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PLoS One. 2018 Jan 31;13(1):e0191151. doi: 10.1371/journal.pone.0191151. eCollection 2018.

Rural versus urban academic hospital mortality following stroke in Canada.

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Department of Family Medicine and Emergency Medicine, Université Laval, Québec, QC, Canada.
Research Chair in Emergency Medicine Université Laval-CHAU Hôtel-Dieu de Lévis, Lévis, QC, Canada.
Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Québec, QC, Canada.
Department of Family Medicine and Emergency Medicine and Knowledge Transfer and Health Technology Assessment Group, CHU de Québec Research Centre and Evaluative Research Unit, Université Laval, Québec, QC, Canada.
Faculty of Medicine, University of British Columbia and Department of Emergency Medicine, Penticton Regional Hospital, Penticton, BC, Canada.
Intensive Care Division, Department of Anesthesiology, Université Laval, Quebec, QC, Canada.
Department of Psychology, Université du Québec à Montréal, Montréal, QC, Canada.



Stroke is one of the leading causes of death in Canada. While stroke care has improved dramatically over the last decade, outcomes following stroke among patients treated in rural hospitals have not yet been reported in Canada.


To describe variation in 30-day post-stroke in-hospital mortality rates between rural and urban academic hospitals in Canada. We also examined 24/7 in-hospital access to CT scanners and selected services in rural hospitals.


We included Canadian Institute for Health Information (CIHI) data on adjusted 30-day in-hospital mortality following stroke from 2007 to 2011 for all acute care hospitals in Canada excluding Quebec and the Territories. We categorized rural hospitals as those located in rural small towns providing 24/7 emergency physician coverage with inpatient beds. Urban hospitals were academic centres designated as Level 1 or 2 trauma centres. We computed descriptive data on local access to a CT scanner and other services and compared mean 30-day adjusted post-stroke mortality rates for rural and urban hospitals to the overall Canadian rate.


A total of 286 rural hospitals (3.4 million emergency department (ED) visits/year) and 24 urban hospitals (1.5 million ED visits/year) met inclusion criteria. From 2007 to 2011, 30-day in-hospital mortality rates following stroke were significantly higher in rural than in urban hospitals and higher than the Canadian average for every year except 2008 (rural average range = 18.26 to 21.04 and urban average range = 14.11 to 16.78). Only 11% of rural hospitals had a CT-scanner, 1% had MRI, 21% had in-hospital ICU, 94% had laboratory and 92% had basic x-ray facilities.


Rural hospitals in Canada had higher 30-day in-hospital mortality rates following stroke than urban academic hospitals and the Canadian average. Rural hospitals also have very limited local access to CT scanners and ICUs. These rural/urban discrepancies are cause for concern in the context of Canada's universal health care system.

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