Importance Over the last decade or so, there have been substantial investments in the development of stroke systems of care to improve access and quality of care in rural communities. Whether these have narrowed rural-urban disparities in care is unclear.

Objective To describe trends among rural and urban patients with acute ischemic stroke or transient ischemic attack in the type of health care centers to which patients were admitted, what care was provided, and the outcomes patients experienced.

Design, Setting, and Participants This descriptive observational study included 100% claims for beneficiaries of traditional fee-for-service Medicare from 2008 through 2017. All rural and urban areas in the US were included, defined by whether a beneficiary’s residential zip code was in a metropolitan or nonmetropolitan area. All admissions in the US among patients with traditional Medicare who had a transient ischemic attack or acute stroke (N = 4.01 million) were eligible to be included in this study. Admissions for beneficiaries with end-stage kidney disease (n = 85 927 [2.14%]), beneficiaries with unidentified Rural-Urban Commuting Area codes (n = 12 797 [0.32%]), and beneficiaries not continuously enrolled in traditional Medicare in the 12 months before and 3 months after their admission (n = 442 963 [11.0%]) were excluded.

Exposures Residence in an urban or rural area; admission to a hospital with a transient ischemic attack or acute stroke.

Main Outcomes and Measures Discharge from a certified stroke center, receiving a neurology consultation during admission, treatment with alteplase, days institutionalized, and 90-day mortality.

Results The final sample included 3.47 million admissions from 2008 through 2017. In this sample, 2.01 million patients (58.0%) were female, and the mean (SD) age was 78.6 (10.5) years. In 2008, 24 681 patients (25.2%) and 161 217 patients (60.6%) in rural and urban areas, respectively, were cared for at a certified stroke center (disparity, −35.4%). By 2017, this disparity was −26.6%, having narrowed by 8.7 percentage points (95% CI, 6.6-10.8 percentage points). There was also narrowing in the rural-urban disparity in neurologist evaluation during admission (6.3% [95% CI, 4.2%-8.4%]). However, the rural-urban disparity widened or was similar with regard to receiving alteplase (0.5% [95% CI, 0.1%-0.8%]), mean days in an institution from admission (0.5 [95% CI, 0.2-0.8] days), and mortality at 90 days (0.3% [95% CI, −0.02% to 0.6%]), respectively.

Conclusions and Relevance In the last decade, care for rural residents with acute ischemic stroke and transient ischemic attack has shifted to certified stroke centers and now more likely includes neurologist input. However, disparities in access to treatments, such as alteplase, and outcomes persist, highlighting that work still is needed to extend improvements in stroke care to all US residents.

重要性在过去十年左右的时间里，人们对中风护理系统的发展进行了大量投资，以改善农村社区的护理机会和质量。这些是否缩小了城乡护理差距尚不清楚。

目的描述农村和城市急性缺血性脑卒中或短暂性脑缺血发作患者就诊的医疗保健中心类型、提供的护理以及患者经历的结果的趋势。

设计、设置和参与者这项描述性观察性研究包括 2008 年至 2017 年传统按服务收费医疗保险受益人 100% 的索赔。美国所有农村和城市地区都包括在内，根据受益人的住宅邮政编码是否在大都市区或非都市区。在美国接受传统医疗保险的所有入院的短暂性脑缺血发作或急性卒中患者（N = 401 万）都有资格纳入本研究。患有终末期肾病的受益人（n = 85 927 [2.14%]）、城乡通勤区号不明的受益人（n = 12 797 [0.32%]）以及未连续参加传统医疗保险的受益人入院入院前 12 个月和入院后 3 个月 (n = 442 963 [11.0%]) 被排除在外。

暴露居住在城市或农村地区；因短暂性脑缺血发作或急性中风入院。

主要结果和措施从经认证的卒中中心出院、入院期间接受神经科会诊、阿替普酶治疗、住院天数和 90 天死亡率。

结果最终样本包括 2008 年至 2017 年入院的 347 万名患者。在该样本中，201 万名患者 (58.0%) 为女性，平均 (SD) 年龄为 78.6 (10.5) 岁。 2008年，农村和城市地区分别有24 681名患者（25.2%）和161 217名患者（60.6%）在经过认证的卒中中心接受治疗（差距为-35.4%）。到 2017 年，这一差距为 -26.6%，缩小了 8.7 个百分点（95% CI，6.6-10.8 个百分点）。入院期间神经科医师评估的城乡差异也有所缩小（6.3% [95% CI, 4.2%-8.4%]）。然而，在接受阿替普酶治疗方面，城乡差距扩大或相似（0.5% [95% CI, 0.1%-0.8%]），入院后在机构的平均天数（0.5 [95% CI, 0.2-0.8]）天）和 90 天死亡率（0.3% [95% CI，-0.02% 至 0.6%]）。

结论和相关性在过去的十年中，对患有急性缺血性中风和短暂性脑缺血发作的农村居民的护理已转移到经过认证的中风中心，现在更有可能包括神经科医生的投入。然而，在获得阿替普酶等治疗方法和结果方面仍然存在差异，这凸显出仍需要努力将中风护理的改善扩大到所有美国居民。