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McCandless MG, Powers AY, Baker KE, Strickland AE. Trends in Demographic and Geographic Disparities in Stroke Mortality Among Older Adults in the United States. World Neurosurg 2024; 185:e620-e630. [PMID: 38403013 DOI: 10.1016/j.wneu.2024.02.094] [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] [Received: 08/10/2023] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Stroke is a leading cause of morbidity and mortality in the United States among older adults. However, the impact of demographic and geographic risk factors remains ambiguous. A clear understanding of these associations and updated trends in stroke mortality can influence health policies and interventions. METHODS This study characterizes stroke mortality among older adults (age ≥55) in the US from January 1999 to December 2020, sourcing data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. Segmented regression was used to analyze trends in crude mortality rate and age-adjusted mortality rate (AAMR) per 100,000 individuals stratified by stroke subcategory, sex, ethnicity, urbanization, and state. RESULTS A total of 3,691,305 stroke deaths occurred in older adults in the US between 1999 and 2020 (AAMR = 233.3), with an overall decrease in AAMR during these years. The highest mortality rates were seen in nonspecified stroke (AAMR = 173.5), those 85 or older (crude mortality rate1276.7), men (AAMR = 239.2), non-Hispanic African American adults (AAMR = 319.0), and noncore populations (AAMR = 276.1). Stroke mortality decreased in all states from 1999 to 2019 with the greatest and least decreases seen in California (-61.9%) and Mississippi (-35.0%), respectively. The coronavirus pandemic pandemic saw increased stroke deaths in most groups. CONCLUSIONS While there's a decline in stroke-related deaths among US older adults, outcome disparities remain across demographic and geographic sectors. The surge in stroke deaths during coronavirus pandemic reaffirms the need for policies that address these disparities.
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Affiliation(s)
- Martin G McCandless
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas, USA; Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA.
| | - Andrew Y Powers
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine E Baker
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Allison E Strickland
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Sun W, Shan S, Hou L, Li S, Cao J, Wu J, Yi Q, Luo Z, Song P. Socioeconomic disparities in the association of age at first live birth with incident stroke among Chinese parous women: A prospective cohort study. J Glob Health 2024; 14:04091. [PMID: 38587297 PMCID: PMC11000532 DOI: 10.7189/jogh.14.04091] [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: 04/09/2024] Open
Abstract
Background Stroke has become a significant public health issue in China. Although studies have shown that women's age at first live birth (AFLB) might be associated with incident stroke, there is limited evidence on this relationship among Chinese parous women. Likewise, the nature of this association across urban-rural socioeconomic status (SES) has yet to be explored. In this prospective study, we sought to investigate the associations of women's AFLB with the risk of incident stroke and its subtypes (ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage) and to explore the differences of these associations as well as the population-level impacts across SES classes. Methods We used data on 290 932 Chinese parous women from the China Kadoorie Biobank who were recruited in the baseline survey between 2004 and 2008 and followed up until 2015. We used latent class analysis to identify urban-rural SES classes and Cox proportional hazard regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for AFLB's association with incident stroke. We then calculated population attributable fraction (PAF) to demonstrate the population-level impact of later AFLB on stroke. Results Around 8.9% of parous women developed stroke after AFLB. Compared with women with AFLB <22 years, those with older AFLB had a higher risk of total stroke, with fully adjusted HRs (95% CI) of 1.71 (95% CI = 1.65-1.77) for 22-24 years and 3.37 (95% CI = 3.24-3.51) for ≥25 years. The associations of AFLB with ischaemic stroke were stronger among rural-low-SES participants. We found the highest PAFs of ischaemic stroke (60.1%; 95% CI = 46.2-70.3) associated with later AFLB for urban-high-SES individuals. Conclusions Older AFLB was associated with higher risks of incident stroke and its subtypes among Chinese parous women, with stronger associations between AFLB and ischaemic stroke among rural-low-SES participants. Targeted medical advice for pregnant women of different ages could have long-term benefits for stroke prevention.
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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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Secondary Stroke Risk Reduction in Black Adults: a Systematic Review. J Racial Ethn Health Disparities 2023; 10:306-318. [PMID: 35032010 PMCID: PMC8759598 DOI: 10.1007/s40615-021-01221-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/03/2021] [Accepted: 12/23/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To address the fact that Black adults (BAs) experience significantly greater stroke burden than the general population, we conducted a systematic literature review which described evidence-based interventions targeting secondary stroke risk reduction in BAs. DATA SOURCE Publications were selected from PubMed, Ovid, Cochrane, and Web of Science databases. We included peer-reviewed, longitudinal, English-language studies performed in the USA which reported results for BAs separately and had adult participants who had experienced stroke-related events. RESULTS Six of the 7 studies employed behavioral interventions which promoted education on stroke risk factors, problem-solving skills, and healthy-coping strategies. These studies demonstrated improvements in one or more biologic outcomes including cholesterol control and systolic blood pressure. CONCLUSIONS Existing interventions on secondary stroke risk reduction approaches are effective in reducing secondary stroke risk among BAs, especially in individuals with poorly controlled blood pressure at baseline. However, additional research is needed because the current approaches may limit generalizability.
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Shen YC, Sarkar N, Hsia RY. Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States. JAMA Neurol 2022; 79:777-786. [PMID: 35759253 PMCID: PMC9237804 DOI: 10.1001/jamaneurol.2022.1621] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/28/2022] [Indexed: 12/22/2022]
Abstract
Importance Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant. Objective To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities. Design, Setting, and Participants This study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022. Main Outcomes and Measures Hospitals' likelihood of adopting stroke care certification. Results A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51). Conclusions and Relevance In this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.
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Affiliation(s)
- Yu-Chu Shen
- Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Nandita Sarkar
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
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Zachrison KS, Samuels‐Kalow ME, Li S, Yan Z, Reeves MJ, Hsia RY, Schwamm LH, Camargo CA. The relationship between stroke system organization and disparities in access to stroke center care in California. J Am Coll Emerg Physicians Open 2022; 3:e12706. [PMID: 35316966 PMCID: PMC8921441 DOI: 10.1002/emp2.12706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/08/2022] Open
Abstract
Background There are significant racial and ethnic disparities in receipt of reperfusion interventions for acute ischemic stroke. Our objective was to determine whether there are disparities in access to stroke center care by race or ethnicity that help explain differences in reperfusion therapy and to understand whether interhospital patient transfer plays a role in improving access. Methods Using statewide administrating data including all emergency department and hospital discharges in California from 2010 to 2017, we identified all acute ischemic stroke patients. Primary outcomes of interest included presentation to primary or comprehensive stroke center (PSC or CSC), interhospital transfer, discharge from PSC or CSC, and discharge from CSC alone. We used hierarchical logistic regression modeling to identify the relationship between patient‐ and hospital‐level characteristics and outcomes of interest. Results Of 336,247 ischemic stroke patients, 55.4% were non‐Hispanic White, 19.6% Hispanic, 10.6% non‐Hispanic Asian/Pacific Islander, and 10.3% non‐Hispanic Black. There was no difference in initial presentation to stroke center hospitals between groups. However, adjusted odds of reperfusion intervention, interhospital transfer and discharge from CSC did vary by race and ethnicity. Adjusted odds of interhospital transfer were lower among Hispanic (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98) and non‐Hispanic Asian/Pacific Islander patients (OR 0.84, 95% CI 0.79 to 0.90) and odds of discharge from a CSC were lower for Hispanic (OR 0.91, 95% CI 0.85 to 0.97) and non‐Hispanic Black patients (OR 0.74, 95% CI 0.67 to 0.81). Conclusions There are racial and ethnic disparities in reperfusion intervention receipt among stroke patients in California. Stroke system of care design, hospital resources, and transfer patterns may contribute to this disparity.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | | | - Sijia Li
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Zhiyu Yan
- Department of Neurology Massachusetts General Hospital Boston Massachusetts USA
| | - Mathew J. Reeves
- Department of Epidemiology and Biostatistics Michigan State University East Lansing Michigan USA
| | - Renee Y. Hsia
- Department of Emergency Medicine 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
| | - Lee H. Schwamm
- Department of Neurology Massachusetts General Hospital Boston Massachusetts USA
| | - Carlos A. Camargo
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
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Stroke Disparities. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00015-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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8
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Howard G. Rural-urban differences in stroke risk. Prev Med 2021; 152:106661. [PMID: 34087323 PMCID: PMC8545748 DOI: 10.1016/j.ypmed.2021.106661] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 10/21/2022]
Abstract
Rural-urban health disparities in life expectancy are large and increasing, with the rural-urban disparity stroke mortality serving as a potential contributor. Data from Vital Statistics shows an unexplained temporal pattern in the rural-urban disparity in stroke-specific mortality, with the magnitude of the disparity increasing from 15% to 25% between 1999 and 2010, but subsequently decreasing to 8% by 2019. This recent decrease in the magnitude of the rural-urban disparity in stroke mortality appears to be driven by a previously unreported plateauing of stroke mortality in urban areas and a continued decline of stroke mortality in rural areas. There is a need to better understand the contributors to these temporal changes; however, a general lack of temporal data on potential contributors prevents this investigation. However considering contributors to the rural-urban differences pooled across time, an overall a higher stroke incidence in rural areas appears to be a contributor to the higher rural stroke mortality, with this higher incidence potentially associated with a higher prevalence of stroke risk factors in rural areas. Conversely, studies assessing rural-urban disparities in stroke case fatality show smaller and inconsistent associations. To the extent that disparities in case fatality do exist, there are many studies showing rural-urban disparities in stroke care could be contributing. While these data offer insights to the overall rural-urban disparities in stroke mortality, additional data are needed to help understand temporal changes in the magnitude of the rural-urban stroke mortality disparity.
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Affiliation(s)
- George Howard
- Department of Biostatistics, UAB School of Public Health, 1665 University Drive, University of Alabama at Birmingham, Birmingham, AL 35294-0022, United States of America.
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9
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Characterizing the performance of emergency medical transport time metrics in a residentially segregated community. Am J Emerg Med 2021; 50:111-119. [PMID: 34340164 DOI: 10.1016/j.ajem.2021.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To derive and characterize the performance of various metrics of emergency transport time in assessing for sociodemographic disparities in the setting of residential segregation. Secondarily to characterize racial disparities in emergency transport time of suspected stroke patients in Austin, Texas. DATA SOURCES We used a novel dataset of 2518 unique entries with detailed spatial and temporal information on all suspected stroke transports conducted by a public emergency medical service in Central Texas between 2010 and 2018. STUDY DESIGN We conducted one-way ANOVA tests with post-hoc pairwise t-tests to assess how mean hospital transport times varied by patient race. We also developed a spatially-independent metric of emergency transport urgency, the ratio of expected duration of self-transport to a hospital and the measured transport time by an ambulance. DATA COLLECTION/EXTRACTION We calculated ambulance arrival and destination times using sequential temporospatial coordinates. We excluded any entries in which patient race was not recorded. We also excluded entries in which ambulances' routes did not pass within 100 m of either the patient's location or the documented hospital destination. PRINCIPAL FINDINGS We found that mean transport time to a hospital was 2.5 min shorter for black patients compared to white patients. However, white patients' transport times to a hospital were found to be, on average, 4.1 min shorter than expected compared to 3.4 min shorter than expected for black patients. One-way ANOVA testing for the spatially-independent index of emergency transport urgency was not statistically significant, indicating that average transport time did not vary significantly across racial groups when accounting for variations in transport distance. CONCLUSIONS Using a novel transport urgency index, we demonstrate that these findings represent race-based variation in spatial distributions rather than racial bias in emergency medical transport. These results highlight the importance of closely examining spatial distributions when utilizing temporospatial data to investigate geographically-dependent research questions.
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10
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Mullen MT, Williams OA. Going the Extra Mile: Disparities in Access to Specialized Stroke Care. Stroke 2021; 52:2580-2582. [PMID: 34107736 DOI: 10.1161/strokeaha.121.035128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Olajide A Williams
- Department of Neurology, Columbia University, New York, NY (O.A.W.).,Department of Neurology, New York Presbyterian Hospital (O.A.W.)
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11
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Yu CY, Blaine T, Panagos PD, Kansagra AP. Demographic Disparities in Proximity to Certified Stroke Care in the United States. Stroke 2021; 52:2571-2579. [PMID: 34107732 DOI: 10.1161/strokeaha.121.034493] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Cathy Y Yu
- Washington University School of Medicine (C.Y.Y.)
| | - Timothy Blaine
- Mallinckrodt Institute of Radiology (T.B., A.P.K.), Washington University School of Medicine, St. Louis, MO
| | - Peter D Panagos
- Department of Emergency Medicine (P.D.P.), Washington University School of Medicine, St. Louis, MO.,Department of Neurology (P.D.P., A.P.K.), Washington University School of Medicine, St. Louis, MO
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology (T.B., A.P.K.), Washington University School of Medicine, St. Louis, MO.,Department of Neurology (P.D.P., A.P.K.), Washington University School of Medicine, St. Louis, MO.,Department of Neurological Surgery (A.P.K.), Washington University School of Medicine, St. Louis, MO
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12
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Reddy S, Wu TC, Zhang J, Rahbar MH, Ankrom C, Zha A, Cossey TC, Aertker B, Vahidy F, Parsha K, Jones E, Sharrief A, Savitz SI, Jagolino-Cole A. Lack of Racial, Ethnic, and Sex Disparities in Ischemic Stroke Care Metrics within a Tele-Stroke Network. J Stroke Cerebrovasc Dis 2020; 30:105418. [PMID: 33152594 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105418] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/03/2020] [Accepted: 10/16/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Differences in access to stroke care and compliance with standard of care stroke management among patients of varying racial and ethnic backgrounds and sex are well-characterized. However, little is known on the impact of telestroke in addressing disparities in acute ischemic stroke care. METHODS We conducted a retrospective review of acute ischemic stroke patients evaluated over our 17-hospital telestroke network in Texas from 2015-2018. Patients were described as Non-Hispanic White (NHW) male or female, Non-Hispanic Black (NHB) male or female, or Hispanic (HIS) male or female. We compared frequency of tPA and mechanical thrombectomy (MT) utilization, door-to-consultation times, door-to-tPA times, and time-to-transfer for patients who went on to MT evaluation at the hub after having been screened for suspected large vessel occlusion at the spoke. RESULTS Among 3873 patients (including 1146 NHW male (30%) and 1134 NHW female (29%), 405 NHB male (10%) and 491 NHB female (13%), and 358 HIS male (9%) and 339 HIS female (9%) patients), we did not find any differences in door-to consultation time, door-to-tPA time, time-to-transfer, frequency of tPA administration, or incidence of MT utilization. CONCLUSION We did not find racial, ethnic, and sex disparities in ischemic stroke care metrics within our telestroke network. In order to fully understand how telestroke alleviates disparities in stroke care, collaboration among networks is needed to formulate a multicenter telestroke database similar to the Get-With-The Guidelines.
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Affiliation(s)
- Sujan Reddy
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center (UTHealth), 6431 Fannin Street, MSB 7.125, Houston, TX 77030, United States.
| | - Tzu-Ching Wu
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center (UTHealth), 6431 Fannin Street, MSB 7.125, Houston, TX 77030, United States.
| | - Jing Zhang
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, United States; Department of Biostatistics and Data Science, The University of Texas Health Science Center (UTHealth), Houston, United States.
| | - Mohammad Hossein Rahbar
- Department of Biostatistics and Data Science, The University of Texas Health Science Center (UTHealth), Houston, United States.
| | - Christy Ankrom
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center (UTHealth), 6431 Fannin Street, MSB 7.125, Houston, TX 77030, United States.
| | - Alicia Zha
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center (UTHealth), 6431 Fannin Street, MSB 7.125, Houston, TX 77030, United States.
| | - T C Cossey
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center (UTHealth), 6431 Fannin Street, MSB 7.125, Houston, TX 77030, United States.
| | - Benjamin Aertker
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center (UTHealth), 6431 Fannin Street, MSB 7.125, Houston, TX 77030, United States.
| | - Farhaan Vahidy
- Center for Outcomes Research, Houston Methodist, United States.
| | - Kaushik Parsha
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center (UTHealth), 6431 Fannin Street, MSB 7.125, Houston, TX 77030, United States.
| | - Erica Jones
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center (UTHealth), 6431 Fannin Street, MSB 7.125, Houston, TX 77030, United States.
| | - Anjail Sharrief
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center (UTHealth), 6431 Fannin Street, MSB 7.125, Houston, TX 77030, United States.
| | - Sean I Savitz
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center (UTHealth), 6431 Fannin Street, MSB 7.125, Houston, TX 77030, United States.
| | - Amanda Jagolino-Cole
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center (UTHealth), 6431 Fannin Street, MSB 7.125, Houston, TX 77030, United States.
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Affiliation(s)
- George Howard
- From the Department of Biostatistics (G.H.), School of Public Health, University of Alabama at Birmingham
| | - Virginia J. Howard
- Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham
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The impact of ethnic/racial status on access to care and outcomes after stroke: A narrative systematic review. JOURNAL OF VASCULAR NURSING 2019; 37:199-212. [DOI: 10.1016/j.jvn.2019.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/20/2019] [Accepted: 07/02/2019] [Indexed: 01/01/2023]
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15
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Dwyer M, Rehman S, Ottavi T, Stankovich J, Gall S, Peterson G, Ford K, Kinsman L. Urban-rural differences in the care and outcomes of acute stroke patients: Systematic review. J Neurol Sci 2018; 397:63-74. [PMID: 30594105 DOI: 10.1016/j.jns.2018.12.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/14/2018] [Accepted: 12/16/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To describe literature pertaining to urban-rural differences in both the quality of care and outcomes of acute stroke patients. METHODS We systematically searched CINAHL, PubMed, ProQuest Dissertations & Theses, and Scopus for published and unpublished literature until 9th December 2017. Studies were included if they compared the acute care provided to, or outcomes of, patients hospitalised for stroke in urban versus rural settings. Abstract, full-text review, and data extraction were conducted in duplicate. Findings are presented in the form of narrative syntheses. RESULTS A total of 28 studies were included in the review (16 on care, 12 on outcomes). With few exceptions, studies addressing the provision of care suggested that rural patients have less access to most aspects of acute stroke care. Studies reporting urban-rural differences in patient outcomes were inconsistent in their findings, however, few of these studies were primarily focused on the issue of urban-rural disparities. Overall, study findings did not appear to differ in line with study quality ratings, stroke subtypes included, or how inter-facility patient transfers were accounted for. CONCLUSIONS There is convincing, albeit not unanimous, evidence to suggest that stroke patients in rural areas receive less acute care than their urban counterparts. Despite this, the available data and methodology have largely not been used to study urban-rural differences in patient outcomes. PROSPERO registration information: URL: https://www.crd.york.ac.uk/prospero. Unique identifier: CRD42017073262.
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16
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Jauch EC, Huang DY, Gardner AJ, Blum JL. Strategies for improving outcomes in the acute management of ischemic stroke in rural emergency departments: a quality improvement initiative in the Stroke Belt. Open Access Emerg Med 2018; 10:53-59. [PMID: 29805271 PMCID: PMC5960248 DOI: 10.2147/oaem.s160269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The timely evaluation and initiation of treatment for acute ischemic stroke (AIS) is critical to optimal patient outcomes. However, clinical practice often falls short of guideline-established goals. Hospitals in rural regions of the USA, and notably those in the Stroke Belt, are particularly challenged to meet timing goals since the vast majority of primary stroke centers (PSCs) are concentrated in urban academic institutions. Methods Between May 2015 and May 2017, emergency department (ED) teams from 5 non-PSC hospitals in the Stroke Belt participated in a quality improvement (QI) initiative. The intervention included a baseline practice assessment survey, repeat audit-and-feedback cycles with patient data on AIS treatment timing, personalized Continuing Medical Education/Continuing Education-certified grand rounds sessions at each participating site with expert study faculty, targeted reinforcement of best practices, and follow-up to evaluate the benefits and limitations of the intervention. Results At the start of the initiative, clinical staff from participating EDs overestimated the proportion of patients with AIS who received alteplase within the guideline-recommended 60-minute door-to-needle window at their facility. At the end of the 6-month intervention period, significantly more patients were treated with alteplase within 60 minutes of ED arrival compared to baseline across the entire sample (1.9% of patients at baseline vs. 5.2% at 6 months; P < 0.01). Similarly, there was a trend toward a decrease in the percentage of patients whose alteplase treatment was initiated more than 60 minutes after their arrival at the ED (67.3% at baseline vs. 22.2% at 6 months). Conclusion Structured QI interventions that engage ED care teams to reflect on processes related to AIS diagnosis and treatment and deploy repeat audit-and-feedback cycles with real-time patient data have the potential to support an increase in the number of patients who receive alteplase within the guideline-recommended timeframe of 60 minutes from hospital arrival.
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Affiliation(s)
- Edward C Jauch
- Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - David Y Huang
- Department of Neurology, Division of Stroke and Vascular Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Bekelis K, Missios S, MacKenzie TA. Access disparities to Magnet hospitals for ischemic stroke patients. J Clin Neurosci 2017. [PMID: 28625585 DOI: 10.1016/j.jocn.2017.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Access disparities to centers of excellence can have detrimental consequences for population health. We investigated the presence of racial disparities in the access of stroke patients to hospitals recognized by the Magnet Recognition Program of the American Nurses Credentialing Center (ANCC). We performed a cohort study of all ischemic stroke patients who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2013. We examined the association of African-American race with Magnet status hospitalization after ischemic stroke. A mixed effects propensity adjusted multivariable regression analysis was used to control for confounding. During the study period, 176,557 patients presented with ischemic stroke, and met the inclusion criteria. Overall, 4,624 (13.7%) African-Americans, and 27,468 (19.2%) non African-Americans with ischemic stroke were admitted to Magnet hospitals. Using a multivariable logistic regression, we demonstrate that African-Americans were associated with lower admission rates to Magnet institutions (OR 0.70; 95% CI, 0.68-0.73) (Table 2). This persisted in a mixed effects logistic regression model (OR 0.75; 95% CI, 0.71-0.78) to adjust for clustering at the county level, and a propensity score adjusted logistic regression model (OR 0.87; 95% CI, 0.83-0.90). Using a comprehensive all-payer cohort of ischemic stroke patients in New York State we identified an association of African-American race with lower rates of admission to Magnet hospitals.
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Affiliation(s)
- Kimon Bekelis
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, United States; Geisel School of Medicine at Dartmouth, Hanover, NH, United States.
| | - Symeon Missios
- Division of Neurosurgery, Cleveland Clinic - Akron General Hospital, Akron, OH, United States
| | - Todd A MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, United States; Geisel School of Medicine at Dartmouth, Hanover, NH, United States; Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States; Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
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18
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Ellis C, Peach RK. Racial-Ethnic Differences in Word Fluency and Auditory Comprehension Among Persons With Poststroke Aphasia. Arch Phys Med Rehabil 2017; 98:681-686. [DOI: 10.1016/j.apmr.2016.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/28/2016] [Accepted: 10/07/2016] [Indexed: 11/30/2022]
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19
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Baehr A, Martinez R, Carr BG. Hospital Emergency Care as a Public Good and Community Health Benefit. Ann Emerg Med 2017; 70:229-232. [PMID: 28356205 DOI: 10.1016/j.annemergmed.2017.01.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Avi Baehr
- Denver Health Residency in Emergency Medicine, Denver, CO
| | | | - Brendan G Carr
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
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20
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Brown SC, Wang K, Dong C, Farrell MB, Heller GV, Gornik HL, Hutchisson M, Needleman L, Benenati JF, Jaff MR, Meier GH, Perese S, Bendick P, Hamburg NM, Lohr JM, LaPerna L, Leers SA, Lilly MP, Tegeler C, Katanick SL, Alexandrov AV, Siddiqui AH, Rundek T. Intersocietal Accreditation Commission Accreditation Status of Outpatient Cerebrovascular Testing Facilities Among Medicare Beneficiaries: The VALUE Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:1957-1965. [PMID: 27466261 DOI: 10.7863/ultra.15.08021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 12/14/2015] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Accreditation of cerebrovascular ultrasound laboratories by the Intersocietal Accreditation Commission (IAC) and equivalent organizations is supported by the Joint Commission certification of stroke centers. Limited information exists on the accreditation status and geographic distribution of cerebrovascular testing facilities in the United States. Our study objectives were to identify the proportion of IAC-accredited outpatient cerebrovascular testing facilities used by Medicare beneficiaries, describe their geographic distribution, and identify variations in cerebrovascular testing procedure types and volumes by accreditation status. METHODS As part of the VALUE (Vascular Accreditation, Location, and Utilization Evaluation) Study, we examined the proportion of IAC-accredited facilities that conducted cerebrovascular testing in a 5% Centers for Medicare and Medicaid Services random Outpatient Limited Data Set in 2011 and investigated their geographic distribution using geocoding. RESULTS Among 7327 outpatient facilities billing Medicare for cerebrovascular testing, only 22% (1640) were IAC accredited. The proportion of IAC-accredited cerebrovascular testing facilities varied by region (χ(2)[3] = 177.1; P < .0001), with 29%, 15%, 13%, and 10% located in the Northeast, South, Midwest, and West, respectively. However, of the total number of cerebrovascular outpatient procedures conducted in 2011 (38,555), 40% (15,410) were conducted in IAC-accredited facilities. Most cerebrovascular testing procedures were carotid duplex, with 40% of them conducted in IAC-accredited facilities. CONCLUSIONS The proportion of facilities conducting outpatient cerebrovascular testing accredited by the IAC is low and varies by region. The growing number of certified stroke centers should be accompanied by more accredited outpatient vascular testing facilities, which could potentially improve the quality of stroke care.
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Affiliation(s)
- Scott C Brown
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida USA
| | - Kefeng Wang
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida USA, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida USA
| | - Chuanhui Dong
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida USA
| | | | - Gary V Heller
- Intersocietal Accreditation Commission, Ellicott City, Maryland USA
| | - Heather L Gornik
- Department of Vascular Medicine, Cleveland Clinic, Cleveland, Ohio USA
| | - Marge Hutchisson
- Intersocietal Accreditation Commission, Ellicott City, Maryland USA
| | - Laurence Needleman
- Department of Radiology, Thomas Jefferson University, Jefferson Medical College, Philadelphia, Pennsylvania USA
| | - James F Benenati
- Baptist Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, Florida USA
| | - Michael R Jaff
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts USA
| | - George H Meier
- Department of Vascular Surgery, University of Cincinnati Academic Health Center, Cincinnati, Ohio USA
| | - Susana Perese
- Department of Vascular Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California USA
| | - Phillip Bendick
- Vascular Laboratory, William Beaumont Hospital, Royal Oak, Michigan USA
| | - Naomi M Hamburg
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
| | - Joann M Lohr
- Good Samaritan Outpatient Center, Cincinnati, Ohio USA
| | - Lucy LaPerna
- Riverside Radiology Associates, Columbus, Ohio USA
| | - Steven A Leers
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania USA
| | - Michael P Lilly
- Vascular Laboratory, University of Maryland School of Medicine, Baltimore, Maryland USA
| | - Charles Tegeler
- Wake Forest Baptist Health, Winston-Salem, North Carolina USA
| | | | | | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York USA
| | - Tatjana Rundek
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida USA, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida USA
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21
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Chapman Smith SN, Govindarajan P, Padrick MM, Lippman JM, McMurry TL, Resler BL, Keenan K, Gunnell BS, Mehndiratta P, Chee CY, Cahill EA, Dietiker C, Cattell-Gordon DC, Smith WS, Perina DG, Solenski NJ, Worrall BB, Southerland AM. A low-cost, tablet-based option for prehospital neurologic assessment: The iTREAT Study. Neurology 2016; 87:19-26. [PMID: 27281534 DOI: 10.1212/wnl.0000000000002799] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 03/08/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES In this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations. METHODS We piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval). RESULTS We conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to -0.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92-0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites. CONCLUSIONS Utilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms.
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Affiliation(s)
- Sherita N Chapman Smith
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Prasanthi Govindarajan
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Matthew M Padrick
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Jason M Lippman
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Timothy L McMurry
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Brian L Resler
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Kevin Keenan
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Brian S Gunnell
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Prachi Mehndiratta
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Christina Y Chee
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Elizabeth A Cahill
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Cameron Dietiker
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - David C Cattell-Gordon
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Wade S Smith
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Debra G Perina
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Nina J Solenski
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Bradford B Worrall
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Andrew M Southerland
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current).
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Karp DN, Wolff CS, Wiebe DJ, Branas CC, Carr BG, Mullen MT. Reassessing the Stroke Belt: Using Small Area Spatial Statistics to Identify Clusters of High Stroke Mortality in the United States. Stroke 2016; 47:1939-42. [PMID: 27197853 DOI: 10.1161/strokeaha.116.012997] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 05/03/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The stroke belt is described as an 8-state region with high stroke mortality across the southeastern United States. Using spatial statistics, we identified clusters of high stroke mortality (hot spots) and adjacent areas of low stroke mortality (cool spots) for US counties and evaluated for regional differences in county-level risk factors. METHODS A cross-sectional study of stroke mortality was conducted using Multiple Cause of Death data (Centers for Disease Control and Prevention) to compute age-adjusted adult stroke mortality rates for US counties. Local indicators of spatial association statistics were used for hot-spot mapping. County-level variables were compared between hot and cool spots. RESULTS Between 2008 and 2010, there were 393 121 stroke-related deaths. Median age-adjusted adult stroke mortality was 61.7 per 100 000 persons (interquartile range=51.4-74.7). We identified 705 hot-spot counties (22.4%) and 234 cool-spot counties (7.5%); 44.5% of hot-spot counties were located outside of the stroke belt. Hot spots had greater proportions of black residents, higher rates of unemployment, chronic disease, and healthcare utilization, and lower median income and educational attainment. CONCLUSIONS Clusters of high stroke mortality exist beyond the 8-state stroke belt, and variation exists within the stroke belt. Reconsideration of the stroke belt definition and increased attention to local determinants of health underlying small area regional variability could inform targeted healthcare interventions.
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Affiliation(s)
- David N Karp
- From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.)
| | - Catherine S Wolff
- From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.)
| | - Douglas J Wiebe
- From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.)
| | - Charles C Branas
- From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.)
| | - Brendan G Carr
- From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.)
| | - Michael T Mullen
- From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.).
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The association between rural residence and stroke care and outcomes. J Neurol Sci 2016; 363:16-20. [DOI: 10.1016/j.jns.2016.02.019] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/04/2016] [Accepted: 02/08/2016] [Indexed: 11/18/2022]
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Southerland AM, Johnston KC, Molina CA, Selim MH, Kamal N, Goyal M. Suspected Large Vessel Occlusion: Should Emergency Medical Services Transport to the Nearest Primary Stroke Center or Bypass to a Comprehensive Stroke Center With Endovascular Capabilities? Stroke 2016; 47:1965-7. [PMID: 26896433 DOI: 10.1161/strokeaha.115.011149] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew M Southerland
- From the Departments of Neurology (A.M.S., K.C.J.) and Public Health Sciences (A.M.S., K.C.J.), University of Virginia Health System, Charlottesville; Department of Neurology, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain (C.A.M.); Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); and Departments of Clinical Neurosciences (N.K., M.G.) and Radiology (M.G.), University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Karen C Johnston
- From the Departments of Neurology (A.M.S., K.C.J.) and Public Health Sciences (A.M.S., K.C.J.), University of Virginia Health System, Charlottesville; Department of Neurology, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain (C.A.M.); Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); and Departments of Clinical Neurosciences (N.K., M.G.) and Radiology (M.G.), University of Calgary, Foothills Medical Centre, Calgary, AB, Canada.
| | - Carlos A Molina
- From the Departments of Neurology (A.M.S., K.C.J.) and Public Health Sciences (A.M.S., K.C.J.), University of Virginia Health System, Charlottesville; Department of Neurology, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain (C.A.M.); Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); and Departments of Clinical Neurosciences (N.K., M.G.) and Radiology (M.G.), University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Magdy H Selim
- From the Departments of Neurology (A.M.S., K.C.J.) and Public Health Sciences (A.M.S., K.C.J.), University of Virginia Health System, Charlottesville; Department of Neurology, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain (C.A.M.); Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); and Departments of Clinical Neurosciences (N.K., M.G.) and Radiology (M.G.), University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Noreen Kamal
- From the Departments of Neurology (A.M.S., K.C.J.) and Public Health Sciences (A.M.S., K.C.J.), University of Virginia Health System, Charlottesville; Department of Neurology, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain (C.A.M.); Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); and Departments of Clinical Neurosciences (N.K., M.G.) and Radiology (M.G.), University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Mayank Goyal
- From the Departments of Neurology (A.M.S., K.C.J.) and Public Health Sciences (A.M.S., K.C.J.), University of Virginia Health System, Charlottesville; Department of Neurology, Hospital Vall d'Hebron-Barcelona, Barcelona, Spain (C.A.M.); Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); and Departments of Clinical Neurosciences (N.K., M.G.) and Radiology (M.G.), University of Calgary, Foothills Medical Centre, Calgary, AB, Canada.
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Wolff C, Boehme AK, Albright KC, Wu TC, Mullen MT, Branas CC, Grotta JC, Savitz SI, Carr BG. Sex Disparities in Access to Acute Stroke Care: Can Telemedicine Mitigate this Effect? JOURNAL OF HEALTH DISPARITIES RESEARCH AND PRACTICE 2016; 9:5. [PMID: 27668134 PMCID: PMC5032905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Women have more frequent and severe ischemic strokes than men, and are less likely to receive treatment for acute stroke. Primary stroke centers (PSCs) have been shown to utilize treatment more frequently. Further, as telemedicine (TM) has expanded access to acute stroke care we sought to investigate the association between PSC, TM and access to acute stroke care in the state of Texas. METHODS Texas hospitals and resources were identified from the 2009 American Hospital Association Annual Survey. Hospitals were categorized as: (1) stand-alone PSCs not using telemedicine for acute stroke care, (2) PSCs using telemedicine for acute stroke care (PSC-TM), (3) non-PSC hospitals using telemedicine for acute stroke care, or (4) non-PSC hospitals not using telemedicine for acute stroke care. The proportion of the population who could reach a PSC within 60 minutes was determined for stand-alone PSCs, PSC-TM, and non-PSCs using TM for stroke care. RESULTS Overall, women were as likely to have 60-minute access to a PSC or PSC-TM as their male counterparts (POR 1.02, 95% CI 1.02-1.03). Women were also just as likely to have access to acute stroke care via PSC or PSC-TM or TM as men (POR 1.03, 95% CI 1.02-1.04). DISCUSSION Our study found no sex disparities in access to stand alone PSCs or to hospitals using TM in the state of Texas. The results of this study suggest that telemedicine can be used as part of an inclusive strategy to improve access to care equally for men and women.
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Affiliation(s)
| | | | | | - Tzu-Ching Wu
- University of Texas-Houston Memorial Herman Medical Center
| | | | | | - James C Grotta
- University of Texas-Houston Memorial Herman Medical Center
| | - Sean I Savitz
- University of Texas-Houston Memorial Herman Medical Center
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Lippman JM, Smith SNC, McMurry TL, Sutton ZG, Gunnell BS, Cote J, Perina DG, Cattell-Gordon DC, Rheuban KS, Solenski NJ, Worrall BB, Southerland AM. Mobile Telestroke During Ambulance Transport Is Feasible in a Rural EMS Setting: The iTREAT Study. Telemed J E Health 2015; 22:507-13. [PMID: 26600433 DOI: 10.1089/tmj.2015.0155] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The use of telemedicine in the diagnosis and treatment of acute stroke, or telestroke, is a well-accepted method of practice improving geographic disparities in timely access to neurological expertise. We propose that mobile telestroke assessment during ambulance transport is feasible using low-cost, widely available technology. MATERIALS AND METHODS We designed a platform including a tablet-based end point, high-speed modem with commercial wireless access, external antennae, and portable mounting apparatus. Mobile connectivity testing was performed along six primary ambulance routes in a rural network. Audiovisual (AV) quality was assessed simultaneously by both an in-vehicle and an in-hospital rater using a standardized 6-point rating scale (≥4 indicating feasibility). We sought to achieve 9 min of continuous AV connectivity presumed sufficient to perform mobile telestroke assessments. RESULTS Thirty test runs were completed: 93% achieved a minimum of 9 min of continuous video transmission with a mean mobile connectivity time of 18 min. Mean video and audio quality ratings were 4.51 (4.54 vehicle; 4.48 hospital) and 5.00 (5.13 in-vehicle; 4.87 hospital), respectively. Total initial cost of the system was $1,650 per ambulance. CONCLUSIONS In this small, single-centered study we maintained high-quality continuous video transmission along primary ambulance corridors using a low-cost mobile telemedicine platform. The system is designed to be portable and adaptable, with generalizability for rapid assessment of emergency conditions in which direct observational exam may improve prehospital diagnosis and treatment. Thus mobile telestroke assessment is feasible using low-cost components and commercial wireless connectivity. More research is needed to demonstrate clinical reliability and efficacy in a live-patient setting.
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Affiliation(s)
- Jason M Lippman
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia
| | - Sherita N Chapman Smith
- 2 Department of Neurology, Virginia Commonwealth University Health System , Richmond, Virginia
| | - Timothy L McMurry
- 3 Department of Public Health Sciences, University of Virginia Health System , Charlottesville, Virginia
| | - Zachary G Sutton
- 4 The Brody School of Medicine, East Carolina University , Greenville, North Carolina
| | - Brian S Gunnell
- 5 Department of Center for Telehealth, University of Virginia Health System , Charlottesville, Virginia
| | - Jack Cote
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia
| | - Debra G Perina
- 6 Department of Emergency Medicine, University of Virginia Health System , Charlottesville, Virginia
| | - David C Cattell-Gordon
- 5 Department of Center for Telehealth, University of Virginia Health System , Charlottesville, Virginia
| | - Karen S Rheuban
- 5 Department of Center for Telehealth, University of Virginia Health System , Charlottesville, Virginia
| | - Nina J Solenski
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia
| | - Bradford B Worrall
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia.,3 Department of Public Health Sciences, University of Virginia Health System , Charlottesville, Virginia
| | - Andrew M Southerland
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia.,3 Department of Public Health Sciences, University of Virginia Health System , Charlottesville, Virginia
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Aparicio HJ, Carr BG, Kasner SE, Kallan MJ, Albright KC, Kleindorfer DO, Mullen MT. Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers. J Am Heart Assoc 2015; 4:e001877. [PMID: 26467999 PMCID: PMC4845141 DOI: 10.1161/jaha.115.001877] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Primary stroke centers (PSCs) utilize more recombinant tissue plasminogen activator (rt-PA) than non-PSCs. The impact of PSCs on racial disparities in rt-PA use is unknown. METHODS AND RESULTS We used data from the Nationwide Inpatient Sample from 2004 to 2010, limited to states that publicly reported hospital identity and race. Hospitals certified as PSCs by The Joint Commission were identified. Adults with a diagnosis of ischemic stroke were analyzed. Rt-PA use was defined by the International Classification of Diseases, 9th Revision procedure code 99.10. Discharges (304 152 patients) from 26 states met eligibility criteria, and of these 71.5% were white, 15.0% black, 7.9% Hispanic, and 5.6% other. Overall, 24.7% of white, 27.4% of black, 16.2% of Hispanic, and 29.8% of other patients presented to PSCs. A higher proportion received rt-PA at PSCs than non-PSCs in all race/ethnic groups (white 7.6% versus 2.6%, black 4.8% versus 2.0%, Hispanic 7.1% versus 2.4%, other 7.2% versus 2.5%, all P<0.001). In a multivariable model adjusting for year, age, sex, insurance, medical comorbidities, a diagnosis-related group-based mortality risk indicator, ZIP code median income, and hospital characteristics, blacks were less likely to receive rt-PA than whites at non-PSCs (odds ratio=0.58, 95% CI 0.50 to 0.67) and PSCs (odds ratio=0.63, 95% CI 0.54 to 0.74) and Hispanics were less likely than whites to receive rt-PA at PSCs (odds ratio=0.77, 95% CI: 0.63 to 0.95). In the fully adjusted model, interaction between race and presentation to a PSC for likelihood of receiving rt-PA did not reach significance (P=0.98). CONCLUSIONS Racial disparities in intravenous rt-PA use were not reduced by presentation to PSCs. Black patients were less likely to receive thrombolytic treatment than white patients at both non-PSCs and PSCs. Hispanic patients were less likely to be seen at PSCs relative to white patients and were less likely to receive intravenous rt-PA in the fully adjusted model.
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Affiliation(s)
- Hugo J Aparicio
- Department of Neurology, Boston University, Boston, MA (H.J.A.) Department of Neurology, University of Pennsylvania, Philadelphia, PA (H.J.A., S.E.K., M.T.M.)
| | - Brendan G Carr
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.)
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (H.J.A., S.E.K., M.T.M.)
| | - Michael J Kallan
- Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, Philadelphia, PA (M.J.K.)
| | - Karen C Albright
- Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham, AL (K.C.A.) Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center, University of Alabama at Birmingham, AL (K.C.A.) Department of Epidemiology, University of Alabama at Birmingham, AL (K.C.A.)
| | | | - Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (H.J.A., S.E.K., M.T.M.) Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (M.T.M.)
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Rhudy JP, Bakitas MA, Hyrkäs K, Jablonski-Jaudon RA, Pryor ER, Wang HE, Alexandrov AW. Effectiveness of regionalized systems for stroke and myocardial infarction. Brain Behav 2015; 5:e00398. [PMID: 26516616 PMCID: PMC4614047 DOI: 10.1002/brb3.398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/18/2015] [Accepted: 08/16/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI. METHODS Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement. RESULTS For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems. CONCLUSION Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.
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Affiliation(s)
- James P Rhudy
- School of Nursing University of Alabama at Birmingham Alabama
| | - Marie A Bakitas
- School of Nursing University of Alabama at Birmingham Alabama
| | - Kristiina Hyrkäs
- Center for Nursing Research and Quality Outcomes Maine Medical Center Birmingham Alabama
| | | | - Erica R Pryor
- School of Nursing University of Alabama at Birmingham Alabama
| | - Henry E Wang
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama
| | - Anne W Alexandrov
- College of Nursing University of Tennessee Health Sciences Center Memphis Tennessee
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Mullen MT, Branas CC, Kasner SE, Wolff C, Williams JC, Albright KC, Carr BG. Optimization modeling to maximize population access to comprehensive stroke centers. Neurology 2015; 84:1196-205. [PMID: 25740858 DOI: 10.1212/wnl.0000000000001390] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The location of comprehensive stroke centers (CSCs) is critical to ensuring rapid access to acute stroke therapies; we conducted a population-level virtual trial simulating change in access to CSCs using optimization modeling to selectively convert primary stroke centers (PSCs) to CSCs. METHODS Up to 20 certified PSCs per state were selected for conversion to maximize the population with 60-minute CSC access by ground and air. Access was compared across states based on region and the presence of state-level emergency medical service policies preferentially routing patients to stroke centers. RESULTS In 2010, there were 811 Joint Commission PSCs and 0 CSCs in the United States. Of the US population, 65.8% had 60-minute ground access to PSCs. After adding up to 20 optimally located CSCs per state, 63.1% of the US population had 60-minute ground access and 86.0% had 60-minute ground/air access to a CSC. Across states, median CSC access was 55.7% by ground (interquartile range 35.7%-71.5%) and 85.3% by ground/air (interquartile range 59.8%-92.1%). Ground access was lower in Stroke Belt states compared with non-Stroke Belt states (32.0% vs 58.6%, p = 0.02) and lower in states without emergency medical service routing policies (52.7% vs 68.3%, p = 0.04). CONCLUSION Optimal system simulation can be used to develop efficient care systems that maximize accessibility. Under optimal conditions, a large proportion of the US population will be unable to access a CSC within 60 minutes.
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Affiliation(s)
- Michael T Mullen
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA.
| | - Charles C Branas
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Scott E Kasner
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Catherine Wolff
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Justin C Williams
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Karen C Albright
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Brendan G Carr
- From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA
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Mullen MT, Wiebe DJ, Bowman A, Wolff CS, Albright KC, Roy J, Balcer LJ, Branas CC, Carr BG. Disparities in accessibility of certified primary stroke centers. Stroke 2014; 45:3381-8. [PMID: 25300972 PMCID: PMC4282182 DOI: 10.1161/strokeaha.114.006021] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE We examine whether the proportion of the US population with ≤60 minute access to Primary Stroke Centers (PSCs) varies based on geographic and demographic factors. METHODS Population level access to PSCs within 60 minutes was estimated using validated models of prehospital time accounting for critical prehospital time intervals and existing road networks. We examined the association between geographic factors, demographic factors, and access to care. Multivariable models quantified the association between demographics and PSC access for the entire United States and then stratified by urbanicity. RESULTS Of the 309 million people in the United States, 65.8% had ≤60 minute PSC access by ground ambulance (87% major cities, 59% minor cities, 9% suburbs, and 1% rural). PSC access was lower in stroke belt states (44% versus 69%). Non-whites were more likely to have access than whites (77% versus 62%), and Hispanics were more likely to have access than non-Hispanics (78% versus 64%). Demographics were not meaningfully associated with access in major cities or suburbs. In smaller cities, there was less access in areas with lower income, less education, more uninsured, more Medicare and Medicaid eligibles, lower healthcare utilization, and healthcare resources. CONCLUSIONS There are significant geographic disparities in access to PSCs. Access is limited in nonurban areas. Despite the higher burden of cerebrovascular disease in stroke belt states, access to care is lower in these areas. Selecting demographic and healthcare factors is strongly associated with access to care in smaller cities, but not in other areas, including major cities.
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Affiliation(s)
- Michael T Mullen
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.).
| | - Douglas J Wiebe
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Ariel Bowman
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Catherine S Wolff
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Karen C Albright
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Jason Roy
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Laura J Balcer
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Charles C Branas
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
| | - Brendan G Carr
- From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.)
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Brazzelli M, Chappell FM, Miranda H, Shuler K, Dennis M, Sandercock PAG, Muir K, Wardlaw JM. Diffusion-weighted imaging and diagnosis of transient ischemic attack. Ann Neurol 2014; 75:67-76. [PMID: 24085376 PMCID: PMC4223937 DOI: 10.1002/ana.24026] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/27/2013] [Accepted: 09/10/2013] [Indexed: 12/04/2022]
Abstract
Objective Magnetic resonance (MR) diffusion-weighted imaging (DWI) is sensitive to small acute ischemic lesions and might help diagnose transient ischemic attack (TIA). Reclassification of patients with TIA and a DWI lesion as “stroke” is under consideration. We assessed DWI positivity in TIA and implications for reclassification as stroke. Methods We searched multiple sources, without language restriction, from January 1995 to July 2012. We used PRISMA guidelines, and included studies that provided data on patients presenting with suspected TIA who underwent MR DWI and reported the proportion with an acute DWI lesion. We performed univariate random effects meta-analysis to determine DWI positive rates and influencing factors. Results We included 47 papers and 9,078 patients (range = 18–1,693). Diagnosis was by a stroke specialist in 26 of 47 studies (55%); all studies excluded TIA mimics. The pooled proportion of TIA patients with an acute DWI lesion was 34.3% (95% confidence interval [CI] = 30.5–38.4, range = 9–67%; I2 = 89.3%). Larger studies (n > 200) had lower DWI-positive rates (29%; 95% CI = 23.2–34.6) than smaller (n < 50) studies (40.1%; 95% CI = 33.5–46.6%; p = 0.035), but no other testable factors, including clinician speciality and time to scanning, reduced or explained the 7-fold DWI-positive variation. Interpretation The commonest DWI finding in patients with definite TIA is a negative scan. Available data do not explain why ⅔ of patients with definite specialist-confirmed TIA have negative DWI findings. Until these factors are better understood, reclassifying DWI-positive TIAs as strokes is likely to increase variance in estimates of global stroke and TIA burden of disease. ANN NEUROL 2014;75:67–76
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Affiliation(s)
- Miriam Brazzelli
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom; Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
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Wu TC, Lyerly MJ, Albright KC, Ward E, Hassler A, Messier J, Wolff C, Brannas CC, Savitz SI, Carr BG. Impact of Telemedicine on Access to Acute Stroke Care in the State of Texas. Ann Clin Transl Neurol 2013; 1:27-33. [PMID: 24535938 PMCID: PMC3925075 DOI: 10.1002/acn3.20] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background To examine the impact of telemedicine (TM) on access to acute stroke care and expertise in the state of Texas. Methods Texas hospitals were surveyed using a standard questionnaire and categorized as: (1) stand-alone Primary Stroke Centers (PSC) not using TM for acute stroke care, (2) PSC using TM for acute stroke care, (3) non-PSC hospitals using TM for acute stroke care, or (4) non-PSC hospitals not using TM for acute stroke care. Population data were obtained from the U.S. Census Bureau and the Neilson Claritas Demographic Estimation Program. Access within 60 min to a designated facility was calculated at the block group level. Results Over 75% of Texans had 60-min access to a stand-alone PSC. Including PSC using TM increased access by 6.5%. Adding non-PSC that use TM for acute stroke care provided 60-min access for an additional 2% of Texans, leaving 16% of Texans without 60-min access to acute stroke care. Approximately 62% of Texans had 60-min access to more than one type of facility that provided acute stroke care. Conclusion The use of TM in the state of Texas brought 60-min access to >2 million Texans who otherwise would not have had access to acute stroke expertise. Our findings demonstrate that using TM for acute stroke has the ability to provide neurologically underserved areas access to acute stroke care.
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Affiliation(s)
- Tzu-Ching Wu
- Stroke Program, Department of Neurology, University of Texas-Houston Memorial Hermann Medical CenterHouston, Texas 77030
- Correspondence Tzu-Ching Wu, Department of Neurology, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.120, Houston, TX 77030. Tel: +1 713-500-7082; Fax: +1 713-500-0660; E-mail:
| | - Michael J Lyerly
- Department of Neurology, School of Medicine, University of Alabama at BirminghamBirmingham, Alabama 35294
| | - Karen C Albright
- Department of Epidemiology, School of Public Health, University of Alabama at BirminghamBirmingham, Alabama 35294
- Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), University of Alabama at BirminghamBirmingham, Alabama 35294
- Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities (CERED) Minority Health and Health Disparities Research Center (MHRC), University of Alabama at BirminghamBirmingham, Alabama 35294
| | - Eric Ward
- Stroke Program, Department of Neurology, University of Texas-Houston Memorial Hermann Medical CenterHouston, Texas 77030
| | - Amanda Hassler
- Stroke Program, Department of Neurology, University of Texas-Houston Memorial Hermann Medical CenterHouston, Texas 77030
| | - Jessica Messier
- Stroke Program, Department of Neurology, University of Texas-Houston Memorial Hermann Medical CenterHouston, Texas 77030
| | - Catherine Wolff
- Department of Clinical Epidemiology and Biostatistics, University of PennsylvaniaPhiladelphia, Pennsylvania 19104
| | - Charles C Brannas
- Department of Clinical Epidemiology and Biostatistics, University of PennsylvaniaPhiladelphia, Pennsylvania 19104
| | - Sean I Savitz
- Stroke Program, Department of Neurology, University of Texas-Houston Memorial Hermann Medical CenterHouston, Texas 77030
| | - Brendan G Carr
- Department of Clinical Epidemiology and Biostatistics, University of PennsylvaniaPhiladelphia, Pennsylvania 19104
- Department of Emergency Medicine, University of PennsylvaniaPhiladelphia, Pennsylvania 19104
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