{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T16:44:10Z","timestamp":1790786650592,"version":"4.1.0"},"reference-count":51,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"2","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circ: Cardiovascular Quality and Outcomes"],"published-print":{"date-parts":[[2019,2]]},"abstract":"<jats:sec>\n            <jats:title>Background:<\/jats:title>\n            <jats:p>Rural residence is associated with stroke incidence and mortality, but little is known about potential rural\/urban differences in ambulatory stroke care.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods and Results:<\/jats:title>\n            <jats:p>\n              We used the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) cohort, created from linked administrative databases from the province of Ontario, Canada, and divided into primary (N=6\u2009207\u2009032) and secondary (N=75\u2009823) prevention cohorts based on the absence or presence of prior stroke. We defined rural communities as those with a population size of \u226410\u2009000 and within each of the primary and secondary prevention cohorts, compared cardiovascular risk factors and care between rural and urban areas. We then calculated sex-\/age-standardized rates of stroke incidence and mortality per 1000 person-years between January 1, 2008 and December 31, 2012 and used cause-specific hazard models to compare outcomes in rural versus urban areas adjusting for age, sex, income, ethnicity, smoking, physical activity and comorbid conditions, and accounting for the competing risk of death in the model for the occurrence of stroke incidence. In the primary prevention cohort, rural residents were less likely than urban ones to be screened for diabetes mellitus (70.9% versus 81.3%) and hyperlipidemia (66.2% versus 78.4%) and less likely to achieve diabetes mellitus control (hemoglobin A1c \u22647% in 51.3% versus 54.3%;\n              <jats:italic>P<\/jats:italic>\n              &lt;0.001 for all comparisons). In the secondary prevention cohort, the prevalence and treatment of risk factors were similar in rural and urban residents. After adjustment for sociodemographic and comorbid conditions, rural residence was associated with higher rates of stroke and all-cause mortality in both the primary prevention (adjusted hazard ratio [aHR] for stroke, 1.06; 95% CI, 1.04\u20131.09; aHR for mortality, 1.09; 95% CI, 1.08\u20131.10) and the secondary prevention cohort (aHR for stroke, 1.11; 95% CI, 1.02\u20131.19; aHR for mortality, 1.07; 95% CI, 1.03\u20131.11).\n            <\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusions:<\/jats:title>\n            <jats:p>In this population-based study of over 6 million people with universal access to physician and hospital services, risk factors were more prevalent but less likely to be controlled in rural than in urban residents without prior stroke, whereas in those with prior stroke, risk factor prevalence and treatment were similar. Rural residence was associated with the rate of stroke and death even after adjustment for risk factors. Future efforts should focus not only on control of known vascular risk factors but also on addressing other determinants of health in rural communities.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1161\/circoutcomes.118.004973","type":"journal-article","created":{"date-parts":[[2019,2,14]],"date-time":"2019-02-14T10:04:40Z","timestamp":1550138680000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":101,"title":["Rural-Urban Differences in Stroke Risk Factors, Incidence, and Mortality in People With and Without Prior Stroke"],"prefix":"10.1161","volume":"12","author":[{"given":"Moira K.","family":"Kapral","sequence":"first","affiliation":[{"name":"Division of General Internal Medicine, Department of Medicine (M.K.K., J.V.T.), University of Toronto, Toronto, Ontario, Canada."},{"name":"Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada."},{"name":"ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter C.","family":"Austin","sequence":"additional","affiliation":[{"name":"Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada."},{"name":"ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Geerthana","family":"Jeyakumar","sequence":"additional","affiliation":[{"name":"Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland (G.J.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruth","family":"Hall","sequence":"additional","affiliation":[{"name":"ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Chu","sequence":"additional","affiliation":[{"name":"ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anam M.","family":"Khan","sequence":"additional","affiliation":[{"name":"ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Albert Y.","family":"Jin","sequence":"additional","affiliation":[{"name":"Department of Medicine, Queen\u2019s University, Kingston, Ontario, Canada (A.Y.J.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cally","family":"Martin","sequence":"additional","affiliation":[{"name":"Kingston Health Sciences Centre, Kingston, Ontario, Canada (C.M.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Doug","family":"Manuel","sequence":"additional","affiliation":[{"name":"ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)."},{"name":"Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.M.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frank L.","family":"Silver","sequence":"additional","affiliation":[{"name":"Division of Neurology, Department of Medicine (F.L.S., R.H.S.), University of Toronto, Toronto, Ontario, Canada."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard H.","family":"Swartz","sequence":"additional","affiliation":[{"name":"Division of Neurology, Department of Medicine (F.L.S., R.H.S.), University of Toronto, Toronto, Ontario, Canada."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jack V.","family":"Tu","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine, Department of Medicine (M.K.K., J.V.T.), University of Toronto, Toronto, Ontario, Canada."},{"name":"Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada."},{"name":"ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_4_2_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000000485"},{"key":"e_1_3_4_3_2","doi-asserted-by":"publisher","DOI":"10.1159\/000441085"},{"key":"e_1_3_4_4_2","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.mm6635e1"},{"key":"e_1_3_4_5_2","doi-asserted-by":"publisher","DOI":"10.1161\/hc4601.099487"},{"key":"e_1_3_4_6_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(10)60834-3"},{"key":"e_1_3_4_7_2","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-2667(18)30030-6"},{"key":"e_1_3_4_8_2","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.117.017089"},{"key":"e_1_3_4_9_2","first-page":"307","article-title":"Racial and rural-urban disparities in stroke mortality outside the stroke belt.","volume":"21","author":"Sergeev AV","year":"2011","unstructured":"Sergeev, AV. Racial and rural-urban disparities in stroke mortality outside the stroke belt. Ethn Dis. 2011;21:307\u2013313.","journal-title":"Ethn Dis"},{"key":"e_1_3_4_10_2","doi-asserted-by":"publisher","DOI":"10.1007\/s11524-013-9847-2"},{"key":"e_1_3_4_11_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0149-2918(04)90062-8"},{"key":"e_1_3_4_12_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCHEARTFAILURE.110.959262"},{"key":"e_1_3_4_13_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCOUTCOMES.114.001076"},{"key":"e_1_3_4_14_2","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.0000000000003562"},{"key":"e_1_3_4_15_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jns.2016.02.019"},{"key":"e_1_3_4_16_2","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.113.001258"},{"key":"e_1_3_4_17_2","doi-asserted-by":"publisher","DOI":"10.1001\/archneur.65.7.887"},{"key":"e_1_3_4_18_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCOUTCOMES.114.001416"},{"key":"e_1_3_4_19_2","unstructured":"Statistics Canada. Table 051-0001. Population by year by province and territory. https:\/\/www150.statcan.gc.ca\/n1\/pub\/12-581-x\/2018000\/pop-eng.htm. Accessed December 19 2018."},{"key":"e_1_3_4_20_2","doi-asserted-by":"publisher","DOI":"10.2337\/diacare.25.3.512"},{"key":"e_1_3_4_21_2","first-page":"e18","article-title":"Accuracy of administrative databases in identifying patients with hypertension.","volume":"1","author":"Tu K","year":"2007","unstructured":"Tu, K, Campbell, NR, Chen, ZL, Cauch-Dudek, KJ, McAlister, FA. Accuracy of administrative databases in identifying patients with hypertension. Open Med. 2007;1:e18\u2013e26.","journal-title":"Open Med"},{"key":"e_1_3_4_22_2","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2288-10-42"},{"key":"e_1_3_4_23_2","unstructured":"Statistics Canada. Canadian Community Health Survey Annual Component. https:\/\/www.statcan.gc.ca\/eng\/survey\/household\/3226. Accessed December 19 2018."},{"key":"e_1_3_4_24_2","unstructured":"Glazier R Gozdyra P Yeritsyan N. Geographic Access to Primary Care and Hospital Services for Rural and Northern Communities: Report to the Ontario Ministry of Health and Long-Term Care; 2011. https:\/\/www.ices.on.ca\/Publications\/Atlases-and-Reports\/2011\/Geographic-Access-to-Primary-Care. Accessed December 19 2018."},{"key":"e_1_3_4_25_2","unstructured":"Canadian Population Health Initiative. How Healthy are Rural Canadians? An Assessment of their Health Status and Health Determinants; 2006. https:\/\/secure.cihi.ca\/free_products\/rural_canadians_2006_report_e.pdf. Accessed December 19 2018."},{"key":"e_1_3_4_26_2","unstructured":"McNiven C Puderer H Janes D. Geography Working Paper Series No. 2000\u20132. Census Metropolitan Area and Census Agglomeration Influenced Zones (MIZ): A Description of the Methodology. https:\/\/www150.statcan.gc.ca\/n1\/pub\/92f0138m\/92f0138m2000002-eng.pdf. Accessed December 19 2018."},{"key":"e_1_3_4_27_2","first-page":"33","article-title":"Measuring \u2018rurality\u2019 for the purposes of health-care planning: an empirical measure for Ontario.","volume":"67","author":"Kralj B","year":"2000","unstructured":"Kralj, B. Measuring \u2018rurality\u2019 for the purposes of health-care planning: an empirical measure for Ontario. Ont Med Rev. 2000; 67:33\u201352.","journal-title":"Ont Med Rev"},{"key":"e_1_3_4_28_2","unstructured":"du Plessis V Beshiri R Bollman R Clemenson H. Statistics Canada Agriculture and Rural Working Paper No. 61: Definitions of \u201cRural\u201d; 2002. https:\/\/www150.statcan.gc.ca\/n1\/pub\/21-006-x\/21-006-x2001003-eng.pdf. Accessed December 19 2018."},{"key":"e_1_3_4_29_2","unstructured":"Statistics Canada. Census Metropolitan Influenced Zones: Detailed Definition. https:\/\/www150.statcan.gc.ca\/n1\/pub\/92-195-x\/2011001\/other-autre\/miz-zim\/def-eng.htm. Accessed December 19 2018."},{"key":"e_1_3_4_30_2","doi-asserted-by":"publisher","DOI":"10.1111\/ijs.12439"},{"key":"e_1_3_4_31_2","doi-asserted-by":"publisher","DOI":"10.1161\/STR.0000000000000024"},{"key":"e_1_3_4_32_2","doi-asserted-by":"publisher","DOI":"10.1161\/01.STR.0000174293.17959.a1"},{"key":"e_1_3_4_33_2","doi-asserted-by":"publisher","DOI":"10.1002\/(SICI)1097-0258(19970415)16:7<791::AID-SIM500>3.0.CO;2-#"},{"key":"e_1_3_4_34_2","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.d2304"},{"key":"e_1_3_4_35_2","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.131358"},{"key":"e_1_3_4_36_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.109.192703"},{"key":"e_1_3_4_37_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2010.11.041"},{"key":"e_1_3_4_38_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.115.017719"},{"key":"e_1_3_4_39_2","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.b2393"},{"key":"e_1_3_4_40_2","doi-asserted-by":"publisher","DOI":"10.1370\/afm.119"},{"key":"e_1_3_4_41_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.puhe.2012.05.029"},{"key":"e_1_3_4_42_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1748-0361.2012.00411.x"},{"key":"e_1_3_4_43_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000000228"},{"key":"e_1_3_4_44_2","unstructured":"Meit M Knudson A Gilbert T Tzy-Chyi Yu A Tanenbaum E Ormson E TenBroeck S Bayne A Popat S; NORC Walsh Center for Rural Health Analysis. The 2014 Update of the Rural-Urban Chartbook. The Rural Health Reform Policy Research Center. http:\/\/www.norc.org\/Research\/Projects\/Pages\/2014-update-of-the-rural-urban-chartbook.aspx. Accessed December 19 2018."},{"key":"e_1_3_4_45_2","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.112.653394"},{"key":"e_1_3_4_46_2","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.114.006021"},{"key":"e_1_3_4_47_2","doi-asserted-by":"publisher","DOI":"10.1111\/jrh.12029"},{"key":"e_1_3_4_48_2","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.0000000000003560"},{"key":"e_1_3_4_49_2","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.121418"},{"key":"e_1_3_4_50_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1748-0361.2010.00352.x"},{"key":"e_1_3_4_51_2","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.ss6601a1"},{"key":"e_1_3_4_52_2","doi-asserted-by":"publisher","DOI":"10.1017\/cjn.2016.12"}],"container-title":["Circulation: Cardiovascular Quality and Outcomes"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ahajournals.org\/doi\/full\/10.1161\/CIRCOUTCOMES.118.004973","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,5,13]],"date-time":"2024-05-13T04:03:02Z","timestamp":1715572982000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ahajournals.org\/doi\/10.1161\/CIRCOUTCOMES.118.004973"}},"subtitle":["The CANHEART Stroke Study"],"short-title":[],"issued":{"date-parts":[[2019,2]]},"references-count":51,"journal-issue":{"issue":"2","published-print":{"date-parts":[[2019,2]]}},"alternative-id":["10.1161\/CIRCOUTCOMES.118.004973"],"URL":"https:\/\/doi.org\/10.1161\/circoutcomes.118.004973","relation":{},"ISSN":["1941-7713","1941-7705"],"issn-type":[{"value":"1941-7713","type":"print"},{"value":"1941-7705","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,2]]},"assertion":[{"value":"2018-06-12","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2018-12-19","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2019-02-14","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e004973"}}