Statewide efforts to narrow the rural-urban gap in acute stroke care.

BACKGROUND: Rural-urban gaps in stroke care remain challenging in part because of the lack of resources, personnel, and necessary infrastructure. PURPOSE: The purpose of this study was to assess changes in the acute stroke diagnosis and treatment capacity among rural hospitals before and after implementation of a regionwide stroke initiative. METHODS: In 2004, the Montana Cardiovascular Health Program partnered with stroke stakeholders throughout the state and surveyed hospitals in Montana and northern Wyoming to assess the availability of technology, services, and personnel for acute stroke care. The Montana Stroke Initiative (MSI) developed protocols, educational material, and stroke awareness campaigns to address the geographic disparities identified in the survey. From 2004 to 2006, protocols and educational material were made available on a website and distributed to rural and critical-access hospitals throughout the region. Stroke awareness campaigns were completed, and MSI members conducted acute stroke care training of prehospital, nursing, and primary providers throughout the region. A follow-up survey in 2008 assessed changes in the stroke systems of care between 2004 and 2008. Data were analyzed in 2009. RESULTS: There were significant increases in availability of prehospital stroke screens, written emergency department protocols, computed tomographic scanning capability, acute stroke teams, and community stroke awareness programs. CONCLUSIONS: A systematic statewide effort to improve stroke care led to improved acute stroke care capabilities in necessary infrastructure in rural facilities and a narrowing of the gap between these facilities and the urban facilities.

Availability of diagnostic and treatment services for acute stroke in frontier counties in Montana and Northern Wyoming.

CONTEXT: Rapid diagnosis and treatment of ischemic stroke can lead to improved patient outcomes. Hospitals in rural and frontier counties, however, face unique challenges in providing diagnostic and treatment services for acute stroke. PURPOSE: The aim of this study was to assess the availability of key diagnostic technology and programs for acute stroke evaluation and treatment in Montana and northern Wyoming. METHODS: In 2004, hospital medical directors or their designees were mailed a survey about the availability of diagnostic technology, programs, and personnel for acute stroke care. FINDINGS: Fifty-eight of 67 (87%) hospitals responded to the survey. Seventy-nine percent (46/58) of responding hospitals were located in frontier counties, with an average bed size of 18 (11 SD). Of the hospitals in frontier counties, 44% reported emergency medical services prehospital stroke identification programs, 39% had 24-hour computed tomography capability, 44% had an emergency department stroke protocol, and 61% had a recombinant tissue plasminogen activator protocol. Thirty percent of hospitals in frontier counties reported that they met 6-10 of the criteria established by the Brain Attack Coalition to improve acute stroke care compared to 67% of hospitals in the nonfrontier counties. CONCLUSION: A stroke network model could enhance care and improve outcomes for stroke victims in frontier counties.

Perceived risk for developing stroke among older adults.

BACKGROUND: Persons who perceive their risk for stroke accurately may be more likely to engage in prevention practices to reduce their risk. METHODS: In 2004, 800 adults aged 45 years and older in two counties participated in a telephone survey to assess their perceived risk for stroke and their history of stroke risk factors. RESULTS: Overall, 39% of respondents perceived themselves to be at risk for having a stroke. In the multivariate analyses, younger age, current smoking, and a history of diabetes, high blood pressure, high cholesterol, heart disease, and stroke/TIA were independently associated with perceived risk for stroke. Respondents with atrial fibrillation were no more likely to report being at risk for stroke compared to respondents without atrial fibrillation. Perceived risk for stroke increased as the number of risk factors increased. However, 46% of respondents with three or more risk factors did not perceive themselves to be at risk. CONCLUSIONS: Many adults with multiple risk factors do not perceive themselves to be at risk for stroke. Clinical and public health efforts are needed to increase awareness of the risk for stroke.

Rural community knowledge of stroke warning signs and risk factors.

INTRODUCTION: Rapid identification and treatment of ischemic stroke can lead to improved patient outcomes. Public education campaigns in selected communities have helped to increase knowledge about stroke, but most data represent large metropolitan centers working with academic institutions. Much less is known about knowledge of stroke among residents in rural communities. METHODS: In 2004, 800 adults aged 45 years and older from two Montana counties participated in a telephone survey using unaided questions to assess awareness of stroke warning signs and risk factors. The survey also asked respondents if they had a history of atrial fibrillation, diabetes, high blood pressure, high cholesterol, smoking, heart disease, or stroke. RESULTS: More than 70% of survey participants were able to correctly report two or more warning signs for stroke: numbness on any side of the face/body (45%) and speech difficulties (38%) were reported most frequently. More than 45% were able to correctly report two or more stroke risk factors: smoking (50%) and high blood pressure (44%) were reported most frequently. Respondents aged 45 to 64 years (odds ratio [OR] 2.44; 95% confidence interval [CI], 1.78-3.46), women (OR 2.02; 95% CI, 1.46-2.80), those with 12 or more years of education (OR 1.96; 95% CI, 1.08-3.56), and those with high cholesterol (OR 1.68; 95% CI, 1.17-2.42) were more likely to correctly identify two or more warning signs compared with respondents without these characteristics. Women (OR 1.48; 95% CI, 1.07-2.05) and respondents aged 45 to 64 years (OR 1.35; 95% CI, 1.01-1.81) were also more likely to correctly identify two or more stroke risk factors compared with men and older respondents. CONCLUSION: Residents of two rural counties were generally aware of stroke warning signs, but their knowledge of stroke risk factors was limited.