Effect of Rurality on Global Access to Mechanical Thrombectomy: A Subanalysis of the MT-GLASS Study

Abstract

BACKGROUND: – Mechanical thrombectomy access (MTA) for large vessel occlusion stroke varies and is limited globally. While regional studies have suggested rurality as a barrier to MTA, the magnitude and variability of this effect across countries remain unknown. This study evaluates the association of country-level rural population proportion with mechanical thrombectomy (MT) access. METHODS: – We conducted an online survey of 75 countries through the Mission Thrombectomy (previously MT2020+) global professional peer network between November 22, 2020, and February 28, 2021. Surveys were distributed by regional committee chairs and completed by stroke-focused neurologists and neurointerventional physicians within the regional committees. Questions covered country-level availability of MT centers, operators, procedures, reimbursement, emergency medical services, cultural barriers, and other factors affecting stroke systems of care. MTA was defined as the estimated proportion of patients with thrombectomy-eligible large vessel occlusions receiving MT in each region annually. We used World Bank data to obtain each country’s income class based on per capita gross national income and the proportion of rural population expressed as a percentage of the total population of each country. In the final analysis, 60 countries were included. We used multivariable generalized linear models with a logit link to evaluate the association of rural population proportion with MTA. RESULTS: – The median country-level rural population proportion among 60 countries was 30.7% (interquartile range, 16.3%–45.9%). In univariate generalized linear models, each 5% increase in country-level rural population proportion was associated with 22% lower odds of MTA (odds ratio, 0.78 [95% CI, 0.70–0.86]; P<0.001). After adjusting for differences in country-level health care gross domestic product, reimbursement for MT, country income class, availability of prehospital emergency medical services, training, and triage systems, each 5% increase in rural population proportion was associated with 13% lower odds of MTA (odds ratio, 0.87 [95% CI, 0.78–0.96]; P=0.006). CONCLUSIONS: – Country-level rural population proportion is an independent negative predictor of access to MT. The unique challenges that rural populations experience within countries should be carefully studied to strategize and align global efforts to bridge thrombectomy access gaps and address rural-urban disparities.