The stroke gap

Acute stroke management has undergone major transformations with the advent of endovascular thrombectomy, but there remains a large gap in care between metropolitan and rural Australia. While metropolitan stroke centres are currently redesigning their services to expedite intervention for patients eligible for endovascular thrombectomy, rural and remote areas are still lagging behind with basic stroke therapies.

Alteplase therapy for acute stroke within 4.5 hours remains the bedrock of treatment. Nevertheless, presenting to a hospital that has the capability to facilitate this treatment is not as simple for a rural patient as for a metropolitan patient. Distance and isolation are major factors in preventing access to treatment, as is lack of local expertise. In addition, there is a paucity of neurologists working in rural Australia. Where Melbourne and Sydney boast one neurologist for every 25 000 persons, rural Australia ranges from one in 100 000–200 000 people (Costello, C. Australian and New Zealand Association of Neurologists Workforce Survey. Sydney: ANZAN; 2016 [unpublished internal report]). There are rural physicians who are skilled in the management of acute stroke, but there remain barriers and reluctance to use thrombolysis within this group.1

The impact of stroke also significantly burdens the rural Indigenous community. In the Northern Territory, the Indigenous population have a three times higher incidence (307 per 100 000 people) of stroke, a younger age of onset (10 years earlier), higher case fatality, higher stroke recurrence and higher cost of lifetime stroke compared with non-Indigenous and metropolitan patients.2,3 Due to remoteness and delays in transfer, Indigenous people often miss the opportunity for acute therapy.

Telestroke services are currently being used in certain parts of regional Australia; they are an effective, safe and efficient method of bringing the metropolitan neurologist to the rural patient’s bedside.4 However, more resources must be invested to make this a service that covers all corners of the country.

In addition, it is necessary to implement better recruitment strategies for neurologists to rural centres and stroke-specific public health campaigns that are culturally appropriate, and to increase funding for research to design innovative and creative ways to provide comprehensive care to remote patients. Urgent action is required now; otherwise, an isolated part of our country and community will only face greater challenges over time.