University of Connecticut/Hartford Hospital, Hartford, Connecticut
    2. Medical Informatics, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Connecticut
    3. VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI) Program, Indianapolis, Indiana
    • For further information, contact: Michael Phipps, MD, MHS, Neurovascular Fellow, Department of Neurology, University of Connecticut/Hartford Hospital, 80 Seymour Street, Hartford, CT 06102; e-mail mphipps@calalum.org.

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  • Huanguang Jia PhD,

    1. VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI) Program, Indianapolis, Indiana
    2. VA HSR&D/Rehabilitation Research and Development (RR&D) Rehabilitation Outcomes Research Center Research Enhancement Award Program (RORC REAP), Gainesville, Florida
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  • Neale R. Chumbler PhD,

    1. VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI) Program, Indianapolis, Indiana
    2. VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
    3. Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, Georgia
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  • Xinli Li MS,

    1. VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI) Program, Indianapolis, Indiana
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  • Jaime G. Castro MS,

    1. VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI) Program, Indianapolis, Indiana
    2. VA HSR&D/Rehabilitation Research and Development (RR&D) Rehabilitation Outcomes Research Center Research Enhancement Award Program (RORC REAP), Gainesville, Florida
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  • Jennifer Myers MSW,

    1. VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI) Program, Indianapolis, Indiana
    2. VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
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  • Linda S. Williams MD,

    1. VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI) Program, Indianapolis, Indiana
    2. VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
    3. Regenstrief Institute, Indianapolis, Indiana
    4. Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
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  • Dawn M. Bravata MD

    1. VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI) Program, Indianapolis, Indiana
    2. VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
    3. Regenstrief Institute, Indianapolis, Indiana
    4. Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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  • Funding: This research was supported by a grant from the Department of Veterans Affairs Health Services Research and Development (VA HSR&D Grant RRP 09-184). The opinions contained in this paper are those of the authors and do not necessarily reflect those of the US Department of Veterans Affairs. The authors have no disclosures to report.

Abstract

Purpose

Differences in stroke care quality for patients in rural and urban locations have been suggested, but whether differences exist across Veteran Administration Medical Centers (VAMCs) is unknown. This study examines whether rural-urban disparities exist in inpatient quality among veterans with acute ischemic stroke.

Methods

In this retrospective study, inpatient stroke care quality was assessed in a national sample of veterans with acute ischemic stroke using 14 quality indicators (QIs). Rural-Urban Commuting Areas codes defined each VAMC's rural-urban status. A hierarchical linear model assessed the rural-urban differences across the 14 QIs, adjusting for patient and facility characteristics, and clustering within VAMCs.

Findings

Among 128 VAMCs, 18 (14.1%) were classified as rural VAMCs and admitted 284 (7.3%) of the 3,889 ischemic stroke patients. Rural VAMCs had statistically significantly lower unadjusted rates on 6 QIs: Deep vein thrombosis (DVT) prophylaxis, antithrombotic at discharge, antithrombotic at day 2, lipid management, smoking cessation counseling, and National Institutes of Health Stroke Scale completion, but they had higher rates of stroke education, functional assessment, and fall risk assessment. After adjustment, differences in 2 QIs remained significant—patients treated in rural VAMCs were less likely to receive DVT prophylaxis, but more likely to have documented functional assessment.

Conclusions

After adjustment for key demographic, clinical, and facility-level characteristics, there does not appear to be a systematic difference in inpatient stroke quality between rural and urban VAMCs. Future research should seek to understand the few differences in care found that could serve as targets for future quality improvement interventions.

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