George Howard1, Dawn O Kleindorfer2, Mary Cushman2, D Leann Long2, Adam Jasne2, Suzanne E Judd2, John C Higginbotham2, Virginia J Howard2. 1. From the Department of Biostatistics (G.H., D.L.L., S.E.J.) and Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology, University of Cincinnati, OH (D.O.K., A.J.); Department of Medicine, University of Vermont, Burlington (M.C.); and College of Community Health Sciences, University of Alabama, Tuscaloosa (J.C.H.). ghoward@uab.edu. 2. From the Department of Biostatistics (G.H., D.L.L., S.E.J.) and Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology, University of Cincinnati, OH (D.O.K., A.J.); Department of Medicine, University of Vermont, Burlington (M.C.); and College of Community Health Sciences, University of Alabama, Tuscaloosa (J.C.H.).
Abstract
BACKGROUND AND PURPOSE: Stroke mortality is 30% higher in the rural United States. This could be because of either higher incidence or higher case fatality from stroke in rural areas. METHODS: The urban-rural status of 23 280 stroke-free participants recruited between 2003 and 2007 in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) was classified using the Rural-Urban Commuting Area scheme as residing in urban, large rural town/city, or small rural town or isolated areas. The risk of incident stroke was assessed using proportional hazards analysis, and case fatality (death within 30 days of stroke) was assessed using logistic regression. Models were adjusted for demographics, traditional stroke risk factors, and measures of socioeconomic status. RESULTS: After adjustment for demographic factors and relative to urban areas, stroke incidence was 1.23-times higher (95% confidence intervals, 1.01-1.51) in large rural town/cities and 1.30-times higher (95% confidence intervals, 1.03-1.62) in small rural towns or isolated areas. Adjustment for risk factors and socioeconomic status only modestly attenuated this association, and the association became marginally nonsignificant (P=0.071). There was no association of rural-urban status with case fatality (P>0.47). CONCLUSIONS: The higher stroke mortality in rural regions seemed to be attributable to higher stroke incidence rather than case fatality. A higher prevalence of risk factors and lower socioeconomic status only modestly contributed to the increased risk of incident stroke risk in rural areas. There was no evidence of higher case fatality in rural areas.
BACKGROUND AND PURPOSE: Stroke mortality is 30% higher in the rural United States. This could be because of either higher incidence or higher case fatality from stroke in rural areas. METHODS: The urban-rural status of 23 280 stroke-free participants recruited between 2003 and 2007 in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) was classified using the Rural-Urban Commuting Area scheme as residing in urban, large rural town/city, or small rural town or isolated areas. The risk of incident stroke was assessed using proportional hazards analysis, and case fatality (death within 30 days of stroke) was assessed using logistic regression. Models were adjusted for demographics, traditional stroke risk factors, and measures of socioeconomic status. RESULTS: After adjustment for demographic factors and relative to urban areas, stroke incidence was 1.23-times higher (95% confidence intervals, 1.01-1.51) in large rural town/cities and 1.30-times higher (95% confidence intervals, 1.03-1.62) in small rural towns or isolated areas. Adjustment for risk factors and socioeconomic status only modestly attenuated this association, and the association became marginally nonsignificant (P=0.071). There was no association of rural-urban status with case fatality (P>0.47). CONCLUSIONS: The higher stroke mortality in rural regions seemed to be attributable to higher stroke incidence rather than case fatality. A higher prevalence of risk factors and lower socioeconomic status only modestly contributed to the increased risk of incident stroke risk in rural areas. There was no evidence of higher case fatality in rural areas.
Authors: Virginia J Howard; Mary Cushman; Leavonne Pulley; Camilo R Gomez; Rodney C Go; Ronald J Prineas; Andra Graham; Claudia S Moy; George Howard Journal: Neuroepidemiology Date: 2005-06-29 Impact factor: 3.282
Authors: Virginia J Howard; Dawn O Kleindorfer; Suzanne E Judd; Leslie A McClure; Monika M Safford; J David Rhodes; Mary Cushman; Claudia S Moy; Elsayed Z Soliman; Brett M Kissela; George Howard Journal: Ann Neurol Date: 2011-03-17 Impact factor: 10.422
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Authors: Michael T Mullen; Douglas J Wiebe; Ariel Bowman; Catherine S Wolff; Karen C Albright; Jason Roy; Laura J Balcer; Charles C Branas; Brendan G Carr Journal: Stroke Date: 2014-10-09 Impact factor: 7.914
Authors: Virginia J Howard; Leslie A McClure; Dawn O Kleindorfer; Solveig A Cunningham; Amanda G Thrift; Ana V Diez Roux; George Howard Journal: Neurology Date: 2016-10-14 Impact factor: 9.910
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Authors: Morgan B Swanson; Aspen C Miller; Marcia M Ward; Fred Ullrich; Kimberly As Merchant; Nicholas M Mohr Journal: J Telemed Telecare Date: 2019-11-04 Impact factor: 6.344
Authors: Allison Willis; Lesli E Skolarus; Roland Faigle; Uma Menon; Hannah Redwine; Amanda M Brown; Elizabeth Felton; Adys Mendizabal; Avindra Nath; Frances Jensen; Justin C McArthur Journal: Ann Neurol Date: 2021-08-05 Impact factor: 11.274
Authors: Tali Elfassy; Leslie Grasset; M Maria Glymour; Samuel Swift; Lanyu Zhang; George Howard; Virginia J Howard; Matthew Flaherty; Tatjana Rundek; Theresa L Osypuk; Adina Zeki Al Hazzouri Journal: Stroke Date: 2019-04 Impact factor: 7.914
Authors: Debora Kamin Mukaz; Erica Dawson; Virginia J Howard; Mary Cushman; John C Higginbotham; Suzanne E Judd; Brett M Kissela; Monika M Safford; Elsayed Z Soliman; George Howard Journal: J Rural Health Date: 2021-07-16 Impact factor: 5.667