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Neurological Review |

Rural-Urban Differences in Acute Stroke Management Practices:  A Modifiable Disparity FREE

Enrique C. Leira, MD, MS; David C. Hess, MD; James C. Torner, PhD; Harold P. Adams Jr, MD
[+] Author Affiliations

Author Affiliations: Division of Cerebrovascular Diseases, Department of Neurology, University of Iowa Roy J. and Lucille A. Carver College of Medicine (Drs Leira and Adams), and Department of Epidemiology, College of Public Health (Dr Torner), University of Iowa, Iowa City; and Department of Neurology, Medical College of Georgia, Augusta (Dr Hess).


Section Editor: David E. Pleasure, MD

More Author Information
Arch Neurol. 2008;65(7):887-891. doi:10.1001/archneur.65.7.887.
Text Size: A A A
Published online

Acute stroke management practices in rural areas of the United States are suboptimal, which creates an unacceptable health disparity between urban patients with stroke and their rural counterparts. The existing gap between urban and rural stroke care may widen in the future as more urban-tested interventions are incorporated into the treatment of acute stroke. We conducted a PubMed search to identify all the articles published from 1997 to 2007 that addressed acute stroke, paramedics, ambulances, emergency services, and interhospital transportation pertaining to the US rural, urban, or nonurban environment. We review herein the problems and potential solutions that exist in 3 aspects of the current rural stroke care system: prehospital care, rural local hospital emergency department care, and interhospital transfer of patients and subsequent reception at a larger tertiary care institution, which often involve long distances and considerable time. We conclude that the current gap in rural-urban stroke management practices could be overcome with a comprehensive strategy that addresses the existing issues, including further education of rural caregivers, remote support from tertiary care institutions, and implementation of future acute clinical trials that test the rural strategies to stroke care.

Figures in this Article

Approximately 25% of the US population lives in rural areas, defined as places with a population of 2500 or fewer (Figure).1 In many parts of the country, rural populations live in areas that are at considerable distances or are remote from large medical centers. Residents of nonurban areas are at particular risk for stroke for multiple reasons, including more elderly people and a higher prevalence of diabetes mellitus, cardiovascular disease, and smoking.2,3 Despite being at high risk, rural patients have a shortage of available health care professionals,2 including specialists such as consultant neurologists.4 As a result, acute stroke care in rural areas often is provided by primary care physicians who work in small hospitals.5 This environment is not reproduced by current stroke trials, which are conducted by academic vascular neurologists in large urban medical centers.6 This disconnect has raised concerns about the generalizability of acute stroke research and the quality of stroke care in nonurban parts of the country.7 Although the impact of such rural-urban differences in stroke practice has not been studied in a systematic randomized way, to our knowledge, ecological studies8,9 suggest worse outcomes in rural hospitals. Furthermore, the existing gap between urban and rural acute stroke management practices is likely to widen in the future as more urban-tested interventions are incorporated into the treatment of acute stroke.

Place holder to copy figure label and caption
Figure.

Distribution of rural areas (yellow) in the United States (downloaded from http://www.census.gov on April 23, 2007).

Graphic Jump Location

We conducted a PubMed search to identify all the articles from 1997 to 2007 that addressed the terms acute stroke, paramedics, ambulances, emergency services, and interhospital transportation pertaining to the US rural, urban, or nonurban environment. We found that this topic is clearly 1-sided; no articles suggested a superiority of rural stroke care over urban stroke care and, therefore, this topic was not appropriate for a systematic review. In this narrative review article, we propose possible solutions to the specific problems that affect the different levels of rural stroke care.

Successful acute stroke management is not possible without an efficient prehospital plan.10 Specifically, the strategy involves prompt recognition of stroke symptoms by patients and their caregivers, rapid notification of emergency services personnel, and a similar rapid response and transport by paramedics. The special challenges faced by rural stroke patients in the prehospital setting are summarized in Table 1. First, although reports11,12 are conflicting about the degree of recognition of stroke symptoms in rural areas, there is a need for improvement. In addition, the availability and level of response of rural emergency services dispatchers to patients with stroke symptoms are also matters of concern; these limitations may be overcome with educational interventions.13 Rural patients are also at a disadvantage with regard to ambulance services. Rural paramedics tend to be older, less educated,14 and volunteers.15 They have, in general, less training,16 less experience, and fewer learning opportunities to achieve the proficiency of their urban counterparts.17 In addition, rural emergency medical services personnel face unique issues of medical direction and supervision.18

Table Graphic Jump LocationTable 1. Problems With and Possible Solutions for the Prehospital Management of Acute Stroke in Rural Areas

This problem needs to be overcome through federal and state initiatives to reduce quality gaps in rural emergency medical services, including incentives to recruit professional, well-trained individuals. Long-distance learning19 is a solution to maintain the proficiency of rural emergency medical services professionals, given their scattered population. The strategy of using paramedics as coinvestigators in acute stroke trials, successful in large urban areas,20 may be difficult to implement in rural areas given the training and dispersion of human resources. Last, the spatial dispersion of hospitals in rural areas21 adds logistic challenges to the timely transportation by ground ambulance services. Those stroke patients far away from small, local hospitals could be eligible for a direct field to tertiary stroke center hospital evacuation.22 Alternative strategies, such as the conception of mobile acute stroke units,23 may not be feasible in vast areas of North America.

Residents of or visitors to small towns, farms, country roads, and other rural areas often have their strokes at locations that are many miles from a tertiary health care center. This calls for an initial evaluation in small, local emergency departments, a scenario that is critical for the prompt stabilization of the patient, and for consideration of the time-dependent treatment with intravenous recombinant tissue-type plasminogen activator (rtPA).24 The challenges faced by rural community hospitals in treating stroke patients are summarized in Table 2. Although general medical care is crucial to maximize outcome after stroke,25 such ancillary care is shown to be suboptimal in rural emergency departments.7 In addition to a lack of experience in treating acute stroke, many emergency physicians in small hospitals have reservations about the use of rtPA, although a trend toward acceptance has been seen since the approval of intravenous thrombolysis.5 These reservations are not surprising because the rtPA trial was conducted using expert vascular neurologists in large urban academic centers.6 Generalization of those results to smaller hospitals with limited neurologic expertise is problematic, particularly with a potentially risky therapy in which violations or deviations in a protocol are associated with more complications.26 As a consequence, the use of intravenous thrombolysis is still limited in rural areas.27,28 This urban-rural gap is likely to worsen in the future as more complex interventions that require more sophisticated diagnostic capabilities and physician expertise, such as intra-arterial or mechanical thrombolysis, are tested and implemented in urban academic centers.

Table Graphic Jump LocationTable 2. Problems With and Possible Solutions for the Rural Emergency Department Care Management of Stroke

Several strategies have been proposed to overcome the concerning disparity in the practices regarding acute stroke management between large urban and small rural hospital emergency departments, such as the certification of primary stroke centers aimed to endorse hospitals where patients could be stabilized before transfer to a tertiary care center.29 Although such an initiative is an important move to promote care, it seems as if such certification was mostly obtained by hospitals with dedicated stroke wards (Joint Commission on Accreditation of Healthcare Organizations Web site [http://www.jointcommission.org], unpublished data, November 2007) rather than by small rural hospitals that aimed to stabilize patients. Ironically, small hospitals that do not treat patients with rtPA usually have the necessary equipment for such treatment, such as round-the-clock laboratory tests or computed tomography scanners.5 Instead, the limiting factors for treating patients are the perceptions and concerns of local physicians about rtPA and the lack of available neurologic expertise to support them in this endeavor.5 The attitudes and knowledge about the treatment are best addressed with educational on-site presentations that reflect local physicians' preferences.5

The lack of available neurologic expertise could be compensated for by the remote assistance of neurologists located at tertiary care stroke centers. A “hub-and-spoke” system, in which a large comprehensive system provides multimodal assistance to a group of rural hospitals, is an efficient way to organize such support.30 Ideally, every small hospital that provides initial care for stroke patients should be backed up by at least 1 hub. Such assistance can be provided by simple telephone consultation or through a more sophisticated and expensive telemedicine link with video, audio, and neuroimaging review capabilities.31,32 Telemedicine equipment has the advantage of providing reliable and objective information, including real-time examination of the patient by a neurologist, which should allow safer treatment decisions to be made. With either of these approaches, patients can be treated locally with the remote advice of tertiary care physicians33 or treated locally with thrombolysis and then transferred to a stroke unit for further care (“drip and ship”). Although rtPA was never tested in a randomized controlled trial through these remote paradigms, the reported experience of limited centers that provide remotely directed thrombolysis has been positive as judged by the increased number of patients treated with rtPA33 and the reasonable rate of complications.34,35 Telemedicine may be the only option for extremely remote rural situations36(frontier states) in which the long distance would not permit a timely evacuation by ambulance or helicopter.

Questions that remain unanswered through the drip-and-ship strategy are whether this strategy is generalizable to multiple rural areas and practice settings, whether enough tertiary resources are available to support all stroke rural care, what the compensation for and liability of distant advisers for stroke treatment should be, how cost-effective telemedicine equipment is, and what the uncertainties are regarding the minimal degree of technical sophistication that is required. An additional limitation to the use of the drip-and-ship system is economic: smaller hospitals could fear a loss of inpatient revenues by such practices. Such concerns should be addressed with educational campaigns that explain the ethical and legal risks37 of suboptimal stroke care and are backed up by legislative initiatives that promote excellence in stroke care.

Although improving the use of thrombolysis in rural emergency departments remains an important issue, we should learn from past mistakes. The long-term goal of reducing the gap in acute stroke care should include strategies to implement future stroke therapies. This goal implies finding ways to simultaneously test future acute stroke interventions in urban and rural settings before their implementation. Serious logistic and regulatory issues limit the performance of acute stroke research in rural settings. The dispersion of potential local investigators, each with limited exposure to stroke patients, is a major impediment.38 Before acute stroke research can be implemented in rural areas, major adjustments in trial logistics and consent regulations are needed. For example, one solution could be well-trained flight nurses as coinvestigators who could initiate acute stroke management trials at multiple outside emergency departments.38 The informed consent process needs to be adopted to the rural setting by either being waived39,40 or allowing ways of remote consent elicitation through telephone lines41 or telemedicine systems.42

The strategy of comprehensive stroke centers35 supporting small hospital stroke care calls for an expeditious transport of the stroke patient. Given the urgency and the distance involved, an aerial transfer is preferred because it has been shown to be safe43 and has been deemed appropriate for the circumstances.44 Helicopters can be used for most areas except extremely remote areas (frontier states), where a fixed-wing evacuation may be needed (Table 3).36 No specific interventions are known to be useful during this critical early period, so research is needed in that setting using the flight crews as coinvestigators.38 The arrival of inbound flight crews needs to be carefully coordinated with the receiving tertiary care stroke team.

Table Graphic Jump LocationTable 3. Problems With and Possible Solutions for Interhospital Transfer to a Tertiary Care Institution

Code stroke systems have been shown to decrease intrahospital delays for patients presenting to urban emergency departments,45 but the same coordinated response is needed for aerially evacuated strokes to tertiary care centers. Such a response includes fluent communication among all the stakeholders in this challenging multihospital operation, including local paramedics, rural hospital emergency department personnel, transporting flight crew and receiving tertiary care center nurses, emergency physicians, and dedicated code stroke teams. In addition, communication with family members who could provide consent for invasive procedures needs to be maintained during the rapid transfer of care among institutions. Family members typically arrive by ground later than the patient and helicopter crew, and the unavailability of consenting family members often impedes the tertiary care team's efforts to consider invasive therapies. Similarly, locally obtained medical ancillary data, including imaging studies and laboratory tests, need to be readily available by electronic or material means.

Acute stroke management practices in rural areas are suboptimal, which creates an unacceptable health disparity between urban stroke patients and their rural counterparts, who constitute 25% of the US population. Such a gap, which is likely to widen as new and more complex interventions become available, can be solved by comprehensibly addressing the existing problems at the following levels: prehospital; in the small, local hospital emergency department; and during interhospital transfer to tertiary care institutions. This includes testing future stroke interventions through an arm rural research paradigm.

Correspondence: Enrique C. Leira, MD, MS, Department of Neurology, 2147-RCP, University of Iowa College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242 (enrique-leira@uiowa.edu).

Accepted for Publication: September 21, 2007.

Author Contributions:Study concept and design: Leira, Hess, and Adams. Acquisition of data: Leira. Analysis and interpretation of data: Torner. Drafting of the manuscript: Leira. Critical revision of the manuscript for important intellectual content: Hess, Torner, and Adams. Administrative, technical, and material support: Hess. Study supervision: Leira and Torner.

Financial Disclosure: Dr Hess is a cofounder of REACH CALL, a telemedicine stroke company, and has founder’s equity.

Funding/Support: This study was supported in part by the Mentored Clinical Research Scholar Program at the University of Iowa and by grant 5K12RR017700-04 from the National Institutes of Health.

US Bureau of the Census, Urban and rural population 2000. http://www.census.gov. Accessed September 12, 2007
Pearson  TALewis  C Rural epidemiology: insights from a rural population laboratory. Am J Epidemiol 1998;148 (10) 949- 957
PubMed
Eberhardt  MSPamuk  ER The importance of place of residence: examining health in rural and nonrural areas. Am J Public Health 2004;94 (10) 1682- 1686
PubMed
Ruland  SGorelick  PBSchneck  MKim  DMoore  CGLeurgans  S Acute stroke care in Illinois: a statewide assessment of diagnostic and treatment capabilities. Stroke 2002;33 (5) 1334- 1339
PubMed
Leira  ECPary  JKDavis  PHGrimsman  KJAdams  HP  Jr Slow progressive acceptance of intravenous thrombolysis for patients with stroke by rural primary care physicians. Arch Neurol 2007;64 (4) 518- 521
PubMed
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333 (24) 1581- 1587
PubMed
Burgin  WSStaub  LChan  W  et al.  Acute stroke care in non-urban emergency departments. Neurology 2001;57 (11) 2006- 2012
PubMed
Centers for Medicare and Medicare Services, Stroke Highlight Report: Full Report of Methods and Appendices.  Baltimore, MD Centers for Medicare and Medicare Services2007;
Qureshi  AISuri  MFNasar  A  et al.  Changes in cost and outcome among US patients with stroke hospitalized in 1990 to 1991 and those hospitalized in 2000 to 2001. Stroke 2007;38 (7) 2180- 2184
PubMed
Suyama  JCrocco  T Prehospital care of the stroke patient. Emerg Med Clin North Am 2002;20 (3) 537- 552
PubMed
Blades  LLOser  CSDietrich  DW  et al.  Rural community knowledge of stroke warning signs and risk factors. Prev Chronic Dis 2005;2 (2) 1- 8
PubMed
Alkadry  MGWilson  CNicholson  D Stroke awareness among rural residents: the case of West Virginia. Soc Work Health Care 2005;42 (2) 73- 92
PubMed
Wein  THStaub  LFelberg  R  et al.  Activation of emergency medical services for acute stroke in a nonurban population: the T.L.L. Temple Foundation Stroke Project. Stroke 2000;31 (8) 1925- 1928
PubMed
Chng  CLCollins  JEaddy  S A comparison of rural and urban Emergency Medical System (EMS) personnel: a Texas study. Prehosp Disaster Med 2001;16 (3) 159- 165
PubMed
Thompson  AM  III Rural emergency medical volunteers and their communities: a demographic comparison. J Community Health 1993;18 (6) 379- 392
PubMed
Brown  LHCopeland  TWGough  JEGarrison  HGDunn  KA EMS knowledge and skills in rural North Carolina: a comparison with the National EMS Education and Practice Blueprint. Prehosp Disaster Med 1996;11 (4) 254- 260
PubMed
Becknell  JOstrow  LS EMS in rural America. Emerg Med Serv 2002;31 (11) 41- 48
PubMed
Knott  A Emergency medical services in rural areas: the supporting role of state EMS agencies. J Rural Health 2003;19 (4) 492- 496
PubMed
Hobbs  GDMoshinskie  JFRoden  SKJarvis  JL A comparison of classroom and distance learning techniques for rural EMT-I instruction. Prehosp Emerg Care 1998;2 (3) 189- 191
PubMed
Saver  JLKidwell  CEckstein  MStarkman  SFAST-MAG Pilot Trial Investigators, Prehospital neuroprotective therapy for acute stroke: results of the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) pilot trial [published online ahead of print March 11, 2004]. Stroke 2004;35 (5) e106- e10810.1161/01.STR.0000124458.98123.52
Messina  JPShortridge  AMGroop  REVarnakovida  PFinn  MJ Evaluating Michigan's community hospital access: spatial methods for decision support. Int J Health Geogr 2006;542
PubMed
Silliman  SLQuinn  BHuggett  VMerino  JG Use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. Stroke 2003;34 (3) 729- 733
PubMed
Fassbender  KWalter  SLiu  Y  et al.  “Mobile stroke unit” for hyperacute stroke treatment [published online ahead of print May 15, 2003]. Stroke 2003;34 (6) e4410.1161/01.STR.0000075573.22885.3B
Adams  HP  JrBrott  TGFurlan  AJ  et al.  Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation 1996;94 (5) 1167- 1174
PubMed
Stroke Unit Trialists' Collaboration, Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2000; (2) CD000197
PubMed
Lopez-Yunez  AMBruno  AWilliams  LSYilmaz  EZurru  CBiller  J Protocol violations in community-based rTPA stroke treatment are associated with symptomatic intracerebral hemorrhage. Stroke 2001;32 (1) 12- 16
PubMed
Alberts  MJ tPA in acute ischemic stroke: United States experience and issues for the future. Neurology 1998;51 (3) ((suppl 3)) S53- S55
PubMed
Katzan  ILHammer  MDHixson  ED  et al.  Utilization of intravenous tissue plasminogen activator for acute ischemic stroke. Arch Neurol 2004;61 (3) 346- 350
PubMed
Alberts  MJHademenos  GLatchaw  RE  et al. Brain Attack Coalition, Recommendations for the establishment of primary stroke centers. JAMA 2000;21 (283) 3102- 3109
PubMed
Adams  LNGrigsby  RK The Georgia State Telemedicine Program: initiation, design, and plans. Telemed J 1995;1 (3) 227- 235
PubMed
Hess  DCWang  SHamilton  W  et al.  REACH: clinical feasibility of a rural telestroke network. Stroke 2005;36 (9) 2018- 2020
PubMed
Wang  DZ Editorial comment–telemedicine: the solution to provide rural stroke coverage and the answer to the shortage of stroke neurologists and radiologists. Stroke 2003;34 (12) 2957
PubMed
Audebert  HJSchenkel  JHeuschmann  PUBogdahn  UHaberl  RL Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. Lancet Neurol 2006;5 (9) 742- 748
PubMed
Silverman  IEBeland  DKChhabra  J McCullough  LD The “drip-and-ship” approach: starting IV t-PA for acute ischemic stroke at outside hospitals prior to transfer to a regional stroke center. Conn Med 2005;69 (10) 613- 620
PubMed
Wang  DZRose  JAHonings  DSGarwacki  DJMilbrandt  JC Treating acute stroke patients with intravenous tPA: the OSF stroke network experience. Stroke 2000;31 (1) 77- 81
PubMed
Okon  NJRodriguez  DVDietrich  DW  et al.  Availability of diagnostic and treatment services for acute stroke in frontier counties in Montana and Northern Wyoming. J Rural Health 2006;22 (3) 237- 241
PubMed
Weintraub  MI Thrombolysis (tissue plasminogen activator) in stroke: a medicolegal quagmire. Stroke 2006;37 (7) 1917- 1922
PubMed
Leira  ECLamb  DLNugent  AS  et al.  Feasibility of acute clinical trials during aerial interhospital transfer. Stroke 2006;37 (10) 2504- 2507
PubMed
Stobbart  LMurtagh  MJLouw  SJFord  GARodgers  H Consent for research in hyperacute stroke. BMJ 2006;332 (7555) 1405- 1406
PubMed
Bateman  BTMeyers  PMSchumacher  HCMangla  SPile-Spellman  J Conducting stroke research with an exception from the requirement for informed consent. Stroke 2003;34 (5) 1317- 1323
PubMed
Saver  JLKidwell  CEckstein  MOvbiagele  BStarkman  S Physician-investigator phone elicitation of consent in the field: a novel method to obtain explicit informed consent for prehospital clinical research. Prehosp Emerg Care 2006;10 (2) 182- 185
PubMed
Dreezen  I Telemedicine and informed consent. Med Law 2004;23 (3) 541- 549
PubMed
Conroy  MBRodriguez  SUKimmel  SEKasner  SE Helicopter transfer offers a potential benefit to patients with acute stroke. Stroke 1999;30 (12) 2580- 2584
PubMed
Hutton  KSand  C Appropriateness of medical transport and access to care in acute stroke syndromes. Air Med J 2005;24 (5) 220- 221
PubMed
Gomez  CRMalkoff  MDSauer  CMTulyapronchote  RBurch  CMBanet  GA Code stroke: an attempt to shorten inhospital therapeutic delays. Stroke 1994;25 (10) 1920- 1923
PubMed

Figures

Place holder to copy figure label and caption
Figure.

Distribution of rural areas (yellow) in the United States (downloaded from http://www.census.gov on April 23, 2007).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Problems With and Possible Solutions for the Prehospital Management of Acute Stroke in Rural Areas
Table Graphic Jump LocationTable 2. Problems With and Possible Solutions for the Rural Emergency Department Care Management of Stroke
Table Graphic Jump LocationTable 3. Problems With and Possible Solutions for Interhospital Transfer to a Tertiary Care Institution

References

US Bureau of the Census, Urban and rural population 2000. http://www.census.gov. Accessed September 12, 2007
Pearson  TALewis  C Rural epidemiology: insights from a rural population laboratory. Am J Epidemiol 1998;148 (10) 949- 957
PubMed
Eberhardt  MSPamuk  ER The importance of place of residence: examining health in rural and nonrural areas. Am J Public Health 2004;94 (10) 1682- 1686
PubMed
Ruland  SGorelick  PBSchneck  MKim  DMoore  CGLeurgans  S Acute stroke care in Illinois: a statewide assessment of diagnostic and treatment capabilities. Stroke 2002;33 (5) 1334- 1339
PubMed
Leira  ECPary  JKDavis  PHGrimsman  KJAdams  HP  Jr Slow progressive acceptance of intravenous thrombolysis for patients with stroke by rural primary care physicians. Arch Neurol 2007;64 (4) 518- 521
PubMed
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333 (24) 1581- 1587
PubMed
Burgin  WSStaub  LChan  W  et al.  Acute stroke care in non-urban emergency departments. Neurology 2001;57 (11) 2006- 2012
PubMed
Centers for Medicare and Medicare Services, Stroke Highlight Report: Full Report of Methods and Appendices.  Baltimore, MD Centers for Medicare and Medicare Services2007;
Qureshi  AISuri  MFNasar  A  et al.  Changes in cost and outcome among US patients with stroke hospitalized in 1990 to 1991 and those hospitalized in 2000 to 2001. Stroke 2007;38 (7) 2180- 2184
PubMed
Suyama  JCrocco  T Prehospital care of the stroke patient. Emerg Med Clin North Am 2002;20 (3) 537- 552
PubMed
Blades  LLOser  CSDietrich  DW  et al.  Rural community knowledge of stroke warning signs and risk factors. Prev Chronic Dis 2005;2 (2) 1- 8
PubMed
Alkadry  MGWilson  CNicholson  D Stroke awareness among rural residents: the case of West Virginia. Soc Work Health Care 2005;42 (2) 73- 92
PubMed
Wein  THStaub  LFelberg  R  et al.  Activation of emergency medical services for acute stroke in a nonurban population: the T.L.L. Temple Foundation Stroke Project. Stroke 2000;31 (8) 1925- 1928
PubMed
Chng  CLCollins  JEaddy  S A comparison of rural and urban Emergency Medical System (EMS) personnel: a Texas study. Prehosp Disaster Med 2001;16 (3) 159- 165
PubMed
Thompson  AM  III Rural emergency medical volunteers and their communities: a demographic comparison. J Community Health 1993;18 (6) 379- 392
PubMed
Brown  LHCopeland  TWGough  JEGarrison  HGDunn  KA EMS knowledge and skills in rural North Carolina: a comparison with the National EMS Education and Practice Blueprint. Prehosp Disaster Med 1996;11 (4) 254- 260
PubMed
Becknell  JOstrow  LS EMS in rural America. Emerg Med Serv 2002;31 (11) 41- 48
PubMed
Knott  A Emergency medical services in rural areas: the supporting role of state EMS agencies. J Rural Health 2003;19 (4) 492- 496
PubMed
Hobbs  GDMoshinskie  JFRoden  SKJarvis  JL A comparison of classroom and distance learning techniques for rural EMT-I instruction. Prehosp Emerg Care 1998;2 (3) 189- 191
PubMed
Saver  JLKidwell  CEckstein  MStarkman  SFAST-MAG Pilot Trial Investigators, Prehospital neuroprotective therapy for acute stroke: results of the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) pilot trial [published online ahead of print March 11, 2004]. Stroke 2004;35 (5) e106- e10810.1161/01.STR.0000124458.98123.52
Messina  JPShortridge  AMGroop  REVarnakovida  PFinn  MJ Evaluating Michigan's community hospital access: spatial methods for decision support. Int J Health Geogr 2006;542
PubMed
Silliman  SLQuinn  BHuggett  VMerino  JG Use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. Stroke 2003;34 (3) 729- 733
PubMed
Fassbender  KWalter  SLiu  Y  et al.  “Mobile stroke unit” for hyperacute stroke treatment [published online ahead of print May 15, 2003]. Stroke 2003;34 (6) e4410.1161/01.STR.0000075573.22885.3B
Adams  HP  JrBrott  TGFurlan  AJ  et al.  Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation 1996;94 (5) 1167- 1174
PubMed
Stroke Unit Trialists' Collaboration, Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2000; (2) CD000197
PubMed
Lopez-Yunez  AMBruno  AWilliams  LSYilmaz  EZurru  CBiller  J Protocol violations in community-based rTPA stroke treatment are associated with symptomatic intracerebral hemorrhage. Stroke 2001;32 (1) 12- 16
PubMed
Alberts  MJ tPA in acute ischemic stroke: United States experience and issues for the future. Neurology 1998;51 (3) ((suppl 3)) S53- S55
PubMed
Katzan  ILHammer  MDHixson  ED  et al.  Utilization of intravenous tissue plasminogen activator for acute ischemic stroke. Arch Neurol 2004;61 (3) 346- 350
PubMed
Alberts  MJHademenos  GLatchaw  RE  et al. Brain Attack Coalition, Recommendations for the establishment of primary stroke centers. JAMA 2000;21 (283) 3102- 3109
PubMed
Adams  LNGrigsby  RK The Georgia State Telemedicine Program: initiation, design, and plans. Telemed J 1995;1 (3) 227- 235
PubMed
Hess  DCWang  SHamilton  W  et al.  REACH: clinical feasibility of a rural telestroke network. Stroke 2005;36 (9) 2018- 2020
PubMed
Wang  DZ Editorial comment–telemedicine: the solution to provide rural stroke coverage and the answer to the shortage of stroke neurologists and radiologists. Stroke 2003;34 (12) 2957
PubMed
Audebert  HJSchenkel  JHeuschmann  PUBogdahn  UHaberl  RL Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. Lancet Neurol 2006;5 (9) 742- 748
PubMed
Silverman  IEBeland  DKChhabra  J McCullough  LD The “drip-and-ship” approach: starting IV t-PA for acute ischemic stroke at outside hospitals prior to transfer to a regional stroke center. Conn Med 2005;69 (10) 613- 620
PubMed
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