Background
Stroke remains one of the leading causes of death and long-term disability in the United States. A persistent rural-urban gap has been reported in stroke mortality, with people living in rural areas experiencing worse outcomes than those in urban settings. Several factors may contribute to this difference, including delayed access to acute stroke treatment, fewer rehabilitation resources, longer travel distances, and limited availability of postacute care services after hospital discharge.
Postacute care is the period of recovery after the initial hospitalization. For patients with ischemic stroke, it often includes discharge to an inpatient rehabilitation facility, a skilled nursing facility, or home with outpatient or home-based therapy. The quality and type of postacute care can strongly affect recovery, independence, readmissions, and survival. This study examined whether patients treated for acute ischemic stroke in rural hospitals received the same postacute care as those treated in urban hospitals, and whether their 1-year outcomes were similar.
Study Design and Methods
This was a cohort study of Medicare beneficiaries aged 65 years and older who were treated for acute ischemic stroke at hospitals participating in the Get With The Guidelines-Stroke program from 2017 through 2022. The investigators compared patients treated in rural hospitals with those treated in urban hospitals.
The main outcomes were the amount of home-time within 1 year, all-cause mortality, and all-cause readmission. Home-time is the number of days a patient is alive and not hospitalized or in a facility; it is often used as a meaningful patient-centered measure because it reflects time spent at home rather than in institutions. The researchers used restricted mean home-time to compare groups and applied Cox proportional hazards models to assess mortality and readmission, while adjusting for important patient and hospital characteristics.
Key Findings on Discharge Destination
The analysis included 29,734 patients treated in rural hospitals and 478,122 patients treated in urban hospitals. The mean age was 79 years, and 55.5% of participants were women.
Important differences were seen in discharge disposition. Compared with patients treated in urban hospitals, patients treated in rural hospitals were less likely to be discharged to inpatient rehabilitation facilities, 20.1% versus 25.1%. After adjustment, the odds of discharge to inpatient rehabilitation were 24% lower among rural patients, with an adjusted odds ratio of 0.76.
In contrast, rural patients were more likely to be discharged to skilled nursing facilities, 24.5% versus 20.9%. After adjustment, the odds of discharge to a skilled nursing facility were 21% higher among rural patients, with an adjusted odds ratio of 1.21.
These findings suggest that the postacute care pathway differs by geography. Inpatient rehabilitation facilities usually provide more intensive therapy, often several hours per day, and are typically designed for patients who can tolerate active rehabilitation. Skilled nursing facilities generally provide less intensive therapy and more custodial or nursing support. Differences in access, referral patterns, bed availability, insurance logistics, and local resources may all influence discharge planning.
Home-Time Outcomes
Overall, rural patients had 1.8 fewer days of home-time over 1 year than urban patients. Although this difference may appear modest, home-time is a sensitive measure that captures the combined burden of death, readmission, and time spent in facilities.
The gap was larger in certain discharge groups. Rural patients discharged to skilled nursing facilities had 5.7 fewer days of home-time than their urban counterparts. Rural patients discharged home also had 2.2 fewer days of home-time.
These results indicate that even when rural patients survive the initial hospitalization, they may spend more time away from home during recovery. That can reflect slower functional recovery, higher complication rates, differences in access to rehabilitation, or fewer community-based support services after discharge.
Mortality and Readmission
Despite the differences in postacute care and home-time, rural patients overall had similar all-cause mortality compared with urban patients after adjustment. The adjusted hazard ratio for death was 1.01, which indicates no meaningful overall difference in mortality risk between the two groups.
Rural patients also had lower all-cause readmission overall, with an adjusted hazard ratio of 0.92. This could reflect several possibilities, including less access to hospital-based care, different thresholds for readmission, barriers to returning to the hospital, or differences in discharge destination and follow-up care.
However, an important subgroup finding emerged: rural patients who were discharged home had higher all-cause mortality than urban patients discharged home, with an adjusted hazard ratio of 1.11. This suggests that when rural patients return home directly after stroke, they may be at increased risk if adequate rehabilitation, monitoring, and support are not available.
Interpretation
The study shows that rural stroke patients do not receive postacute care in exactly the same way as urban patients. They are less often sent to inpatient rehabilitation and more often to skilled nursing facilities. These differences are associated with fewer days spent at home during the year after stroke, even though overall mortality was similar.
This pattern is important because postacute care is a major part of stroke recovery. The right setting can improve mobility, communication, swallowing, self-care, and caregiver burden. If rural patients have reduced access to intensive rehabilitation, they may experience slower recovery or lower functional independence, even if short-term survival is not worse.
Several structural issues may explain the disparity. Rural communities often have fewer rehabilitation facilities and fewer stroke specialists. Transportation barriers, limited availability of therapists, shortages of skilled nursing resources, and financial or insurance constraints may also affect discharge decisions. In some regions, patients may be discharged to facilities farther from home, making family involvement more difficult and potentially reducing continuity of care.
Clinical and Public Health Implications
These findings have practical implications for hospitals, clinicians, policymakers, and health systems. First, discharge planning for stroke should account not only for medical stability but also for the patient’s functional needs and the local availability of rehabilitation services. Second, rural hospitals may need stronger partnerships with rehabilitation networks, tele-rehabilitation programs, and home-based therapy services to improve access to appropriate postacute care.
Improving rural stroke outcomes may require a broader systems approach, including better ambulance routing, faster transfer to stroke-capable centers, expanded rehabilitation infrastructure, and support for caregivers after discharge. Telehealth may help with follow-up visits and therapy supervision, but it is not a complete substitute for in-person intensive rehabilitation when that level of care is needed.
The study also highlights the value of home-time as an outcome. Traditional measures such as death and readmission are important, but they do not fully capture recovery after stroke. Home-time provides a more patient-centered view of what matters: living at home with as much independence as possible.
Limitations
As with all observational studies, this analysis cannot prove that rural residence itself caused the differences seen. There may be unmeasured factors, such as stroke severity, social support, caregiver availability, baseline disability, or local practice patterns, that influenced both discharge destination and outcomes.
The study included Medicare beneficiaries aged 65 years and older, so the findings may not fully apply to younger patients or those without Medicare. Also, although the analysis adjusted for many characteristics, claims and registry data may not capture all details of rehabilitation intensity, outpatient therapy use, or patient preferences.
Conclusion
Among older adults hospitalized for acute ischemic stroke, those treated in rural hospitals were less likely to be discharged to inpatient rehabilitation facilities and more likely to be discharged to skilled nursing facilities than those treated in urban hospitals. Rural patients had fewer days of home-time over 1 year, but overall mortality was similar. Notably, rural patients discharged home had higher mortality than urban patients discharged home.
These findings suggest that postacute stroke care is not fully equitable across rural and urban settings. Efforts to expand access to high-quality rehabilitation and postdischarge support in rural areas are needed to improve recovery and help more stroke survivors return home safely and stay there.
