Stroke care pathways according to rural-urban residency

Abstract

Abstract Context There is concern in France about geographical access to health care, particularly in remote areas with scarce medical services. The objective of our study was to compare the care pathway of stroke patients according to their residence context (rural/urban) and their affiliation to the “agricultural social security” scheme (“MSA”). Methods The study population included ischaemic strokes occurring between 2010 and 2013 in the 79 communes covered by the Brest stroke register (BSR). State sequence analysis using BSR data linked to medico-administrative records led to the construction of a typology of care pathways encompassing a period of 12 months before and after stroke occurrence. The associations between the typology, communal density (3 levels: dense, intermediate, and sparse), and affiliation to MSA were analysed by multinomial logistic regression. Results The study involved 2499 strokes (men 47%, mean age 71 years) distributed equally between the three levels of density. The pathway typology identifies a 1st group of severe strokes (n = 539). Pre-stroke care consumption distinguishes the 2nd (high consumption, n = 844) and 3rd (low, n = 1117) groups. Communal density was not associated with the pathway type, although the use of post-hospitalisation care was lower in the intermediate density (e.g. use of GP services in the year: 85% versus 92%, p < 10-3). Affiliation to MSA (n = 389, 16%) was positively associated with the low care consumption group. MSA patients had a lower prevalence of diabetes (10.5 versus 14.4%, p = 0.05) but a higher prevalence of cardiac arrhythmia (29% versus 22%, p < 0.01). Stroke occurred significantly later in these patients (e.g. mean age in men: 76 versus 70, p < 10-3). Conclusions In the BSR territory, stroke patients’ pathway did not vary according to communal density suggesting equitable access to care. The unexpected result of higher age at stroke occurrence among MSA patients (reflecting lower incidence) requests further investigation. Key messages • Access to stroke care was comparable in rural and urban areas of Brittany, France. • Affiliation to the agricultural social security scheme was associated with lower risk of stroke.