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Legere B, Mohamed A, Elsherif S, Saqqur R, Schoenfeld D, Slebonick AM, McCartin M, Price J, Zachrison KS, Edlow JA, Saqqur M, Shuaib A, Thomas SH. Success with incrementally faster times to endovascular therapy (SWIFT-EVT): A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107964. [PMID: 39182706 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 08/18/2024] [Accepted: 08/21/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND A major systematic review and meta-analysis assessing trial data through 2014 (the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials, HERMES) demonstrated that particularly over the initial six hours of acute ischemic stroke (AIS), rapid performance of endovascular therapy (EVT) markedly improves outcomes. The current analysis, Success with Incrementally Faster Times to EVT (SWIFT-EVT), aimed to provide an updated metric summarizing latest estimates for modified Rankin Scale (mRS) improvements accrued by streamlining time to EVT. METHODS A systematic review and meta-analysis was conducted using electronic databases. Eligible studies reported a time-benefit slope with times from AIS onset (or time last known normal) to EVT commencement; the predictor was onset-to-groin (OTG) time. Primary and secondary outcomes were 90-day functional independence (mRS 0-2) and 90-day excellent function (mRS 0-1), respectively. RESULTS Five studies were included. Results showed increased change of good outcome with each hour of pre-EVT time savings for mRS 0-2 for 0-270' (OR 1.25, 95 % CI 1.16-1.35, I2 40 %) and 271-360' time frame (1.22, 95 % CI 1.12-1.33, I2 58 %). For the studies assessing mRS 0-1, estimates were found appropriate for both the 0-270' time frame (OR 1.34, 95 % CI 1.19-1.51, I2 27 %) and the 271-360' time frame (OR 1.20, 95 % CI 1.03-1.38, I2 60 %). CONCLUSIONS Each hour saved from AIS onset to EVT start is associated with a 22-25 % increased odds of achieving functional independence, a useful metric to inform patient-specific and systems planning decisions.
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Affiliation(s)
- Brittney Legere
- Department of Applied Human Sciences, University of Guelph, Guelph, Ontario, Canada.
| | - Ahmed Mohamed
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada.
| | - Salah Elsherif
- Department of Health Sciences, Queens University, Kingston, Ontario, Canada.
| | - Razan Saqqur
- Department of Health, University of Waterloo, Waterloo, Ontario, Canada.
| | - David Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA.
| | | | - Michael McCartin
- Section of Emergency Medicine, University of Chicago, Chicago, IL, USA.
| | - James Price
- Department of Emergency Medicine, Cambridge University NHS Trust, Cambridge, UK.
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA.
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA.
| | - Maher Saqqur
- Department of Neurology, University of Toronto, Mississauga, ON, Canada.
| | - Ashfaq Shuaib
- Department of Neurology, University of Alberta, Edmonton, AB, Canada.
| | - Stephen H Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA; Blizard Institute for Neuroscience, Surgery, & Trauma, Barts & The London School of Medicine, London, UK.
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Hsia RY, Sarkar N, Shen YC. Provision of Stroke Care Services by Community Disadvantage Status in the US, 2009-2022. JAMA Netw Open 2024; 7:e2421010. [PMID: 39052294 PMCID: PMC11273237 DOI: 10.1001/jamanetworkopen.2024.21010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/08/2024] [Indexed: 07/27/2024] Open
Abstract
Importance Stroke center certification is granted to facilities that demonstrate distinct capabilities for treating patients with stroke. A thorough understanding of structural discrimination in the provision of stroke centers is critical for identifying and implementing effective interventions to improve health inequities for socioeconomically disadvantaged populations. Objective To determine whether (1) hospitals in socioeconomically disadvantaged communities (defined using the Area Deprivation Index) are less likely to adopt any stroke certification and (2) adoption rates differ between entry-level (acute stroke-ready hospitals) and higher-level certifications (primary, thrombectomy capable, and comprehensive) by community disadvantage status. Design, Setting, and Participants This cohort study used newly collected stroke center data merged with data from the American Hospital Association, Healthcare Cost Report Information datasets, and the US Census. All general acute hospitals in the continental US between January 1, 2009, and December 31, 2022, were included. Data analysis was conducted from July 2023 to May 2024. Main Outcomes and Measures The primary outcome was the likelihood of hospitals adopting stroke care certification. Cox proportional hazard and competing risk models were used to estimate the likelihood of a hospital becoming stroke certified based on the socioeconomic disadvantage status of the community. Results Among the 5055 hospitals studied from 2009 to 2022, 2415 (47.8%) never achieved stroke certification, 602 (11.9%) were certified as acute stroke-ready hospitals, and 2038 (40.3%) were certified as primary stroke centers or higher. When compared with mixed-advantage communities, adoption of any stroke certification was most likely to occur near the most advantaged communities (hazard ratio [HR], 1.24; 95% CI, 1.07-1.44) and least likely near the most disadvantaged communities (HR, 0.43; 95% CI, 0.34-0.55). Adoption of acute stroke-ready certification was most likely in mixed-advantage communities, while adoption of higher-level certification was more likely in the most advantaged communities (HR,1.41; 95% CI, 1.22-1.62) and less likely for the most disadvantaged communities (HR, 0.31; 95% CI, 0.21-0.45). After adjusting for population size and hospital capacity, compared with mixed-advantage communities, stroke certification adoption hazard was still 20% lower for relatively disadvantaged communities (adjusted HR, 0.80; 95% CI, 0.73-0.87) and 42% lower for the most disadvantaged communities (adjusted HR, 0.58; 95% CI, 0.45-0.74). Conclusions and Relevance In this cohort study examining hospital adoption of stroke services, when compared with mixed-advantage communities, hospitals located in the most disadvantaged communities had a 42% lower hazard of adopting any stroke certification and relatively disadvantaged communities had a 20% lower hazard of adopting any stroke certification. These findings suggest that there is a need to support hospitals in disadvantaged communities to obtain stroke certification as a way to reduce stroke disparities.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Nandita Sarkar
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Yu-Chu Shen
- National Bureau of Economic Research, Cambridge, Massachusetts
- Department of Defense Management, Naval Postgraduate School, Monterey, California
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Hsia RY, Shen YC. Structural Inequities In The Adoption Of Percutaneous Coronary Intervention Services By US Hospitals, 2000-20. Health Aff (Millwood) 2024; 43:1011-1020. [PMID: 38950302 PMCID: PMC11293955 DOI: 10.1377/hlthaff.2023.01649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Percutaneous coronary intervention (PCI) is a procedure that opens blocked arteries and restores blood flow to the heart. Timely access to hospitals offering PCI services can be a matter of life or death for patients experiencing a heart attack; however, hospitals' adoption of PCI services may vary between communities, posing potential barriers to critical care. Our cohort study of US general acute hospitals during the period 2000-20 examined PCI service adoption across communities stratified by race, ethnicity, income, and rurality and further classified as segregated or integrated. Of 5,260 hospitals, 1,621 offered PCI services in 2020 or before, 630 added PCI services between 2001 and 2010, and 225 added PCI services between 2011 and 2020. Hospitals serving Black, racially segregated communities were 48 percent less likely to adopt PCI services compared with hospitals serving non-Black, racially segregated communities, and hospitals serving Hispanic, ethnically segregated communities were 41 percent less likely to do so than those serving non-Hispanic, ethnically segregated communities. Hospitals in high-income, economically integrated communities were 1.8 times more likely to adopt PCI services than those in high-income, economically segregated communities, and rural hospitals were less likely to do so than urban hospitals. Understanding where services are expanding in relation to community need may aid in successful policy interventions.
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Affiliation(s)
- Renee Y Hsia
- Renee Y. Hsia , University of California San Francisco, San Francisco, California
| | - Yu-Chu Shen
- Yu-Chu Shen, Naval Postgraduate School, Monterey, California; and National Bureau of Economic Research, Cambridge, Massachusetts
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Srinivasan M, Scott A, Soo J, Sreedhara M, Popat S, Beasley KL, Jackson TN, Abbas A, Keaton WA, Holmstedt C, Harvey J, Kruis R, McLeod S, Ahn R. The role of stroke care infrastructure on the effectiveness of a hub-and-spoke telestroke model in South Carolina. J Stroke Cerebrovasc Dis 2024; 33:107702. [PMID: 38556068 PMCID: PMC11088489 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVE To examine the relationship between stroke care infrastructure and stroke quality-of-care outcomes at 29 spoke hospitals participating in the Medical University of South Carolina (MUSC) hub-and-spoke telestroke network. MATERIALS AND METHODS Encounter-level data from MUSC's telestroke patient registry were filtered to include encounters during 2015-2022 for patients aged 18 and above with a clinical diagnosis of acute ischemic stroke, and who received intravenous tissue plasminogen activator. Unadjusted and adjusted generalized estimating equations assessed associations between time-related stroke quality-of-care metrics captured during the encounter and the existence of the two components of stroke care infrastructure-stroke coordinators and stroke center certifications-across all hospitals and within hospital subgroups defined by size and rurality. RESULTS Telestroke encounters at spoke hospitals with stroke coordinators and stroke center certifications were associated with shorter door-to-needle (DTN) times (60.9 min for hospitals with both components and 57.3 min for hospitals with one, vs. 81.2 min for hospitals with neither component, p <.001). Similar patterns were observed for the percentage of encounters with DTN time of ≤60 min (63.8% and 68.9% vs. 32.0%, p <.001) and ≤45 min (34.0% and 38.4% vs. 8.42%, p <.001). Associations were similar for other metrics (e.g., door-to-registration time), and were stronger for smaller (vs. larger) hospitals and rural (vs. urban) hospitals. CONCLUSIONS Stroke coordinators or stroke center certifications may be important for stroke quality of care, especially at spoke hospitals with limited resources or in rural areas.
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Affiliation(s)
- Mithuna Srinivasan
- NORC at the University of Chicago, 4350 East-West Hwy 8th Floor, Bethesda, MD 20814, United States.
| | - Amber Scott
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, United States; Oak Ridge Institute for Science and Education, Oak Ridge, TN, United States
| | - Jackie Soo
- NORC at the University of Chicago, Chicago, IL, United States
| | - Meera Sreedhara
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, United States; Cherokee Nation Operational Solutions, Tulsa, OK, United States
| | - Shena Popat
- NORC at the University of Chicago, 4350 East-West Hwy 8th Floor, Bethesda, MD 20814, United States
| | - Kincaid Lowe Beasley
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, United States
| | - Tiara N Jackson
- Decision Information Resources, Inc., Houston, TX, United States
| | - Amena Abbas
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, United States; ASRT, Inc., Atlanta, GA, United States
| | - W Alexander Keaton
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, United States; Oak Ridge Institute for Science and Education, Oak Ridge, TN, United States
| | | | - Jillian Harvey
- Medical University of South Carolina, Charleston, SC, United States
| | - Ryan Kruis
- Medical University of South Carolina, Charleston, SC, United States
| | - Shay McLeod
- Medical University of South Carolina, Charleston, SC, United States
| | - Roy Ahn
- NORC at the University of Chicago, Chicago, IL, United States
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Hsuan C, Vanness DJ, Zebrowski A, Carr BG, Norton EC, Buckler DG, Wang Y, Leslie DL, Dunham EF, Rogowski JA. Racial and ethnic disparities in emergency department transfers to public hospitals. Health Serv Res 2024; 59:e14276. [PMID: 38229568 PMCID: PMC10915485 DOI: 10.1111/1475-6773.14276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Abstract
OBJECTIVE To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences. DATA SOURCES AND STUDY SETTING ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018). STUDY DESIGN Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means. DATA COLLECTION/EXTRACTION METHODS We examined 1,265,588 adult ED patients transferred from 187 hospitals. PRINCIPAL FINDINGS Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer. CONCLUSIONS Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.
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Affiliation(s)
- Charleen Hsuan
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - David J. Vanness
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Alexis Zebrowski
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Brendan G. Carr
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Edward C. Norton
- Department of Health Management and PolicyUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
- Department of EconomicsUniversity of MichiganAnn ArborMichiganUSA
| | - David G. Buckler
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Yinan Wang
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Douglas L. Leslie
- Department of Public Health Sciences, College of MedicinePennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Eleanor F. Dunham
- Department of Emergency Medicine, College of MedicinePennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Jeannette A. Rogowski
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
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Perez MA, Reyes-Esteves S, Mendizabal A. Racial and Ethnic Disparities in Neurological Care in the United States. Semin Neurol 2024; 44:178-192. [PMID: 38485124 DOI: 10.1055/s-0043-1778639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
The burden of neurological disease is increasing globally. In the United States, this burden is disproportionally greater for Black and Latino communities who have limited access to neurological care. Health services researchers have attempted to identify racial and ethnic disparities in neurological care and possible solutions. This article reviews the most current literature on racial and ethnic disparities in commonly encountered neurological conditions, including Stroke, Alzheimer's Disease, Multiple Sclerosis, Epilepsy, Parkinson's Disease, and Migraine. Disparities exist in disease incidence, diagnosis, access to care, treatment, outcomes, and representation in epidemiologic studies and clinical trials. Many of the disparities observed in neurological care in the United States are a consequence of longstanding racist and discriminatory policies and legislation that increase risk factors for the development of neurological disease or lead to disparities in accessing quality neurological care. Therefore, additional efforts on the legislative, community health, and healthcare system levels are necessary to prevent the onset of neurological disease and achieve equity in neurological care.
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Affiliation(s)
- Michael A Perez
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Adys Mendizabal
- Department of Neurology, University of California, Los Angeles, California
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Feldmeier M, Kim AS, Zachrison KS, Alberts MJ, Shen YC, Hsia RY. Heterogeneity of State Stroke Center Certification and Designation Processes. Stroke 2024; 55:1051-1058. [PMID: 38469729 DOI: 10.1161/strokeaha.123.045368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/04/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Stroke centers are critical for the timely diagnosis and treatment of acute stroke and have been associated with improved treatment and outcomes; however, variability exists in the definitions and processes used to certify and designate these centers. Our study categorizes state stroke center certification and designation processes and provides examples of state processes across the United States, specifically in states with independent designation processes that do not rely on national certification. METHODS In this cross-sectional study from September 2022 to April 2023, we used peer-reviewed literature, primary source documents from states, and communication with state officials in all 50 states to capture each state's process for stroke center certification and designation. We categorized this information and outlined examples of processes in each category. RESULTS Our cross-sectional study of state-level stroke center certification and designation processes across states reveals significant heterogeneity in the terminology used to describe state processes and the processes themselves. We identify 3 main categories of state processes: No State Certification or Designation Process (category A; n=12), State Designation Reliant on National Certification Only (category B; n=24), and State Has Option for Self-Certification or Independent Designation (category C; n=14). Furthermore, we describe 3 subcategories of self-certification or independent state designation processes: State Relies on Self-Certification or Independent Designation for Acute Stroke Ready Hospital or Equivalent (category C1; n=3), State Has Hybrid Model for Acute Stroke Ready Hospital or Equivalent (category C2; n=5), and State Has Hybrid Model for Primary Stroke Center and Above (category C3; n=6). CONCLUSIONS Our study found significant heterogeneity in state-level processes. A better understanding of how these differences may impact the rigor of each process and clinical performance of stroke centers is worthy of further investigation.
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Affiliation(s)
- Madeline Feldmeier
- Department of Emergency Medicine, University of California, San Francisco. (M.F., R.Y.H.)
| | - Anthony S Kim
- Department of Neurology, UCSF Weill Institute of Neurosciences, University of California, San Francisco. (A.S.K.)
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston (K.S.Z.)
- Harvard Medical School, Boston, MA (K.S.Z.)
| | - Mark J Alberts
- Ayer Neuroscience Institute, Hartford HealthCare, CT (M.J.A.)
| | - Yu-Chu Shen
- Department of Defense Management, Naval Postgraduate School, Monterey, CA (Y.-C.S.)
- National Bureau of Economic Research, Cambridge, MA (Y.-C.S.)
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco. (M.F., R.Y.H.)
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. (R.Y.H.)
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Daniel D, Maillie L, Dhamoon MS. Provider Care Segregation and Hospital-Region Racial Disparities in the United States for Acute Ischemic Stroke and Endovascular Therapy Outcomes. J Am Heart Assoc 2024; 13:e029255. [PMID: 38214294 PMCID: PMC10926824 DOI: 10.1161/jaha.122.029255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 09/27/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Reasons for racial disparities in the use and outcomes of endovascular treatment (ET) are not known. We examined patterns in care segregation for acute ischemic stroke (AIS) in the United States, and outcomes of segregation of care after ET. METHODS AND RESULTS We used deidentified Medicare data sets to identify AIS admissions between January 1, 2016 and December 31, 2019, using validated International Classification of Diseases, Tenth Revision (ICD-10) codes. For AIS, we calculated (1) the proportion of White patients at the hospital, (2) the proportional difference in the proportion of White patients between hospital patients and the county, and (3) provider care segregation by the dissimilarity index for ET cases. Using unadjusted and adjusted multilevel logistic models, we examined associations between measures of segregation and outcomes of discharge home, inpatient mortality, and 30-day mortality. The mean proportional difference in the proportion of White patients comparing hospitalized patients with AIS to the county race distribution was 0.015 (SD, 0.219) at the hospital level. For ET, the mean proportional difference in the proportion of White patients comparing patients receiving ET to the county race distribution was much higher, at 0.146 (SD, 0.374). The dissimilarity index for ET providers was high, with a mean of 0.48 (SD, 0.29) across all hospitals. Black patients with AIS (compared with White patients) had reduced odds of discharge home, inpatient mortality, and 30-day mortality. CONCLUSIONS In this national study with contemporary data in the endovascular era of AIS treatment, we found substantial evidence for segregation of care in the United States, not for only AIS in general but also especially for ET.
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Affiliation(s)
- David Daniel
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Luke Maillie
- Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Mandip S. Dhamoon
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNYUSA
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Stein LK, Maillie L, Erdman J, Loebel E, Mayman N, Sharma A, Wolmer S, Tuhrim S, Fifi JT, Jette N, Mocco J, Dhamoon MS. Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence. J Neurointerv Surg 2024; 16:151-155. [PMID: 37068938 PMCID: PMC11192062 DOI: 10.1136/jnis-2023-020128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/02/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Although national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in revascularization therapies and stroke center certification. We hypothesized that we would observe overall growth in revascularization therapy utilization, but observed differences would vary greatly regionally. METHODS A retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019. We identified AIS admissions and treatment with thrombolysis and endovascular thrombectomy (ET) with International Classification of Diseases, 10th Revision, Clinical Modification codes. We grouped hospitals in Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR) and calculated hospital, demographic, and acute stroke treatment characteristics for each HRR. We calculated the percent of hospitals with stroke certification and AIS cases treated with thrombolysis or ET per HRR. RESULTS There were 957 958 AIS admissions. Relative mean (SD) growth in percent of AIS admissions receiving revascularization therapy per HRR from 2016 to 2019 was 13.4 (31.7)% (IQR -6.1-31.7%) for thrombolysis and 28.0 (72.0)% (IQR 0-56.0%) for ET. The proportion of HRRs with decreased or no difference in ET utilization was 38.9% and the proportion of HRRs with decreased or no difference in thrombolysis utilization was 32.7%. Mean (SD) stroke center certification proportion across HRRs was 45.3 (31.5)% and this varied widely (IQR 18.3-73.4%). CONCLUSIONS Overall growth in AIS treatment has been modest and, within HRRs, growth in AIS treatment and the proportion of centers with stroke certification varies dramatically.
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Affiliation(s)
- Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luke Maillie
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Erdman
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Emma Loebel
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Naomi Mayman
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Akarsh Sharma
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Stanley Tuhrim
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Forman R, Okumu R, Mageid R, Baker A, Neu D, Parker R, Peyravi R, Schindler JL, Sansing LH, Sheth KN, de Havenon A, Jasne A, Narula R, Wira C, Warren J, Sharma R. Association of Neighborhood-Level Socioeconomic Factors With Delay to Hospital Arrival in Patients With Acute Stroke. Neurology 2024; 102:e207764. [PMID: 38165368 PMCID: PMC10834135 DOI: 10.1212/wnl.0000000000207764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/03/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Delivery of acute ischemic stroke (AIS) therapies is contingent on the duration from last known well (LKW) to emergency department arrival time (EDAT). One reason for treatment ineligibility is delay in presentation to the hospital. We evaluate patient and neighborhood characteristics associated with time from LKW to EDAT. METHODS This was a retrospective observational study of patients presenting to the Yale New Haven Hospital in the AIS code pathway from 2010 to 2020. Patients presenting within 4.5 hours from LKW who were recorded in the institutional Get With the Guidelines Stroke registry were classified as early while those presenting beyond 4.5 hours were designated as late. Temporal trends in late presentation were explored by univariate logistic regression. Using variables significant in univariate analysis at p < 0.05, we developed a mixed-effect logistic regression model to estimate the probability of late presentation as a function of patient-level and neighborhood (ZIP)-level characteristics (area deprivation index [ADI] derived from the Health Resources and Services Administration), adjusted for calendar year and geographic distance from the centroid of the ZIP code to the hospital. RESULTS A total of 2,643 patients with AIS from 2010 to 2020 were included (63.4% presented late and 36.6% presented early). The frequency of late presentation increased significantly from 68% in 2010 to 71% in 2020 (p = 0.002) and only among non-White patients. Patients presenting late were more likely to be non-White (37.1% vs 26.9%, p < 0.0001), arrive by means other than emergency medical services (EMS) (32.7% vs 16.1%, p < 0.0001), have an NIHSS <6 (68.7% vs 55.2%, p < 0.0001), and present from a neighborhood with a higher ADI category (p = 0.0001) that was nearer to the hospital (median 5.8 vs 7.7 miles, p = 0.0032). In the mixed model, the ADI by units of 10 (odds ratio [OR] 1.022, 95% confidence interval [CI] 1.020-1.024), non-White race (OR 1.083, 95% CI 1.039-1.127), arrival by means other than EMS (OR 1.193, 95% CI 1.145-1.124), and an NIHSS <6 (OR 1.085, 95% CI 1.041-1.129) were associated with late presentation. DISCUSSION In addition to patient-level factors, socioeconomic deprivation of neighborhood of residence contributes to delays in hospital presentation for AIS. These findings may provide opportunities for targeted interventions to improve presentation times in at-risk communities.
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Affiliation(s)
- Rachel Forman
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Rita Okumu
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Razaz Mageid
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Anna Baker
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Dalton Neu
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Ranisha Parker
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Reza Peyravi
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Joseph L Schindler
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Lauren H Sansing
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Kevin N Sheth
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Adam de Havenon
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Adam Jasne
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Reshma Narula
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Charles Wira
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Joshua Warren
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
| | - Richa Sharma
- From the Departments of Neurology (R.F., R.O., R.M., A.B., D.N., R. Parker, R. Peyravi, J.L.S., L.H.S., K.N.S., A.H., A.J., R.N., R.S.) and Emergency Medicine (C.W.), Yale School of Medicine, New Haven, CT; and Department of Biostatistics (J.W.), Yale School of Public Health, New Haven, CT
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11
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Rasool A, Bailey M, Lue B, Omeaku N, Popoola A, Shantharam SS, Brown AA, Fulmer EB. Policy implementation strategies to address rural disparities in access to care for stroke patients. FRONTIERS IN HEALTH SERVICES 2023; 3:1280250. [PMID: 38130727 PMCID: PMC10733855 DOI: 10.3389/frhs.2023.1280250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/07/2023] [Indexed: 12/23/2023]
Abstract
Context Stroke systems of care (SSOC) promote access to stroke prevention, treatment, and rehabilitation and ensure patients receive evidence-based treatment. Stroke patients living in rural areas have disproportionately less access to emergency medical services (EMS). In the United States, rural counties have a 30% higher stroke mortality rate compared to urban counties. Many states have SSOC laws supported by evidence; however, there are knowledge gaps in how states implement these state laws to strengthen SSOC. Objective This study identifies strategies and potential challenges to implementing state policy interventions that require or encourage evidence-supported pre-hospital interventions for stroke pre-notification, triage and transport, and inter-facility transfer of patients to the most appropriate stroke facility. Design Researchers interviewed representatives engaged in implementing SSOC across six states. Informants (n = 34) included state public health agency staff and other public health and clinical practitioners. Outcomes This study examined implementation of pre-hospital SSOCs policies in terms of (1) development roles, processes, facilitators, and barriers; (2) implementation partners, challenges, and solutions; (3) EMS system structure, protocols, communication, and supervision; and (4) program improvement, outcomes, and sustainability. Results Challenges included unequal resource allocation and EMS and hospital services coverage, particularly in rural settings, lack of stroke registry usage, insufficient technologies, inconsistent use of standardized tools and protocols, collaboration gaps across SSOC, and lack of EMS stroke training. Strategies included addressing scarce resources, services, and facilities; disseminating, training on, and implementing standardized statewide SSOC protocols and tools; and utilizing SSOC quality and performance improvement systems and approaches. Conclusions This paper identifies several strategies that can be incorporated to enhance the implementation of evidence-based stroke policies to improve access to timely stroke care for all patient populations, particularly those experiencing disparities in rural communities.
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Affiliation(s)
- Aysha Rasool
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, United States
| | - Moriah Bailey
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Brittany Lue
- Chenega Corporation, Anchorage, AK, United States
| | - Nina Omeaku
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Adebola Popoola
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Sharada S. Shantharam
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Amanda A. Brown
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Erika B. Fulmer
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
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12
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Zachrison KS, Beaulieu ND, Mehrotra A. Changing Health Care Markets Have the Potential to Undermine Stroke Systems of Care. JAMA Neurol 2023; 80:1131-1132. [PMID: 37695597 DOI: 10.1001/jamaneurol.2023.3103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
This Viewpoint discusses the importance of prioritizing quality of care for patients with stroke in a changing health care environment.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Nancy D Beaulieu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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13
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Glance LG, Benesch CG, Joynt Maddox KE, Bender MT, Shang J, Stone PW, Lustik SJ, Nadler JW, Galton C, Dick AW. Was COVID-19 Associated With Worsening Inequities in Stroke Treatment and Outcomes? J Am Heart Assoc 2023; 12:e031221. [PMID: 37750574 PMCID: PMC10727248 DOI: 10.1161/jaha.123.031221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/18/2023] [Indexed: 09/27/2023]
Abstract
Background COVID-19 stressed hospitals and may have disproportionately affected the stroke outcomes and treatment of Black and Hispanic individuals. Methods and Results This retrospective study used 100% Medicare Provider Analysis and Review file data from between 2016 and 2020. We used interrupted time series analyses to examine whether the COVID-19 pandemic exacerbated disparities in stroke outcomes and reperfusion therapy. Among 1 142 560 hospitalizations for acute ischemic strokes, 90 912 (8.0%) were Hispanic individuals; 162 752 (14.2%) were non-Hispanic Black individuals; and 888 896 (77.8%) were non-Hispanic White individuals. The adjusted odds of mortality increased by 51% (adjusted odds ratio [aOR], 1.51 [95% CI, 1.34-1.69]; P<0.001), whereas the rates of nonhome discharges decreased by 11% (aOR, 0.89 [95% CI, 0.82-0.96]; P=0.003) for patients hospitalized during weeks when the hospital's proportion of patients with COVID-19 was >30%. The overall rates of motor deficits (P=0.25) did not increase, and the rates of reperfusion therapy did not decrease as the weekly COVID-19 burden increased. Black patients had lower 30-day mortality (aOR, 0.70 [95% CI, 0.69-0.72]; P<0.001) but higher rates of motor deficits (aOR, 1.14 [95% CI, 1.12-1.16]; P<0.001) than White individuals. Hispanic patients had lower 30-day mortality and similar rates of motor deficits compared with White individuals. There was no differential increase in adverse outcomes or reduction in reperfusion therapy among Black and Hispanic individuals compared with White individuals as the weekly COVID-19 burden increased. Conclusions This national study of Medicare patients found no evidence that the hospital COVID-19 burden exacerbated disparities in treatment and outcomes for Black and Hispanic individuals admitted with an acute ischemic stroke.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative MedicineUniversity of Rochester School of MedicineRochesterNY
- Department of Public Health SciencesUniversity of Rochester School of MedicineRochesterNY
- RAND Health, RANDBostonMA
| | - Curtis G. Benesch
- Department of NeurologyUniversity of Rochester School of MedicineRochesterNY
| | - Karen E. Joynt Maddox
- Department of MedicineWashington University in St. LouisSt. LouisMO
- Center for Health Economics and Policy at the Institute for Public HealthWashington University in St. LouisSt. LouisMO
| | - Matthew T. Bender
- Department of NeurosurgeryUniversity of Rochester School of MedicineRochesterNY
| | - Jingjing Shang
- Columbia School of Nursing, Center for Health PolicyNew YorkNY
| | | | - Stewart J. Lustik
- Department of Anesthesiology and Perioperative MedicineUniversity of Rochester School of MedicineRochesterNY
| | - Jacob W. Nadler
- Department of Anesthesiology and Perioperative MedicineUniversity of Rochester School of MedicineRochesterNY
| | - Christopher Galton
- Department of Anesthesiology and Perioperative MedicineUniversity of Rochester School of MedicineRochesterNY
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14
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Zachrison KS, Hsia RY, Schwamm LH, Yan Z, Samuels-Kalow ME, Reeves MJ, Camargo CA, Onnela JP. Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach. Circ Cardiovasc Qual Outcomes 2023; 16:e009868. [PMID: 37746725 PMCID: PMC10592016 DOI: 10.1161/circoutcomes.122.009868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 08/18/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer. METHODS This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center. RESULTS Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22-0.26] and 0.59 [95% CI, 0.50-0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23-0.29] and odds ratio, 0.49 [95% CI, 0.38-0.62], uninsured odds ratio, 0.75 [95% CI, 0.63-0.89], and 0.72 [95% CI, 0.6-0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer. CONCLUSIONS Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster.
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Affiliation(s)
- Kori S Zachrison
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco (R.Y.H.)
| | - Lee H Schwamm
- Neurology (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Zhiyu Yan
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Margaret E Samuels-Kalow
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Carlos A Camargo
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (J.-P.O.)
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Hunt LJ, Gan S, Smith AK, Aldridge MD, Boscardin WJ, Harrison KL, James JE, Lee AK, Yaffe K. Hospice Quality, Race, and Disenrollment in Hospice Enrollees With Dementia. J Palliat Med 2023; 26:1100-1108. [PMID: 37010377 PMCID: PMC10440673 DOI: 10.1089/jpm.2023.0011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 04/04/2023] Open
Abstract
Background: Racial and ethnic minoritized people with dementia (PWD) are at high risk of disenrollment from hospice, yet little is known about the relationship between hospice quality and racial disparities in disenrollment among PWD. Objective: To assess the association between race and disenrollment between and within hospice quality categories in PWD. Design/Setting/Subjects: Retrospective cohort study of 100% Medicare beneficiaries 65+ enrolled in hospice with a principal diagnosis of dementia, July 2012-December 2017. Race and ethnicity (White/Black/Hispanic/Asian and Pacific Islander [AAPI]) was assessed with the Research Triangle Institute (RTI) algorithm. Hospice quality was assessed with the publicly-available Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey item on overall hospice rating, including a category for hospices exempt from public reporting (unrated). Results: The sample included 673,102 PWD (mean age 86, 66% female, 85% White, 7.3% Black, 6.3% Hispanic, 1.6% AAPI) enrolled in 4371 hospices nationwide. Likelihood of disenrollment was higher in hospices in the lowest quartile of quality ratings (vs. highest quartile) for both White (adjusted odds ratio [AOR] 1.12 [95% confidence interval 1.06-1.19]) and minoritized PWD (AOR range 1.2-1.3) and was substantially higher in unrated hospices (AOR range 1.8-2.0). Within both low- and high-quality hospices, minoritized PWD were more likely to be disenrolled compared with White PWD (AOR range 1.18-1.45). Conclusions: Hospice quality predicts disenrollment, but does not fully explain disparities in disenrollment for minoritized PWD. Efforts to improve racial equity in hospice should focus both on increasing equity in access to high-quality hospices and improving care for racial minoritized PWD in all hospices.
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Affiliation(s)
- Lauren J. Hunt
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Siqi Gan
- Northern California Institute for Research and Education, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Alexander K. Smith
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Krista L. Harrison
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer E. James
- Institute for Health and Aging, University of California, San Francisco, San Francisco, California, USA
| | - Alexandra K. Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Kristine Yaffe
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
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16
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Zachrison KS, Nielsen VM, de la Ossa NP, Madsen TE, Cash RE, Crowe RP, Odom EC, Jauch EC, Adeoye OM, Richards CT. Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care. Stroke 2023; 54:1138-1147. [PMID: 36444720 PMCID: PMC11050637 DOI: 10.1161/strokeaha.122.039586] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Natalia Perez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias I Pujol, Badalona, Spain and Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (N.P.d.l.O)
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI (T.E.M.)
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (E.C.O.)
| | - Edward C Jauch
- Department of Research, University of North Carolina Health Sciences at Mountain Area Health Education Center, Asheville, NC (E.C.J.)
| | - Opeolu M Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO (O.M.A.)
| | - Christopher T Richards
- Division of EMS, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH (C.T.R.)
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17
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Faigle R. Racial and Ethnic Disparities in Stroke Reperfusion Therapy in the USA. Neurotherapeutics 2023; 20:624-632. [PMID: 37219714 PMCID: PMC10275817 DOI: 10.1007/s13311-023-01388-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 05/24/2023] Open
Abstract
Racial and ethnic inequities in stroke care are ubiquitous. Acute reperfusion therapies, i.e., IV thrombolysis (IVT) and mechanical thrombectomy (MT), are central to acute stroke care and are highly efficacious at preventing death and disability after stroke. Disparities in the use of IVT and MT in the USA are pervasive and contribute to worse outcomes among racial and ethnic minority individuals with ischemic stroke. A meticulous understanding of disparities and underlying root causes is necessary in order to develop targeted mitigation strategies with lasting effects. This review details racial and ethnic disparities in the use of IVT and MT after stroke and highlights inequities in the underlying process measures as well as the contributing root causes. Furthermore, this review spotlights the systemic and structural inequities that contribute to race-based differences in the use of IVT and MT, including geographic and regional differences and differences based on neighborhood, zip code, and hospital type. In addition, recent promising trends suggesting improvements in racial and ethnic IVT and MT disparities and potential approaches for future solutions to achieve equity in stroke care are briefly discussed.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA.
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Sarkar U, Bibbins-Domingo K. Achieving Diagnostic Equity in Cardiovascular Disease. JAMA 2022; 328:827-828. [PMID: 35969406 DOI: 10.1001/jama.2022.14424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Urmimala Sarkar
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco
- Division of General Internal Medicine, University of California, San Francisco
| | - Kirsten Bibbins-Domingo
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Editor in Chief, JAMA
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