# Ischemic stroke care for patients affiliated to the French agricultural health insurance scheme: A national study

Olivier Grimaud, Sandrine Kerbrat, L. Menant, S. Timsit, Jean-Marie André, E. Nowak, V. Olié, C. Padilla, Nolwenn Le Meur

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Olivier Grimaud, Sandrine Kerbrat, L. Menant, S. Timsit, Jean-Marie André, et al. Ischemic stroke care for patients affiliated to the French agricultural health insurance scheme: A national study. Revue Neurologique, 2025, 181 (4), pp.298-304. 10.1016/j.neurol.2025.01.410. hal-04967029

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Original article

# Ischemic stroke care for patients affiliated to the French agricultural health insurance scheme: A national study

<figure><img src="image_2.png" /></figure>

O. Grimaud<sup>a,*</sup>, S. Kerbrat<sup>b</sup>, L. Menant<sup>a</sup>, S. Timsit<sup>c</sup>, J.-M. André<sup>d</sup>, E. Nowak<sup>b</sup>, V. Olié<sup>e</sup>, C. Padilla<sup>a</sup>, N. Le Meur<sup>a</sup>

## INFO ARTICLE

**Article history:**
Received 29 July 2024
Received in revised form
20 January 2025
Accepted 22 January 2025
Available online 22 February 2025

**Keywords:**
Ischemic stroke
Rural
Care pathway
Social insurance
Agricultural sector

## ABSTRACT

**Background.** – Health disparities along the rural-urban spectrum are a growing concern. The objective of this study was to determine whether in France, clinical profile, care and outcome after ischemic stroke differed between patients affiliated to the statutory health insurance system dedicated to the agricultural economic sector (i.e., *Mutualité Sociale Agricole* [MSA]) and all other patients.

**Methods.** – Data on all patients aged ≥ 20 years hospitalized for ischemic stroke in mainland France in 2018 were extracted from the French National Health Insurance Data System. Age-standardized percentages were used to compare the care accessed by MSA versus other stroke patients. Associations between health insurance scheme and case fatality were assessed using Poisson regression.

**Results.** – Of 87,864 stroke cases 7928 (9%) were MSA patients. MSA patients were more often rural dwellers (75.4 versus 32%) and older (median age: 84 versus 76 years). In the 12 months prior to the stroke, access to general practitioner (GP) was similar, but MSA patients were less likely to have an appointment with a cardiologist. Pre-stroke drug prescriptions suggested a better cardiovascular profile in male MSA patients (e.g., antidiabetics: 18.1 versus 21.5%). A part from a lower access to stroke unit (e.g., women: 55.3 versus 59%) other acute care indicators, including reperfusion therapy, were comparable. The crude 7-day case fatality was higher for MSA patients (Relative Risk [RR]: 1.44, 95% CI [1.32–1.57]), but this disadvantage reduced to non-significant level after adjustment for age, comorbidities and stroke management (adjusted RR: 1.07 95% CI [0.98–1.18])

<footnote><sup>a</sup> EHESP, CNRS, Inserm, ARENES UMR 6051, RSMS U 1309, Rennes University, Rennes, France</footnote>

<footnote><sup>b</sup> DAMAD, 29280 Plouzane, France</footnote>

<footnote><sup>c</sup> Neurology and Stroke Unit Department, CHRU de Brest, Inserm 1078, université de Bretagne Occidentale, Brest, France</footnote>

<footnote><sup>d</sup> EHESP, CNRS, ARENES UMR 6051, Rennes University, Rennes, France</footnote>

<footnote><sup>e</sup> Santé Publique France, Saint Maurice, France</footnote>

<footnote>* Corresponding author: EHESP, avenue du Professeur-Léon-Bernard, 35043 Rennes cedex, France.</footnote>

<footnote>E-mail address: olivier.grimaud@ehesp.fr (O. Grimaud).</footnote>

<footnote>https://doi.org/10.1016/j.neurol.2025.01.410</footnote>

<footnote>0035-3787/© 2025 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).</footnote>
*Conclusions.* – For the mostly farming, rural, MSA population, pre-stroke, acute and post-stroke care did not differ markedly from that provided to other patients. The lower density of GP in rural areas and the remoteness from specialized center did not result in less access to preventive and acute stroke care for MSA patients in 2018.

© 2025 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

# 1. Abbreviations

MSA *Mutualité Sociale Agricole*

SNDS *Système national des données de santé*

# 2. Introduction

Health disparities along the rural-urban spectrum are a growing issue. In the last decades, the life expectancy divide in favor of urban areas has continued to grow in the USA [1] and also in Nordic countries that implemented the welfare model [2]. Differences in access to healthcare might contribute to these disparities. In many countries, rural areas struggle to maintain access to primary healthcare. Restricted access can result in the lack of early detection and control of risk factors, which in turn increases the incidence of diseases. Furthermore, rural area residents live usually far away from specialist healthcare. Therefore, they may be less likely to benefit from timely effective treatments, which in turn increases case fatality. Stroke is a leading cause of death and disability affecting up to one in five people in high-income countries [3]. According to the latest Global Burden of Disease estimates, stroke accounted for 94,000 new cases and 43,000 deaths in France in 2021 [4]. Stroke is amenable to evidence-based preventive, curative and rehabilitative interventions. Specifically, management of cardiovascular risk factors (to prevent stroke occurrence), timely access to specialized acute care such as reperfusion therapy and to rehabilitative care (to reduce lethality and disability) are essential components of the care pathway. Achieving timeliness and swift coordination of all these components is likely to be more challenging for patients living in rural areas which are remote from acute care hospitals and where primary care is under stress. As an illustration, patients residing in small towns (< 2000 inhabitants) were more than twice less likely to be admitted in a stroke unit compared to those residing in large towns in France during the period 2009–2014 [5]. Stroke is therefore a useful marker for analysing and understanding health inequalities along the rural-urban spectrum. However, according to two recent reviews [6,7], the scientific literature on this topic is scarce and inconclusive. For instance, the REGARDS cohort study demonstrated that in the USA, the higher stroke mortality in rural areas is mainly driven by higher stroke incidence [8]. Conversely, an analysis of stroke registry data in France did not show clinically significant variations in incidence or case fatality between urban and rural areas [9].

Rurality is mostly used as a spatial concept and is pragmatically approached using objective measurements, such as population density, settlement size and remoteness. However, this approach does not consider rurality "as a social construct" [10] that encompasses cultural, sociological and economical dimensions [11]. Nowadays, the whole spectrum of occupational categories is represented among residents of French rural areas. Contrary to other occupations however, farming is strongly associated with rural residency [12]. Taking into account the social profiles at the individual level may help to understand the rural-urban health disparities.

France has put in place a statutory health insurance system in which a specific scheme, the "Mutualité Sociale Agricole" (MSA), is dedicated to the agricultural economic sector in the mainland territory [13]. In 2018, 5.6 million people (9% of the 65 million population in mainland France) were affiliated to the MSA; 64% of the active MSA population worked directly in the farming/agricultural sector and the others in related services (e.g., cooperatives, banking) [14]. A wealth of information on the access to all healthcare services is available from the French national clinical administrative database (Système national des données de santé [SNDS]) where insurance affiliation is recorded. Therefore, the objective of this study was to determine whether the clinical profile, care and mortality of patients admitted in hospital for ischemic stroke differed between those affiliated to the MSA scheme and all the other patients.

# 3. Material and methods

## 3.1. Data and study population

For this observational study, data were extracted from the SNDS, a comprehensive clinical administrative database with information on contacts with primary care professionals and ambulatory healthcare specialists, prescriptions, and details of hospital admissions [15,16]. From the SNDS, all ≥ 20-year-old patients hospitalized for ischemic stroke (ICD 10: I63, as main diagnosis) in mainland France in 2018 were identified. To focus on the first event, patients admitted with a diagnosis of stroke (any type) in the previous 24 months were excluded. Patients were categorized in function of their health insurance scheme (MSA versus other schemes; our main exposure variable) on the basis of being reimbursed for at least one care by the MSA during the year of stroke occurrence (i.e., 2018). They were also categorized according to the area where they lived (rural versus urban) using the classification of municipalities from the French national statistical office (Insee). This typology is based on the clustering of small areas with similar
population density [17]. We derived from the SNDS consumers table counts of the whole population insured either to MSA or to other insurance schemes in 2018, broken down by age and sex. These counts were used as denominators for the comparison of hospital admission rates.

From the SNDS, data on three stages of the stroke care pathway (pre-stroke, acute, and post-acute) was collected. During the pre-stroke stage, indicators reflecting cardiovascular disease risk factor management were identified based on the delivery of three or more prescriptions of drugs (antihypertensive, lipid-lowering, antidiabetics, antiplatelets and anticoagulants) in the 12 months before the hospitalization for stroke. To assess the opportunities for the detection and management of cardiovascular risk factors, outpatient visits to general practitioners (GPs) and cardiologists in the 12 months before hospitalization were identified. Similarly, comorbidities in the 12 months before the stroke were identified to compute the Charlson's comorbidity index (version described by Bannay et al., adapted to electronic health records [18]). The following key elements of the acute care stage (that is care provided in acute care hospitals) were collected: stroke unit admission, brain imaging, echocardiography, thrombolysis, thrombectomy and discharge modalities (death, transfer to rehabilitation hospital, home). Death was identified from the discharge modality of hospital record or from the "référentiel des bénéficiaires" table in SNDS. We considered mortality at 7 days (in or out hospital setting) and at the end of the acute hospital stay. Seven-day case fatality is strongly related to stroke severity [19], a parameter that is not available in the SNDS database, whereas longer-term fatality is also determined by access to and quality of care. For patients who survived acute care, consultations with GPs and physiotherapists were collected up to 12 months after the initial hospital admission. During the post-acute care stage, the percentage of patients who initiated cardiovascular disease risk factor management in the twelve months after stroke occurrence was calculated. All the codes used to identify drug prescriptions, ICD 10 diagnosis codes, and care are available in supplement (Tables S1-S3).

## 3.2. Statistical analysis

We first calculated the age- and sex-standardized incidence of ischemic stroke hospital admission according to the insurance scheme for the year 2018, using the SNDS consumer's table to define the denominators. The reference population used for standardization was the French population in 2018.

We then described sociodemographic characteristics of patients according to insurance scheme. In the following detailed comparisons of patients characteristics, access and outcome of stroke care, continuous variables were described with medians and interquartile ranges, and binary or other categorized variables with percentages. As age differed markedly in function of sex and health insurance scheme, age-standardized percentages and the corresponding 95% confidence interval (CI) were calculated using the age distribution of the whole population of patients as standard (10-year age band). Given the differences in stroke epidemiology and the current debates regarding stroke management and outcome across gender [20], we decided to present these descriptive statistics for men and women separately.

Finally, associations between health insurance scheme and case fatality at different time points were assessed using the modified Poisson regression with a robust error variance [21] to estimate relative risks and their 95% confidence intervals. Case fatality depends on individual characteristics and then on care management. Therefore, we run models adjusting first for individual (age, sex, comorbity) and then added care management (stroke unit admission, thrombolysis and thrombectomy) variables in order to examine the specific impact of these characteristics.

## 3.3. Ethical approval

Our study complies with the reference methodology MR 005 that sets out the obligations for carrying out research based on anonymous hospital records data in France. Our research team is also granted access to SNDS data (cf. Code de la Santé Publique; article R1464-12) [22]. In accordance with this legislation, no formal patient consent is required in this context. The study was declared and registered with the data protection officer of EHESP (French National School of Public Health).

## 4. Results

The SNDS database included data on 93,051 adults hospitalized with a diagnosis of ischemic stroke in mainland France in 2018; 4759 (5.1%) were excluded because they had been admitted with a similar diagnosis between 2016 and 2017 and 428 (0.5%) because their town of residence was unknown. Therefore, the study population included 87,864 patients among whom 7928 (9%) were MSA patients. This corresponds to an age-sex-standardized rate of 1.66 per 1000 inhabitants in the MSA population versus 1.62 per 1000 in the non-MSA population, leading to a rate ratio of 1.025 (95% CI: 0.999-1.052) indicating similar risk of stroke-related hospitalization between groups (MSA vs. others). Compared with the other patients, MSA patients were more often rural dwellers (75.4 versus 32%) and older (median age: 84 versus 76 years) (Table 1). This large age difference reflects the older age

<table><caption>Table 1 - Sociodemographic characteristics of patients admitted for ischemic stroke in mainland France in 2018 according to their health insurance scheme.</caption><thead><tr><th rowspan="2"></th><th rowspan="2">All</th><th colspan="2">Health insurance scheme</th></tr><tr><th>MSA</th><th>Other</th></tr></thead><tbody><tr><td>Number</td><td>87,864</td><td>7928</td><td>79,936</td></tr><tr><td>Age (year)</td><td></td><td></td><td></td></tr><tr><td>Median</td><td>77</td><td>84</td><td>76</td></tr><tr><td>Interquartile range</td><td>66-86</td><td>75-89</td><td>65-85</td></tr><tr><td>Men</td><td></td><td></td><td></td></tr><tr><td>Number</td><td>45,162</td><td>3738</td><td>41,423</td></tr><tr><td>%</td><td>51.4</td><td>47.1</td><td>51.8</td></tr><tr><td>Rural dweller</td><td></td><td></td><td></td></tr><tr><td>Number</td><td>31,593</td><td>5977</td><td>25,616</td></tr><tr><td>%</td><td>36.0</td><td>75.4</td><td>32.0</td></tr></tbody></table>

MSA: "Mutualité Sociale Agricole" (agricultural health insurance scheme).
structure of the overall MSA population compared with that of other health insurance scheme group.

To compare care use between health insurance schemes and sexes at each stroke care stage (Table 2), frequencies were age-standardized to avoid age differences as confounding factor. Irrespective of the health insurance scheme or sex, approximately 90% of included patients had at least one GP outpatient visit in the year before the stroke-linked hospitalization. However, the percentage of patients with ≥ 3 visits was slightly higher among MSA patients and the difference was statistically significant in men (68 versus 65%, MSA/Other ratio = 1.05, P < 0.05). Overall, approximately one in seven patients had a cardiologist outpatient visit in the year before hospitalization; however, for this indicator, percentages were lower in MSA patients (e.g., 10.7 versus 15.6% among women, MSA/other ratio = 0.68, P < 0.001). With the exception of the higher percentage of patients on antihypertensive treatment

(+3%) in the MSA group, cardiovascular disease prevention in the year before the stroke was similar in women of the two groups. Conversely, prescription for three of the four drug categories was lower in male MSA patients (e.g., 18.1 versus 21.5% for antidiabetics).

Overall, admission to stroke units was about 4% lower for MSA patients, regardless of sex (e.g., in men 57 versus 61.1%, MSA/other ratio = 0.93, P < 0.01). Within each health insurance scheme, stroke unit admission was slightly lower for women (~-2%). Differences between MSA and other patients were not detected for other acute care management indicators, notably reperfusion therapy. The median length of stay for all patients was 8 days (interquartile range: 5-14 days) and did not vary across insurance group (not shown). Case fatality at the acute care end and discharge to rehabilitation center were higher in the MSA group, but differences were small (e.g., in men, 10.7 versus 9.4%, MSA/other ratio = 1.13, P < 0.05). Post-acute care

<table><caption>Table 2 - Care management of patients with ischemic stroke according to their health insurance scheme (sex and age-standardized percentages).</caption><thead><tr><th rowspan="3"></th><th colspan="4">Women</th><th colspan="4">Men</th></tr><tr><th colspan="2">Health insurance</th><th colspan="2">MSA/Other ratio (95% CI)</th><th colspan="2">Health insurance</th><th colspan="2">MSA/Other ratio (95% CI)</th></tr><tr><th>MSA</th><th>Other</th><th>MSA</th><th>Other</th><th>MSA</th><th>Other</th><th>MSA</th><th>Other</th></tr></thead><tbody><tr><td>Pre-stroke care<sup>d</sup></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Access to healthcare</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>GP (≥ 1 visit)</td><td>92.0</td><td>91.7</td><td>1.00 (0.96-1.05)</td><td></td><td>90.6</td><td>89.6</td><td>1.01 (0.98-1.05)</td><td></td></tr><tr><td>GP (&gt; 3 visits)</td><td>73.5</td><td>71.2</td><td>1.03 (0.98-1.08)</td><td></td><td>68.0</td><td>65.0</td><td>1.05 (1.00-1.09)<sup>a</sup></td><td></td></tr><tr><td>Cardiologist (≥ 1 visit)</td><td>10.7</td><td>15.6</td><td>0.68 (0.60-0.78)<sup>c</sup></td><td></td><td>14.3</td><td>17.8</td><td>0.80 (0.73-0.88)<sup>c</sup></td><td></td></tr><tr><td>CVD prevention<sup>e</sup></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Antihypertensive</td><td>68.3</td><td>64.6</td><td>1.06 (1.01-1.11)<sup>a</sup></td><td></td><td>63.8</td><td>63.7</td><td>1.00 (0.96-1.04)</td><td></td></tr><tr><td>Lipid-lowering</td><td>27.7</td><td>26.4</td><td>1.05 (0.97-1.14)</td><td></td><td>32.4</td><td>34.8</td><td>0.93 (0.88-0.99)<sup>a</sup></td><td></td></tr><tr><td>Antidiabetics</td><td>16.5</td><td>17.9</td><td>0.92 (0.83-1.03)</td><td></td><td>18.1</td><td>21.5</td><td>0.84 (0.78-0.91)<sup>c</sup></td><td></td></tr><tr><td>Antiplatelets</td><td>25.5</td><td>28.1</td><td>0.91 (0.85-0.98)<sup>a</sup></td><td></td><td>34.9</td><td>38.2</td><td>0.91 (0.86-0.97)<sup>b</sup></td><td></td></tr><tr><td>Comorbidity</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>High (Charlson index &gt; 2)</td><td>3.7</td><td>4.0</td><td>0.94 (0.79-1.12)</td><td></td><td>4.8</td><td>4.8</td><td>0.98 (0.84-1.14)</td><td></td></tr><tr><td>Acute stroke care</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Admitted to stroke unit</td><td>55.3</td><td>59.0</td><td>0.94 (0.88-1.00)<sup>a</sup></td><td></td><td>57.0</td><td>61.1</td><td>0.93 (0.89-0.98)<sup>b</sup></td><td></td></tr><tr><td>Brain imaging</td><td>85.8</td><td>85.8</td><td>1.00 (0.95-1.05)</td><td></td><td>86.0</td><td>86.0</td><td>1.00 (0.96-1.04)</td><td></td></tr><tr><td>Echocardiography</td><td>69.5</td><td>68.1</td><td>1.02 (0.97-1.08)</td><td></td><td>69.1</td><td>70.2</td><td>0.98 (0.94-1.03)</td><td></td></tr><tr><td>Thrombolysis</td><td>8.1</td><td>6.9</td><td>1.17 (0.99-1.38)</td><td></td><td>7.0</td><td>6.7</td><td>1.03 (0.9-1.19)</td><td></td></tr><tr><td>Thrombectomy</td><td>6.1</td><td>6.5</td><td>0.94 (0.78-1.13)</td><td></td><td>5.3</td><td>5.3</td><td>1.00 (0.85-1.16)</td><td></td></tr><tr><td>Acute care outcome</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Death in acute care</td><td>9.5</td><td>8.7</td><td>1.09 (0.97-1.21)</td><td></td><td>10.7</td><td>9.4</td><td>1.13 (1.02-1.26)<sup>a</sup></td><td></td></tr><tr><td>Discharged to rehab.</td><td>31.2</td><td>30.1</td><td>1.04 (0.96-1.12)</td><td></td><td>30.3</td><td>27.6</td><td>1.10 (1.03-1.17)<sup>b</sup></td><td></td></tr><tr><td>Discharged to home</td><td>59.4</td><td>61.2</td><td>0.97 (0.91-1.03)</td><td></td><td>59.0</td><td>63.0</td><td>0.94 (0.90-0.98)<sup>b</sup></td><td></td></tr><tr><td>Post-acute care</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Access to healthcare</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>GP</td><td>83.1</td><td>82.2</td><td>1.01 (0.96-1.06)</td><td></td><td>82.5</td><td>82.7</td><td>1.00 (0.96-1.04)</td><td></td></tr><tr><td>Physiotherapist</td><td>47.7</td><td>49.9</td><td>0.96 (0.9-1.02)</td><td></td><td>42.4</td><td>45.4</td><td>0.93 (0.89-0.98)<sup>a</sup></td><td></td></tr><tr><td>Initiation of CVD prevention</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Antihypertensive</td><td>14.5</td><td>16.3</td><td>0.89 (0.78-1.02)</td><td></td><td>17.4</td><td>18.0</td><td>0.97 (0.89-1.05)</td><td></td></tr><tr><td>Lipid-lowering</td><td>36.3</td><td>36.5</td><td>0.99 (0.92-1.08)</td><td></td><td>34.4</td><td>35.9</td><td>0.96 (0.90-1.02)</td><td></td></tr><tr><td>Antidiabetics</td><td>2.2</td><td>2.8</td><td>0.80 (0.58-1.11)</td><td></td><td>2.9</td><td>3.6</td><td>0.81 (0.66-1.00)<sup>a</sup></td><td></td></tr><tr><td>Antiplatelets</td><td>43.9</td><td>42.3</td><td>1.04 (0.96-1.12)</td><td></td><td>38.6</td><td>37.6</td><td>1.03 (0.97-1.09)</td><td></td></tr></tbody></table>

CVD: cardiovascular diseases; GP: General Practitioner; MSA: "Mutalité Sociale Agricole" (agricultural insurance scheme). Acute care refers to care provided in acute care hospitals. Percentages were age-standardized using the combined age distribution of all patients as standard.

<footnote>a P < 0.05.</footnote>

<footnote>b P < 0.01.</footnote>

<footnote>c P < 0.001.</footnote>

<footnote>d During the 12 months before hospitalization for stroke.</footnote>

<footnote>e Three or more prescriptions.</footnote>
<table><caption>Table 3 – Associations between health insurance scheme and case fatality.</caption><thead><tr><th rowspan="2"></th><th rowspan="2">Number of deaths</th><th rowspan="2">Number of patients</th><th rowspan="2">Risk (10<sup>-3</sup>)</th><th colspan="3">Relative risk (95% CI)</th></tr><tr><th>Crude</th><th>Adjusted for patients' characteristics<sup>a</sup></th><th>Adjusted for patients' characteristics and stroke management<sup>b</sup></th></tr></thead><tbody><tr><td>7-day case fatality</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Other schemes</td><td>3689</td><td>79,936</td><td>4.61</td><td>Ref.</td><td>Ref.</td><td>Ref.</td></tr><tr><td>MSA</td><td>527</td><td>7928</td><td>6.65</td><td>1.44<br>(1.32-1.57)</td><td>1.07<br>(0.98-1.78)</td><td>1.07<br>(0.98-1.17)</td></tr><tr><td>Case fatality at the end of acute care</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Other schemes</td><td>6994</td><td>79,936</td><td>8.75</td><td>Ref</td><td>Ref</td><td>Ref</td></tr><tr><td>MSA</td><td>1012</td><td>7928</td><td>12.76</td><td>1.46<br>(1.37-1.55)</td><td>1.09<br>(1.03-1.17)</td><td>1.09<br>(1.03-1.17)</td></tr></tbody></table>

MSA: "Mutualité Sociale Agricole" (agricultural insurance scheme).

a Patients' characteristics: age, sex, comorbidities and rural residency.

b Stroke management: stroke unit admission, thrombectomy, thrombolysis.

was similar between health insurance groups. Only physiotherapy care was less prescribed to MSA patients.

Comparisons according to the area where the MSA patients lived (rural versus urban) showed identical levels of access to GPs, but lower access to cardiologists (standardized percentages: 11 versus 16%, $P < 10^{-3}$) and lower prescription of antidiabetic drugs to rural dwellers (16 versus 19%, $P = 0.02$, see Table S4). Acute and post-acute care management were similar between rural and urban MSA patients.

The overall case fatality rates were 4.8% (4216/87,864) seven days after admission and 9.1% (8006/87,864) at the acute care end (Table 3). The crude 7-day case fatality was 44% higher for MSA patients than the other patients (relative risk = 1.44, 95% CI [1.32-1.57]). However, when the patients' age, sex, comorbidities and residency were taken into account, the 7-day case fatality was only 7% higher in the MSA group (not significant). Further adjusting for care management did not change this result. Similar results were obtained for the case fatality rate at the acute care end.

## 5. Discussion

To our knowledge, our study if the first to compare ischemic stroke care according to the health insurance scheme in France. We focused our analysis on patients affiliated to the MSA, a health insurance scheme dedicated to people working in the agricultural sector. Currently, the farming population is older than the rest of the French population because of a downfall of employment over the last century. This explains the older age (+8 years) of MSA patients among all ischemic stroke patients admitted in 2018. By taking into account this age difference, our results suggest that preventive pre-stroke care, acute stroke care and post-stroke care did not differ markedly between MSA patients and patients affiliated to other health insurance schemes. Although MSA patients had slightly less access to key acute care, such as stroke units and reperfusion therapy, most differences were small and did not reach clinical or statistical significance. This conclusion also

applies to the slight increase in case fatality observed in MSA patients.

The issue of medically underserved areas is a concern for many health systems. Most people affiliated to the MSA live in rural areas where the density of primary care professionals is low. Therefore, one would expect that they would have less access to such services and less opportunity for the detection and prevention of cardiovascular disease risk factors. However, our results suggest that MSA patients had more access to GP services in the 12 months before the stroke. The literature on medically underserved areas shows that a single indicator, such as the density of healthcare professionals, may not capture all dimensions of access to services (i.e., geographical accessibility, affordability, availability as indicated by the waiting times and cultural acceptability of care) [23]. Furthermore, the GPs' level of activity may be higher in rural areas than in urban areas, thus compensating for the lower density [24]. Therefore, access to primary care may be more critical in suburban than in rural areas. On the basis of our findings, lower GPs' density in rural areas did not translate into lower level of access to primary healthcare for MSA stroke patients in 2018. However, close monitoring of healthcare access may be required in the future, given the changing medical demography in France [25].

We found only limited differences concerning the pre-stroke management of cardiovascular disease risk factors between health insurance scheme groups. Antihypertensive drugs were more frequently prescribed to women MSA patients, whereas lipid-lowering, antidiabetic and antiplatelet drugs were less frequently prescribed to men MSA patients. Our data do not allow determining whether these differences result from varying levels of disease prevalence, detection or treatment (or some combination of those). However, the similar rates of contact with primary care professionals and of treatment initiation do not support the hypothesis of a strong influence of lower detection. Of note, irrespective of the health insurance scheme, stroke occurrence triggered the initiation of lipid-lowering and antihypertensive treatments in one in three and approximately one in seven patients, highlighting
scope for progress in primary prevention. To our knowledge, estimates of risk factor prevalence according to the health insurance schemes are not available to put our findings into a wider population context. Estimates are available from studies on farmers. In the 2005-2009 period, mortality due to diabetes and cerebrovascular disease was lower (by about 30-40%) in farmers in the AGRICAN cohort study compared with the general French population [26]. In Sweden in the 2000s, cardiovascular mortality [27] and type 2 diabetes incidence were lower among farmers than in the urban referents, a decrease explained by the higher level of physical activity and healthier diet [28]. These findings are consistent with our results of lower prescription of antidiabetic drugs to MSA patients, particularly in the subpopulation living in rural areas where farmers are found. There is also evidence that smoking is less prevalent among farmers in France [29] and in North Carolina [30]. Overall, farming communities in the western world seem to enjoy better health levels thanks to a healthier lifestyle, including better diet, less smoking and probably more work-related physical activity. In France, it is not known the extent to which affiliation to the MSA contributes to this favorable health profile. Unlike managed care organizations in the USA, MSA is not directly involved in care provision, but only in reimbursement. However, insurance schemes in France can launch health promotion campaigns at their own discretion. Compared to other French health insurance schemes, MSA governance is more decentralized, and therefore, its health promotion actions may be better tuned to the local needs [31]. MSA is also the only health insurance scheme to manage its own occupational medicine services, which could also promote effective and pertinent health education.

The rate of admission to stroke units has markedly increased in France over the past decades [5] to reach a level of ~61% for ischemic stroke patients in 2019 [32]. Our results confirm previous findings that the deployment of stroke units in France has coincided with increased equity of territorial access [5]. Specifically, we identified only minor differences in stroke unit admission rates between health insurance affiliation groups and between sexes once the age differences were taken into account. In 2014, 44% of stroke patients (all types) were admitted to a stroke unit, with a men/women ratio of 1.10. Our study shows that stroke admission rates have increased by ~15% and that the difference between sexes has decreased (e.g., men/women ratio among non-MSA patients: 61.1/59 = 1.03).

The limitations of our study are related to the absence in the SNDS database of data on recognized prognostic factors, such as stroke severity and time from symptom onset to hospital arrival [33]. Richer clinical data would be needed to determine whether delay in access to care and stroke severity interact to lead to the slightly and non-significantly higher case fatality in MSA patients. SNDS is also a limited source of information for assessing the whole spectrum of post-stroke impairments and disabilities. Conversely, the strength of the SNDS database is its exhaustiveness and the reliability of its hospital admission component for the identification of ischemic stroke [34].

In conclusion, we found that MSA patients with ischemic stroke had comparable access to keystroke preventive and therapeutic care compared with patients affiliated to other

health insurance schemes in France. Our results also suggest that MSA patients presented a slightly better cardiovascular health profile, probably a consequence of a more active lifestyle in the farming subgroup of this population. Understanding whether the MSA specific features (i.e., provision of integrated preventive, social and occupational services operating under local governance) also contribute to this favorable pattern would be useful knowledge for the French and other health systems.

## Funding

This work was funded by the Mutualité Sociale Agricole (MSA).

## Disclosure of interest

The authors declare that they have no competing interest.

## Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.neurol.2025.01.410.

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