Strategies to improve acute stroke care of patients in rural and other geographically dispersed areas.

The 25% of Americans living in rural areas receive suboptimal stroke care. To eliminate the current disparity in rural acute stroke care, we need a comprehensive plan of education and increased resources targeting all levels of the paradigm. This plan includes improving recognition of stroke in rural areas, rural prehospital emergency services, emergency room care in small hospitals, remote support from tertiary stroke centers, and expeditious interhospital transfer with adequate communication and transfer of data between all the stakeholders. Because stroke trials are generally conducted by expert vascular neurologists working in large urban academic centers, physicians in small rural hospitals cannot be expected to immediately embrace future stroke therapies that were not tested in their system of care. The methodology of stroke trials needs to be adapted to allow the inclusion of a proportional number of patients treated in small, rural hospitals in order to improve fairness and adequately generalize future stroke therapies to large, underserved areas.