Abstract
BACKGROUND AND OBJECTIVES: Although stroke technology and care infrastructure have advanced significantly, it remains unclear whether recent expansions of certified stroke centers have benefited rural patients equitably across income levels. This study assessed whether rural communities of varying income experienced similar gains in access to certified stroke centers and whether such expansions were associated with improvements in acute stroke treatment and outcomes. METHODS: We conducted a retrospective cohort study using 100% Medicare Provider and Analysis Review data from January 1, 2009, to December 31, 2019. This study included all Medicare fee-for-service beneficiaries diagnosed with acute ischemic stroke who resided in rural US communities. Communities were classified as exposed if a newly certified stroke center-acute stroke ready hospital (ASRH), primary stroke center, thrombectomy-capable stroke center (TSC), or comprehensive stroke center (CSC)-opened within a 30-minute drive. A community fixed-effects linear probability model was used to evaluate changes in outcomes after stroke center certification. Primary outcomes included the following: (1) admission to a stroke-certified hospital, (2) receipt of thrombolytic therapy, (3) receipt of thrombectomy, and (4) one-year mortality. RESULTS: Among 590,191 rural stroke patients, 4% of low-income and 22% of high-income patients had access to a nearby certified stroke center in 2009. By 2019, 30% of low-income and 50% of high-income communities had gained access to at least 1 newly certified stroke center; high-income communities were 3 times more likely than low-income communities to be exposed to a newly certified TSC or CSC (5.4% vs 1.8%). Exposure to ASRHs increased the probability of thrombolysis by 0.63 percentage points (95% 0.05-1.22), whereas exposure to TSC/CSCs increased the probability by 1.39 points (95% CI 0.28-2.49) and thrombectomy by 1.12 points (95% CI 0.41-1.83). No differences in 1-year mortality were observed. DISCUSSION: During the study period, high-income rural communities experienced more frequent and higher tier stroke center expansion than low-income rural communities. These access disparities were associated with differential gains in advanced stroke treatments, suggesting that expansions may have inadvertently widened income-based disparities in rural stroke care. These findings underscore the need for equity-focused implementation strategies, ensuring that infrastructure improvements translate into equitable clinical benefits.