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Rubin MA, Lewis A, Creutzfeldt CJ, Shrestha GS, Boyle Q, Illes J, Jox RJ, Trevick S, Young MJ. Equity in Clinical Care and Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2024:10.1007/s12028-024-02012-3. [PMID: 38872033 DOI: 10.1007/s12028-024-02012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/09/2024] [Indexed: 06/15/2024]
Abstract
People with disorders of consciousness (DoC) are characteristically unable to synchronously participate in decision-making about clinical care or research. The inability to self-advocate exacerbates preexisting socioeconomic and geographic disparities, which include the wide variability observed across individuals, hospitals, and countries in access to acute care, expertise, and sophisticated diagnostic, prognostic, and therapeutic interventions. Concerns about equity for people with DoC are particularly notable when they lack a surrogate decision-maker (legally referred to as "unrepresented" or "unbefriended"). Decisions about both short-term and long-term life-sustaining treatment typically rely on neuroprognostication and individual patient preferences that carry additional ethical considerations for people with DoC, as even individuals with well thought out advance directives cannot anticipate every possible situation to guide such decisions. Further challenges exist with the inclusion of people with DoC in research because consent must be completed (in most circumstances) through a surrogate, which excludes those who are unrepresented and may discourage investigators from exploring questions related to this population. In this article, the Curing Coma Campaign Ethics Working Group reviews equity considerations in clinical care and research involving persons with DoC in the following domains: (1) access to acute care and expertise, (2) access to diagnostics and therapeutics, (3) neuroprognostication, (4) medical decision-making for unrepresented people, (5) end-of-life decision-making, (6) access to postacute rehabilitative care, (7) access to research, (8) inclusion of unrepresented people in research, and (9) remuneration and reciprocity for research participation. The goal of this discussion is to advance equitable, harmonized, guideline-directed, and goal-concordant care for people with DoC of all backgrounds worldwide, prioritizing the ethical standards of respect for autonomy, beneficence, and justice. Although the focus of this evaluation is on people with DoC, much of the discussion can be extrapolated to other critically ill persons worldwide.
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Affiliation(s)
- Michael A Rubin
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | | | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Quinn Boyle
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Judy Illes
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Neurocritical Care, Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, USA.
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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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Bensken WP, Alberti PM, Khan OI, Williams SM, Stange KC, Vaca GFB, Jobst BC, Sajatovic M, Koroukian SM. A framework for health equity in people living with epilepsy. Epilepsy Res 2022; 188:107038. [PMID: 36332544 PMCID: PMC9797034 DOI: 10.1016/j.eplepsyres.2022.107038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/22/2022] [Accepted: 10/17/2022] [Indexed: 12/31/2022]
Abstract
Epilepsy is a disease where disparities and inequities in risk and outcomes are complex and multifactorial. While most epilepsy research to date has identified several key areas of disparities, we set out to provide a multilevel life course model of epilepsy development, diagnosis, treatment, and outcomes to highlight how these disparities represent true inequities. Our piece also presents three hypothetical cases that highlight how the solutions to address inequities may vary across the lifespan. We then identify four key domains (structural, socio-cultural, health care, and physiological) that contribute to the persistence of inequities in epilepsy risk and outcomes in the United States. Each of these domains, and their core components in the context of epilepsy, are reviewed and discussed. Further, we highlight the connection between domains and key areas of intervention to strive towards health equity. The goal of this work is to highlight these domains while also providing epilepsy researchers and clinicians with broader context of how their work fits into health equity.
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Affiliation(s)
- Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA.
| | - Philip M Alberti
- AAMC Center for Health Justice, Association of American Medical Colleges, Washington, DC, USA
| | - Omar I Khan
- Epilepsy Center of Excellence, Baltimore VA Medical Center US Department of Veterans Affairs, Baltimore, MD, USA
| | - Scott M Williams
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Department of Genetics and Genome Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Kurt C Stange
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Center for Community Health Integration, Departments of Family Medicine & Community Health, and Sociology Case Western Reserve University, Cleveland, OH, USA
| | - Guadalupe Fernandez-Baca Vaca
- Department of Neurology, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Barbara C Jobst
- Department of Neurology, Geisel School of Medicine Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Martha Sajatovic
- Department of Neurology, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Department Psychiatry, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA
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Young Y, Hsu WH, Chen YM, Chung KP, Chen HH, Kane C, Shayya A, Schumacher P, Yeh YP. Determinants associated with medical-related long-term care service use among community-dwelling older adults in Taiwan. Geriatr Nurs 2022; 48:58-64. [PMID: 36126442 DOI: 10.1016/j.gerinurse.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Medical-related long-term care (LTC) service use among community-dwelling older adults in Taiwan is resource-intensive, and planning is essential to promote aging-in-place. METHODS Administrative data from 4/1/2017 to 11/26/2019 among more than 14,000 residents were analyzed with generalized estimating equations (GEEs) to identify determinants of medical-related LTC service use. RESULTS Older adults using medical-related LTC services tended to be younger (79.9 vs. 80.7; p<.0001), male (42.7% vs. 38.5%; p<.0001), multi-morbid (3.1 vs. 2.5; p<.0001), and higher mean activities of daily living (ADL) disability (8.2 vs. 4.2; p<.0001), instrumental ADL (IADL) disability (11.0 vs. 9.1; p<.0001), and hospitalizations (1.1 vs. 0.4; p<.0001). Significant determinants of medical-related LTC services include age, education, stroke, coronary heart disease, diabetes, vision impairment, ADL disability, and prior hospitalization. DISCUSSION The success of LTC 2.0 will depend on ADL support and care coordination to manage chronic conditions such as diabetes, vision impairment, coronary heart disease, and stroke.
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Affiliation(s)
- Yuchi Young
- University at Albany, School of Public Health, Department of Health Policy, Management & Behavior, 1 University Place, Rensselaer, NY, 12144, USA.
| | - Wan-Hsiang Hsu
- University at Albany, School of Public Health, Department of Health Policy, Management & Behavior, 1 University Place, Rensselaer, NY, 12144, USA
| | - Ya-Mei Chen
- National Taiwan University, College of Public Health, 17, Hsu-Chou Road, Taipei, 100225, Taiwan
| | - Kuo-Piao Chung
- National Taiwan University, College of Public Health, 17, Hsu-Chou Road, Taipei, 100225, Taiwan
| | - Hsiu-Hsi Chen
- National Taiwan University, College of Public Health, 17, Hsu-Chou Road, Taipei, 100225, Taiwan; Changhua County Public Health Bureau, 162 Zhongshan Road, Section 2, Changhua City, Changhua, 500009, Taiwan
| | - Cassandra Kane
- University at Albany, School of Public Health, Department of Health Policy, Management & Behavior, 1 University Place, Rensselaer, NY, 12144, USA
| | - Ashley Shayya
- University at Albany, School of Public Health, Department of Health Policy, Management & Behavior, 1 University Place, Rensselaer, NY, 12144, USA
| | - Patrick Schumacher
- University at Albany, School of Public Health, Department of Health Policy, Management & Behavior, 1 University Place, Rensselaer, NY, 12144, USA
| | - Yen-Po Yeh
- Changhua County Public Health Bureau, 162 Zhongshan Road, Section 2, Changhua City, Changhua, 500009, Taiwan
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Shen JZ, Martin KD, Malla G, Lin C. Rural-urban differences in functional outcomes after acute stroke therapy within the stroke belt. Clin Neurol Neurosurg 2022; 219:107346. [DOI: 10.1016/j.clineuro.2022.107346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/27/2022] [Accepted: 06/19/2022] [Indexed: 11/29/2022]
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Zachrison KS, Ganti L, Sharma D, Goyal P, Decker‐Palmer M, Adeoye O, Goldstein JN, Jauch EC, Lo BM, Madsen TE, Meurer W, Oostema JA, Mendez‐Hernandez C, Venkatesh AK. A survey of stroke-related capabilities among a sample of US community emergency departments. J Am Coll Emerg Physicians Open 2022; 3:e12762. [PMID: 35898236 PMCID: PMC9307290 DOI: 10.1002/emp2.12762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/20/2022] [Accepted: 02/09/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives Most acute stroke research is conducted at academic and larger hospitals, which may differ from many non-academic (ie, community) and smaller hospitals with respect to resources and consultant availability. We describe current emergency department (ED) and hospital-level stroke-related capabilities among a sample of community EDs participating in the Emergency Quality Network (E-QUAL) stroke collaborative. Methods Among E-QUAL-participating EDs, we conducted a survey to collect data on ED and hospital stroke-related structural and process capabilities associated with quality of stroke care delivery and patient outcomes. EDs submitted data using a web-based submission portal. We present descriptive statistics of self-reported capabilities. Results Of 154 participating EDs in 30 states, 97 (63%) completed the survey. Many were rural (33%); most (82%) were not certified stroke centers. Although most reported having stroke protocols (67%), many did not include hemorrhagic stroke or transient ischemic attack (45% and 57%, respectively). Capability to perform emergent head computed tomography and to administer thrombolysis were not universal (absent in 4% and 5%, respectively). Access to neurologic consultants varied; 18% reported no 24/7 availability onsite or remotely. Of those with access, 48% reported access through telemedicine only. Admission capabilities also varied with patient transfer commonly performed (79%). Conclusion Stroke-related capabilities vary substantially between community EDs and are different from capabilities typically found in larger stroke centers. These data may be valuable for identifying areas for future investment. Additionally, the design of stroke quality improvement interventions and metrics to evaluate emergency stroke care delivery should account for these key structural differences.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency MedicineMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Latha Ganti
- Department of Emergency MedicineUniversity of Central FloridaOrlandoFloridaUSA
| | - Dhruv Sharma
- American College of Emergency PhysiciansIrvingTexasUSA
| | - Pawan Goyal
- American College of Emergency PhysiciansIrvingTexasUSA
| | | | - Opeolu Adeoye
- Department of Emergency MedicineWashington UniversitySt. LouisMissouriUSA
| | - Joshua N. Goldstein
- Department of Emergency MedicineMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Bruce M. Lo
- Department of Emergency MedicineEastern Virginia Medical School/Sentara Norfolk General HospitalNorfolkVirginiaUSA
| | - Tracy E. Madsen
- Department of Emergency MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - William Meurer
- Department of Emergency MedicineUniversity of Michigan School of MedicineAnn ArborMichiganUSA
| | - John A. Oostema
- Department of Emergency MedicineMichigan State UniversityEast LansingMichiganUSA
| | | | - Arjun K. Venkatesh
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
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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, Amati V, Schwamm LH, Yan Z, Nielsen V, Christie A, Reeves MJ, Sauser JP, Lomi A, Onnela JP. Influence of Hospital Characteristics on Hospital Transfer Destinations for Patients With Stroke. Circ Cardiovasc Qual Outcomes 2022; 15:e008269. [PMID: 35369714 DOI: 10.1161/circoutcomes.121.008269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients with stroke are frequently transferred between hospitals. This may have implications on the quality of care received by patients; however, it is not well understood how the characteristics of sending and receiving hospitals affect the likelihood of a transfer event. Our objective was to identify hospital characteristics associated with sending and receiving patients with stroke. METHODS Using a comprehensive statewide administrative dataset, including all 78 Massachusetts hospitals, we identified all transfers of patients with ischemic stroke between October 2007 and September 2015 for this observational study. Hospital variables included reputation (US News and World Report ranking), capability (stroke center status, annual stroke volume, and trauma center designation), and institutional affiliation. We included network variables to control for the structure of hospital-to-hospital transfers. We used relational event modeling to account for complex temporal and relational dependencies associated with transfers. This method decomposes a series of patient transfers into a sequence of decisions characterized by transfer initiations and destinations, modeling them using a discrete-choice framework. RESULTS Among 73 114 ischemic stroke admissions there were 7189 (9.8%) transfers during the study period. After accounting for travel time between hospitals and structural network characteristics, factors associated with increased likelihood of being a receiving hospital (in descending order of relative effect size) included shared hospital affiliation (5.8× higher), teaching hospital status (4.2× higher), stroke center status (4.3× and 3.8× higher when of the same or higher status), and hospitals of the same or higher reputational ranking (1.5× higher). CONCLUSIONS After accounting for distance and structural network characteristics, in descending order of importance, shared hospital affiliation, hospital capabilities, and hospital reputation were important factor in determining transfer destination of patients with stroke. This study provides a starting point for future research exploring how relational coordination between hospitals may ensure optimized allocation of patients with stroke for maximal patient benefit.
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Affiliation(s)
- Kori S Zachrison
- Departments of Emergency Medicine (K.S.Z.), Massachusetts General Hospital, Boston.,Harvard Medical School (K.S.Z., L.H.S.), Boston, MA
| | - Viviana Amati
- Social Networks Lab of the Department of Humanities, Social, and Political Sciences, ETH Zurich, Switzerland (V.A.)
| | - Lee H Schwamm
- Neurology (L.H.S., Z.Y.), Massachusetts General Hospital, Boston.,Harvard Medical School (K.S.Z., L.H.S.), Boston, MA
| | - Zhiyu Yan
- Neurology (L.H.S., Z.Y.), Massachusetts General Hospital, Boston
| | - Victoria Nielsen
- Massachusetts Department of Public Health, Boston, MA (V.N., A.C.)
| | - Anita Christie
- Massachusetts Department of Public Health, Boston, MA (V.N., A.C.)
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics of Michigan State University, East Lansing (M.J.R.)
| | - Joseph P Sauser
- Hankamer School of Business at Baylor University, Waco, TX (J.P.S.)
| | - Alessandro Lomi
- Faculty of Economics of the University of Italian Switzerland, Lugano, Switzerland (A.L.)
| | - Jukka-Pekka Onnela
- Department of Biostatistics at the Harvard T.H. Chan School of Public Health, Boston, MA (J.P.O.)
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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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10
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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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11
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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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Daly M, Cummings C, Kittell M, Dubuque A, Plante L, Linares G, Wolfson D. Validation of field assessment stroke triage for emergency destination for prehospital use in a rural EMS system. Am J Emerg Med 2021; 50:178-182. [PMID: 34371326 DOI: 10.1016/j.ajem.2021.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/15/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Field Assessment Stroke Triage for Emergency Destination (FAST-ED) is a simple and accurate prehospital stroke severity scale that has been shown to have comparable accuracy to the gold standard National Institutes of Health Stroke Scale (NIHSS) but requires further field validation for use by emergency medical services (EMS), particularly in rural systems. FAST-ED scores ≥4 are considered high probability for large vessel occlusion (LVO) strokes, while scores <4 are low to moderate probability for LVO. The objective of this study was to assess inter-rater reliability of the EMS FAST-ED (EMS) score to the emergency department FAST-ED (ED-MD) scores. METHODS EMS calculated FAST-ED scores prior to transport to the emergency department (ED) on patients with a positive prehospital stroke screen. EDMD calculated FAST-ED scores for the same patients upon arrival to the ED. Interrater reliability and test characteristics were calculated. RESULTS A total of 95 patients were included in this study and 14 were subsequently diagnosed with an LVO. EMS assigned 34 patients (35.8%) a FAST-ED score of ≥4. EDMD assigned 25 patients (26.3%) a FAST-ED score of ≥4. Using the clinical cut-points of FAST-ED scores <4 and ≥ 4, a linearly weighted Cohen's kappa coefficient showed moderate interrater reliability when comparing EMS and EDMD scores (kw 0.44, 95% CI 0.25-0.63). At ≥4, EMS FAST-ED scores had a sensitivity 0.48, specificity 0.75, PPV 0.62, NPV 0.62 for predicting an LVO, while EDMD FAST-ED scores had a sensitivity 0.36, specificity 0.82, PPV 0.64, NPV 0.60. Comparable receiver operator curve area under the curve values were obtained. CONCLUSIONS EMS and EDMD FAST-ED scores were moderately comparable in a rural EMS system. Similar NPVs compared to EDMD suggest the use of FAST-ED as an appropriate screening tool for EMS to predict the probability of LVO in the prehospital setting and make destination determinations regarding primary transport to a thrombectomy-capable stroke center.
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Affiliation(s)
- Madison Daly
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America.
| | - Cori Cummings
- Medical University of South Carolina, Department of Neurology, Charleston, SC, United States of America
| | - Miles Kittell
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
| | - Amy Dubuque
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
| | - Laurel Plante
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
| | - Guillermo Linares
- Saint Louis University School of Medicine, Department of Neurology, Saint Louis, MO, United States of America
| | - Daniel Wolfson
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
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13
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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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14
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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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15
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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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16
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Aldstadt J, Waqas M, Yasumiishi M, Mokin M, Tutino VM, Rai HH, Chin F, Levy BR, Rai AT, Mocco J, Snyder KV, Davies JM, Levy EI, Siddiqui AH. Mapping access to endovascular stroke care in the USA and implications for transport models. J Neurointerv Surg 2021; 14:neurintsurg-2020-016942. [PMID: 33593798 DOI: 10.1136/neurintsurg-2020-016942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/12/2021] [Accepted: 01/19/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The purpose of this cross-sectional study was to determine the percentage of the US population with 60 min ground or air access to accredited or state-designated endovascular-capable stroke centers (ECCs) and non-endovascular capable stroke centers (NECCs) and the percentage of NECCs with an ECC within a 30 min drive. METHODS Stroke centers were identified and classified broadly as ECCs or NECCs. Geographic mapping of stroke centers was performed. The population was divided into census blocks, and their centroids were calculated. Fastest air and ground travel times from centroid to nearest ECC and NECC were estimated. RESULTS Overall, 49.6% of US residents had 60 min ground access to ECCs. Approximately 37.7% (113 million) lack 60 min ground or air access to ECCs. Approximately 84.4% have 60 min access to NECCs. Ground-only access was available to 77.9%. Approximately 738 NECCs (45.4%) had an ECC within a 30 min drive. CONCLUSION Nearly one-third of the US population lacks 60 min access to endovascular stroke care, but this is highly variable. Transport models and planning of additional centers should be tailored to each state depending on location and proximity of existing facilities.
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Affiliation(s)
- Jared Aldstadt
- National Center for Geographic Information and Analysis and Department of Geography, University at Buffalo - The State University of New York, Buffalo, New York, USA
| | - Muhammad Waqas
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Misa Yasumiishi
- National Center for Geographic Information and Analysis and Department of Geography, University at Buffalo - The State University of New York, Buffalo, New York, USA
| | - Maxim Mokin
- Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA.,Neurosciences Center, Tampa General Hospital, Tampa, Florida, USA
| | - Vincent M Tutino
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,University at Buffalo Canon Stroke and Vascular Research Center, Buffalo, New York, USA
| | - Hamid H Rai
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Felix Chin
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Bennett R Levy
- (Medical school student), The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - J Mocco
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kenneth V Snyder
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA.,Neurosurgery and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Jason M Davies
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA.,Neurosurgery and Bioinformatics and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Elad I Levy
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA .,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
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17
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Abstract
Ischemic stroke is a leading cause of death and major disability that impacts societies across the world. Earlier thrombolysis of blocked arteries with intravenous tissue plasminogen activator (tPA) and/or endovascular clot extraction is associated with better clinical outcomes. Mobile stroke units (MSU) can deliver faster tPA treatment and rapidly transport stroke patients to centers with endovascular capabilities. Initial MSU trials in Germany indicated more rapid tPA treatment times using MSUs compared with standard emergency room treatment, a higher proportion of patients treated within 60 minutes of stroke onset, and a trend toward better 3-month clinical outcomes with MSU care. In the United States, the first multicenter, randomized clinical trial comparing standard versus MSU treatment began in 2014 in Houston, TX, and has demonstrated feasibility and safety of MSU operations, reliability of telemedicine technology to assess patients for tPA eligibility without additional time delays, and faster door-to-groin puncture times of MSU patients needing endovascular thrombectomy in interim analysis. Scheduled for completion in 2021, this trial will determine the cost-effectiveness and benefit of MSU treatment on clinical outcomes compared with standard ambulance and hospital treatment. Beyond ischemic stroke, MSUs have additional clinical and research applications that can profoundly impact other cohorts of patients who require time-sensitive neurological care.
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Affiliation(s)
- Ritvij Bowry
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center-Houston, Houston, Texas
| | - James C Grotta
- Mobile Stroke Unit and Stroke Research, Clinical Innovation and Research Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
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18
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Rabinovich EP, Capek S, Kumar JS, Park MS. Tele-robotics and artificial-intelligence in stroke care. J Clin Neurosci 2020; 79:129-132. [PMID: 33070881 DOI: 10.1016/j.jocn.2020.04.125] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/13/2020] [Indexed: 01/17/2023]
Abstract
In the last forty years, the field of medicine has experienced dramatic shifts in technology-enhanced surgical procedures - from its initial use in 1985 for neurosurgical biopsies to current implementation of systems such as magnetic-guided catheters for endovascular procedures. Systems such as the Niobe Magnetic Navigation system and CorPath GRX have allowed for utilization of a fully integrated surgical robotic systems for perioperative manipulation, as well as tele-controlled manipulation systems for telemedicine. These robotic systems hold tremendous potential for future implementation in cerebrovascular procedures, but lack of relevant clinical experience and uncharted ethical and legal territory for real-life tele-robotics have stalled their adoption for neurovascular surgery, and might present significant challenges for future development and widespread implementation. Yet, the promise that these technologies hold for dramatically improving the quality and accessibility of cerebrovascular procedures such as thrombectomy for acute stroke, drives the research and development of surgical robotics. These technologies, coupled with artificial intelligence (AI) capabilities such as machine learning, deep-learning, and outcome-based analyses and modifications, have the capability to uncover new dimensions within the realm of cerebrovascular surgery.
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Affiliation(s)
- Emily P Rabinovich
- University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - Stepan Capek
- Department of Neurological Surgery, University of Virginia, 1215 Lee Street, Charlottesville, VA 22908, USA; 2nd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Jeyan S Kumar
- Department of Neurological Surgery, University of Virginia, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - Min S Park
- Department of Neurological Surgery, University of Virginia, 1215 Lee Street, Charlottesville, VA 22908, USA.
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19
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Shen C, Zhou Z, Lai S, Lu L, Dong W, Su M, Zhang J, Wang X, Deng Q, Chen Y, Chen X. Measuring spatial accessibility and within-province disparities in accessibility to county hospitals in Shaanxi Province of Western China based on web mapping navigation data. Int J Equity Health 2020; 19:99. [PMID: 32552715 PMCID: PMC7302366 DOI: 10.1186/s12939-020-01217-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Chinese government proposed the "XIAO BING BU CHU CUN, DA BING BU CHU XIAN" initiative in 2016, which states the rate of health care service provided by county hospitals should reach 90% of overall health care service provision. The prerequisite for achieving this goal is that citizens should be able to access county hospitals' services conveniently and impartially. However, little research has been done on the actual levels of the spatial accessibility of citizens to county hospitals in Western China. Therefore, we aimed to measure the spatial accessibility to county hospitals for county residents and to identify any regional disparities in Shaanxi Province in Western China. METHODS We implemented a novel method - involving utilizing navigation data from the AutoNavi web mapping system (knows as Gaode map in Chinese) - to assess the time and distance from villages and neighborhoods to the county hospitals. The navigation data were collected by request through an application-programming-interface using a web crawler (web data extraction tool) in Python. The shortest driving time and distance were extracted from the navigation data. The travel impedance to the nearest provider (TINP) indicator was used to measure spatial accessibility. RESULTS The results show that county residents in Western China's Shaanxi Province have poor spatial accessibility to county hospitals. Only 68.8% of villages and neighborhoods are within 60 min travel time (based on driving mode) to a county hospital, while 13.4% of such villages and neighborhoods are beyond 90 min travel time. Moreover, a significant within-province disparity exists, with residents in the central area enjoying the best accessibility to county hospitals, while the northern and southern areas still need improvements in accessibility. CONCLUSIONS Focused health resource planning is required to improve the spatial accessibility to county hospitals and to eliminate regional disparities. Further studies are called for to integrate the navigation data of web mapping systems with GIS methods to the measure spatial accessibility of health facilities in more complex contexts.
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Affiliation(s)
- Chi Shen
- School of Public Policy and Administration, Xi'an Jiaotong University, No.28 Xianning West Road, Xi'an, 710049, Shaanxi, China
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi'an Jiaotong University, No.28 Xianning West Road, Xi'an, 710049, Shaanxi, China.
| | - Sha Lai
- School of Public Policy and Administration, Xi'an Jiaotong University, No.28 Xianning West Road, Xi'an, 710049, Shaanxi, China
| | - Li Lu
- Team IETO, Bordeaux Population Health Research Center, University de Bordeaux, 33076, Bordeaux, France
| | - Wanyue Dong
- School of Public Health, Health Science Center, Xi'an Jiaotong University, Xi'an, 710063, China
| | - Min Su
- School of Public Administration, Inner Mongolia University, Hohhot, 010021, China
| | - Jian Zhang
- School of Public Policy and Administration, Xi'an Jiaotong University, No.28 Xianning West Road, Xi'an, 710049, Shaanxi, China
| | - Xinyu Wang
- School of Public Health, Health Science Center, Xi'an Jiaotong University, Xi'an, 710063, China
| | - Qiwei Deng
- School of Public Health, Health Science Center, Xi'an Jiaotong University, Xi'an, 710063, China
| | - Yaru Chen
- Centre for HealthCare Innovation Research, Cass Business School & School of Health Sciences, City, University of London, London, EC1V 0HB, UK
| | - Xi Chen
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, 06520, USA
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20
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Spatial distribution and differences of stroke occurrence in the Rhone department of France (STROKE 69 cohort). Sci Rep 2020; 10:9910. [PMID: 32555403 PMCID: PMC7303109 DOI: 10.1038/s41598-020-67011-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 05/07/2020] [Indexed: 11/26/2022] Open
Abstract
In France, 110,000 patients are admitted to hospital per year for stroke. Even though the relationship between stroke and risk factors such as low socio-economic status is well known, research in the spatial distribution (SD) of stroke as a contributing risk factor is less documented. Understanding the geographic differences of the disease may improve stroke prevention. In this study, a statistical spatial analysis was performed using a French cohort (STROKE 69) to describe spatial inequalities in the occurrence of stroke. STROKE 69 was a cohort study of 3,442 patients, conducted in the Rhône department of France, from November 2015 to December 2016. The cohort included all consecutive patients aged 18 years or older, with a likelihood of acute stroke within 24 hours of symptoms onset. Patients were geolocated, and incidence standardized rates ratio were estimated. SD models were identified using global spatial autocorrelation analysis and cluster detection methods. 2,179 patients were selected for analysis with spatial autocorrelation methods, including 1,467 patients with stroke, and 712 with a transient ischemic attack (TIA). Within both cluster detection methods, spatial inequalities were clearly visible, particularly in the northern region of the department and western part of the metropolitan area where rates were higher. Geographic methods for SD analysis were suitable tools to explain the spatial occurrence of stroke and identified potential spatial inequalities. This study was a first step towards understanding SD of stroke. Further research to explain SD using socio-economic data, care provision, risk factors and climate data is needed in the future.
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21
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Abstract
Mechanical thrombectomy (MT) has revolutionized the treatment of large-vessel occlusion stroke and markedly improved patient outcomes. Unfortunately, there remains a large proportion of patients that do not benefit from this technology. This review takes a look at recent and upcoming technologies that may help to increase the number of MT-treated patients, thereby improving their outcomes. To that end, an overview of digital health solutions, innovative pharmacological treatment, and futuristic robotic endovascular interventions is provided.
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Affiliation(s)
- Eitan Abergel
- Invasive Neuroradiology Unit, Rambam Health Care Campus, Haifa, Israel
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22
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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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23
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Ajinkya S, Almallouhi E, Turner N, Al Kasab S, Holmstedt CA. Racial/Ethnic Disparities in Acute Ischemic Stroke Treatment Within a Telestroke Network. Telemed J E Health 2019; 26:1221-1225. [PMID: 31755828 DOI: 10.1089/tmj.2019.0127] [Citation(s) in RCA: 18] [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 growth of telestroke services expanded the reach of acute stroke treatment. However, ethnic disparities in receiving such treatment have not been fully assessed. Materials and Methods: We reviewed prospectively maintained data on patients evaluated through the Medical University of South Carolina telestroke program between January 2016 and November 2018. Outcomes included odds of receiving intravenous recombinant tissue plasminogen activator (tPA), receiving mechanical thrombectomy (MT), and achieving door-to-needle (DTN) time ≤60 and ≤45 min among patients receiving tPA. We used logistic regression to analyze the contribution of race/ethnicity. Results: We included 2,977 patients, of whom 1,093 (36.7%) identified as nonwhite; of these, 1,048 patients (95.9%) identified as black or African American. Significantly more nonwhite patients were seen at a primary stroke center (PSC) (68.4% vs. 52.3% in whites, p < 0.001). However, white patients had significantly higher odds of receiving tPA (odds ratio [OR] 1.47, confidence interval [95% CI] 1.17-1.84). There was no significant difference in receiving MT between races. Among patients receiving tPA, whites had higher odds of DTN ≤45 min (OR 1.76, 1.20-2.57) and ≤60 min (OR 1.87, 95% CI 1.31-2.66). Conclusions: White patients had better odds achieving DTN ≤45 min and DTN ≤60 min if receiving tPA within a telestroke setting, as well as higher odds of receiving tPA, even after adjustment for comorbidities. This was noted despite white patients having less access to PSCs. However, larger scale studies are needed to further study the impact of ethnic disparities.
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Affiliation(s)
- Shaun Ajinkya
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nancy Turner
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sami Al Kasab
- Department of Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Christine A Holmstedt
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
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24
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Hall EW, Vaughan AS, Ritchey MD, Schieb L, Casper M. Stagnating National Declines in Stroke Mortality Mask Widespread County-Level Increases, 2010-2016. Stroke 2019; 50:3355-3359. [PMID: 31694505 DOI: 10.1161/strokeaha.119.026695] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background and Purpose- Recent national and state-level trends show a stalling or reversal of previously declining stroke death rates. These national trends may mask local geographic variation and changes in stroke mortality. We assessed county-level trends in stroke mortality among adults aged 35 to 64 and ≥65 years. Methods- We used data from National Vital Statistics Systems and a Bayesian multivariate space-time conditional autoregressive model to estimate age-standardized annual stroke death rates for 2010 through 2016 among middle-aged adults (35-64 years) and older adults (≥65 years) in US counties. We used log-linear regression models to estimate average annual and total percent change in stroke mortality during the period. Results- Nationally, the annual percent change in stroke mortality from 2010 to 2016 was -0.7% (95% CI, -4.2% to 3.0%) among middle-aged adults and -3.5% (95% CI, -10.7% to 4.3%) among older adults, resulting in 2016 rates of 15.0 per 100 000 and 259.8 per 100 000, respectively. Increasing county-level stroke mortality was more prevalent among middle-aged adults (56.6% of counties) compared with among older adults (26.1% of counties). About half (48.3%) of middle-aged adults, representing 60.2 million individuals, lived in counties in which stroke mortality increased. Conclusions- County-level increases in stroke mortality clarify previously reported national and state-level trends, particularly among middle-aged adults. Roughly 3×as many counties experienced increases in stroke death rates for middle-aged adults compared with older adults. This highlights a need to address stroke prevention and treatment for middle-aged adults while continuing efforts to reduce stroke mortality among the more highly burdened older adults. Efforts to reverse these troubling local trends will likely require joint public health and clinical efforts to develop innovative and integrated approaches for stroke prevention and care, with a focus on community-level characteristics that support stroke-free living for all.
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Affiliation(s)
- Eric W Hall
- From the Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (E.W.H.)
| | - Adam S Vaughan
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (A.S.V., M.D.R., L.S., M.C.)
| | - Matthew D Ritchey
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (A.S.V., M.D.R., L.S., M.C.)
| | - Linda Schieb
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (A.S.V., M.D.R., L.S., M.C.)
| | - Michele Casper
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (A.S.V., M.D.R., L.S., M.C.)
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25
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Swanson MB, Miller AC, Ward MM, Ullrich F, Merchant KA, Mohr NM. Emergency department telemedicine consults decrease time to interpret computed tomography of the head in a multi-network cohort. J Telemed Telecare 2019; 27:343-352. [PMID: 31684801 DOI: 10.1177/1357633x19877746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Telemedicine can improve access to emergency stroke care in rural areas, but the benefit of telemedicine across different types and models of telemedicine networks is unknown. The objectives of this study were to (a) identify the impact of telemedicine on emergency department (ED) stroke care, (b) identify if telemedicine impact varied by network and (c) describe the variation in process outcomes by telemedicine across EDs. METHODS A prospective cohort study identified stroke patients in four telemedicine networks between November 2015 and December 2017. Primary exposure was telemedicine consultation during ED evaluation. Outcomes included: (a) interpretation of computed tomography (CT) of the head within 45 minutes and (b) time to administer tissue plasminogen activator (tPA). An interaction term tested for differences in telemedicine effect on stroke care by network and hospital. RESULTS Of the 932 stroke subjects, 36% received telemedicine consults. For subjects with a last known well time within two hours of ED arrival (27.9%), recommended CT interpretation within 45 minutes was met for 66.8%. Telemedicine was associated with higher odds of timely head CT interpretation (adjusted odds ratio = 3.03; 95% confidence interval (CI) 1.69-5.46). The magnitude of the association between telemedicine and time to interpret a CT of the head differed between telemedicine networks (interaction term p = 0.033). Among eligible patients, telemedicine was associated with faster time to administer tPA (adjusted hazard ratio = 1.81; 95% CI 1.31-2.50). DISCUSSION Telemedicine consultation during the ED encounter decreased the time to interpret at CT of the head among stroke patients, with differing magnitudes of benefit across telemedicine networks. The effect of heterogeneity of telestroke affects across different networks should be explored in future analyses.
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Affiliation(s)
- Morgan B Swanson
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA.,Department of Epidemiology, Colleges of Medicine and Public Health, University of Iowa, Iowa City, IA, USA
| | - Aspen C Miller
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA
| | - Marcia M Ward
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Fred Ullrich
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Kimberly As Merchant
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA.,Department of Epidemiology, Colleges of Medicine and Public Health, University of Iowa, Iowa City, IA, USA.,Department of Anesthesia, Division of Critical Care, University of Iowa, Iowa City, IA, USA
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Sack KD, Sigounas DG. Getting with the Guidelines for Stroke Triage: Progress Toward Meaningful Change. World Neurosurg 2019; 131:281-282. [PMID: 31658552 DOI: 10.1016/j.wneu.2019.08.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kenneth D Sack
- Department of Neurosurgery, The George Washington University, Washington, D.C., USA
| | - Dimitri G Sigounas
- Department of Neurosurgery, The George Washington University, Washington, D.C., USA
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27
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Asaithambi G, Castle AL, Tipps ME, Ho BM, Marino EH, Hanson SK. Weekday Versus Weekend Presentation in the Acute Management of Ischemic Stroke Through Telemedicine. Neurohospitalist 2019; 10:115-117. [PMID: 32373274 DOI: 10.1177/1941874419878020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A "weekend effect" resulting in higher mortality rates for patients with stroke admitted on weekends has been reported. We examine this phenomenon for patients with acute ischemic stroke (AIS) presenting to telestroke (TS) sites to determine its effect on stroke alert process times and outcomes. From October 2015 to June 2017, we reviewed patients with AIS receiving intravenous alteplase within our TS network. We compared patients presenting to TS sites on weekdays (Monday 07:00 to Friday 18:59) to those presenting on weekends (Friday 19:00 to Monday 06:59). We analyzed door-to-alert activation, alert activation-to-TS evaluation, door-to-imaging, and door-to-needle times. Rates of favorable outcome (modified Rankin Scale score ≤2) and death at 90 days were compared. We identified 89 (54 weekday and 35 weekend) patients (mean age: 71.8 ± 13.3 years, 47.2% women) during the study period. Median door-to-alert activation (P = .01) and door-to-needle (P = .004) times were significantly longer for patients presenting on weekends compared to weekdays. There were no significant differences in median door-to-imaging (P = .1) and alert activation-to-TS evaluation (P = .07) times. Rates of favorable outcome (P = .19) and death (P = .56) at 90 days did not differ. While there were no significant differences in outcomes, patients presenting on weekends had longer door-to-alert activation and door-to-needle times. Efforts to improve methods in efficiency of care on weekends should be considered.
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Affiliation(s)
- Ganesh Asaithambi
- Department of Neurosciences, United Hospital Comprehensive Stroke Center, Part of Allina Health, St Paul, MN, USA
| | - Amy L Castle
- Department of Neurosciences, United Hospital Comprehensive Stroke Center, Part of Allina Health, St Paul, MN, USA
| | - Megan E Tipps
- Department of Neurosciences, United Hospital Comprehensive Stroke Center, Part of Allina Health, St Paul, MN, USA
| | - Bridget M Ho
- Department of Neurosciences, United Hospital Comprehensive Stroke Center, Part of Allina Health, St Paul, MN, USA
| | - Emily H Marino
- Department of Neurosciences, United Hospital Comprehensive Stroke Center, Part of Allina Health, St Paul, MN, USA
| | - Sandra K Hanson
- Department of Neurosciences, United Hospital Comprehensive Stroke Center, Part of Allina Health, St Paul, MN, USA
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Girkar UM, Palacios R, Gupta A, Schwamm LH, Singla P, May H, Estrada J, Whitney C, Matiello M. Teleneurology Consultations for Prognostication and Brain Death Diagnosis. Telemed J E Health 2019; 26:482-486. [PMID: 31503539 DOI: 10.1089/tmj.2019.0033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The diagnosis of brain death and the determination of neurologic prognosis following cardiac arrest are important reasons for neurology consultation in the intensive care unit. In hospitals without access to neurology consultation, it may be challenging to address these important questions with high reliability in a timely manner. The American Academy of Neurology has established consensus criteria for diagnosis of brain death, which include (i) comatose state; (ii) presence of apnea; and (iii) absence of brainstem reflexes in the setting of a diagnosis of underlying brain injury compatible with brain death. It has recently been shown that virtual assessment of coma using standardized scales is feasible with good inter-rater reliability. The supervision of apnea testing and the neurologic examination of the brainstem by a remote neurologist are possible if conducted in conjunction with a well-trained and experienced bedside team. In this communication, we explore the essential clinical and legal framework that can support using virtual teleconsultations to address this complex topic.
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Affiliation(s)
- Uma M Girkar
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Boston, Massachusetts
| | - Rafael Palacios
- Institute for Research in Technology, Pontifical Comillas University, Madrid, Spain.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Boston, Massachusetts
| | - Amar Gupta
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Boston, Massachusetts
| | - Lee H Schwamm
- Center for TeleHealth Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Pooja Singla
- SOAR Management Consulting Group, Brookline, Massachusetts
| | - Hanna May
- Computer Science Department, Wellesley College, Wellesley, Massachusetts
| | - Juan Estrada
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Cindy Whitney
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Marcelo Matiello
- Harvard Medical School, Harvard University, Boston, Massachusetts.,Neurology Inpatient Services, Massachusetts General Hospital, Boston, Massachusetts
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Shen YC, Chen G, Hsia RY. Community and Hospital Factors Associated With Stroke Center Certification in the United States, 2009 to 2017. JAMA Netw Open 2019; 2:e197855. [PMID: 31348507 PMCID: PMC6661722 DOI: 10.1001/jamanetworkopen.2019.7855] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The increased number of stroke centers in the United States may not be equitably distributed across all populations. Anecdotal reports suggest there may be differential proliferation in wealthier and urban communities. OBJECTIVE To examine hospital characteristics and economic conditions of communities surrounding hospitals with and without stroke centers. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all general, short-term, acute hospitals in the continental United States and used merged data from the Joint Commission, Det Norske Veritas, Healthcare Facilities Accreditation Program, state health departments, the Centers for Medicare & Medicaid Services, the American Hospital Association, the Dartmouth Atlas of Health Care, and the US Census Bureau from January 1, 2009, to September 30, 2017, to compare hospital and community characteristics of stroke-certified and non-stroke-certified hospitals and assessed characteristics of early and late adopters of stroke certification. MAIN OUTCOMES AND MEASURES Stroke center certification was the primary outcome. Risk factors were grouped into 3 categories: economic and financial, hospital, and community characteristics. Survival analyses were performed using a Cox proportional hazards regression model. RESULTS The study included 4546 US hospitals. During the study period, 1689 hospitals (37.2%) were stroke certified (961 adopted certification on or before January 1, 2009, 728 afterward). After controlling for other area and hospital characteristics, hospitals in low-income hospital service areas and the lower tertile of profit-margin distribution were less likely to adopt stroke certification (hazard ratio [HR], 0.62; 95% CI, 0.52-0.74 and HR, 0.87; 95% CI, 0.78-0.98, respectively). Urban hospitals had a higher likelihood of stroke certification than rural hospitals (HR, 12.79; 95% CI, 10.64-15.37). CONCLUSIONS AND RELEVANCE This study found that stroke centers have proliferated unevenly across geographic localities, where hospitals in high-income hospital service areas and with higher profit margins have a greater likelihood of being stroke certified. These findings suggest that market-driven factors may be associated with stroke center certification.
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Affiliation(s)
- Yu-Chu Shen
- Graduate School of Business and Public Policy, Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | | | - Renee Y. Hsia
- Department of Emergency Medicine, University of California at San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco
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Patel MD, Honvoh G, Fernandez AR, Cadena R, Kelly ER, McDaniel P, Brice JH. Availability of Hospital Resources and Specialty Services for Stroke Care in North Carolina. South Med J 2019; 112:331-337. [PMID: 31158888 DOI: 10.14423/smj.0000000000000986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Effective regionalization of acute stroke care requires assessment and coordination of limited hospital resources. We described the availability of stroke-specific hospital resources (neurology specialty physicians and neuro-intensive care unit [neuro-ICU] bed capacity) for North Carolina overall and by region and population density. We also assessed daily trends in hospital bed availability. METHODS This statewide descriptive study was conducted with data from the State Medical Asset Resource Tracking Tool (SMARTT), a Web-based system used by North Carolina to track available medical resources within the state. The SMARTT system was queried for stroke-specific physician and bed resources at each North Carolina hospital during a 1-year period (June 2015-May 2016), including daily availability of neuro-ICU beds. We compared hospital resources by geographic region and population density (metropolitan, urban, and rural). RESULTS Data from 108 acute care hospitals located in 75 of 100 counties in North Carolina were included in the analysis. Fifty-seven percent of hospitals had no neurology specialty physicians. Western and eastern North Carolina had the lowest prevalence of these physicians. Most hospitals (88%) had general ICUs, whereas only 17 hospitals (16%) had neuro-ICUs. Neuro-ICUs were concentrated in metropolitan areas and in central North Carolina. On average, there were 276 general ICU and 27 neuro-ICU beds available statewide each day. Daily neuro-ICU bed availability was lowest in eastern and southeastern regions and during the week compared with weekends. CONCLUSIONS In North Carolina, stroke-specific hospital subspecialists and resources are not distributed evenly across the state. Daily bed availability, particularly in neuro-ICUs, is lacking in rural areas and noncentral regions and appears to decrease on weekdays. Regionalization of stroke care needs to consider the geographic distribution and daily variability of hospital resources.
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Affiliation(s)
- Mehul D Patel
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Gilson Honvoh
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Antonio R Fernandez
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Rhonda Cadena
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Emma R Kelly
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Philip McDaniel
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
| | - Jane H Brice
- From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill
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31
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Jasne AS, Sucharew H, Alwell K, Moomaw CJ, Flaherty ML, Adeoye O, Woo D, Mackey J, Ferioli S, Martini S, de Los Rios la Rosa F, Kissela BM, Kleindorfer D. Stroke Center Certification Is Associated With Improved Guideline Concordance. Am J Med Qual 2019; 34:585-589. [PMID: 30868922 DOI: 10.1177/1062860619835317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Measurement of quality of stroke care has become increasingly important, but data come mostly from programs in hospitals that choose to participate in certification programs, which may not be representative of the care provided in nonparticipating hospitals. The authors sought to determine differences in quality of care metric concordance for acute ischemic stroke among hospitals designated as a primary stroke center, comprehensive stroke center, and non-stroke center in a population-based epidemiologic study. Significant differences were found in both patient demographics and in concordance with guideline-based quality metrics. These differences may help inform quality improvement efforts across hospitals involved in certification as well as those that are not.
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Affiliation(s)
| | - Heidi Sucharew
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | | | | | - Daniel Woo
- University of Cincinnati, Cincinnati, OH
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32
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Mathur S, Walter S, Grunwald IQ, Helwig SA, Lesmeister M, Fassbender K. Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units. Front Neurol 2019; 10:159. [PMID: 30881334 PMCID: PMC6407433 DOI: 10.3389/fneur.2019.00159] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/07/2019] [Indexed: 12/11/2022] Open
Abstract
In acute stroke management, time is brain, as narrow therapeutic windows for both intravenous thrombolysis and mechanical thrombectomy depend on expedient and specialized treatment. In rural settings, patients are often far from specialized treatment centers. Concurrently, financial constraints, cutting of services and understaffing of specialists for many rural hospitals have resulted in many patients being underserved. Mobile Stroke Units (MSU) provide a valuable prehospital resource to rural and remote settings where patients may not have easy access to in-hospital stroke care. In addition to standard ambulance equipment, the MSU is equipped with the necessary tools for diagnosis and treatment of acute stroke or similar emergencies at the emergency site. The MSU strategy has proven to be effective at facilitating time-saving stroke triage decisions. The additional on-board imaging helps to determine whether a patient should be taken to a primary stroke center (PSC) for standard treatment or to a comprehensive stroke center (CSC) for advanced stroke treatment (such as intra-arterial therapy) instead. Diagnosis at the emergency site may prevent additional in-hospital delays in workup, handover and secondary (inter-hospital) transport. MSUs may be adapted to local needs-especially in rural and remote settings-with adjustments in staffing, ambulance configuration, and transport models. Further, with advanced imaging and further diagnostic capabilities, MSUs provide a valuable platform for telemedicine (teleradiology and telestroke) in these underserved areas. As MSU programmes continue to be implemented across the world, optimal and adaptable configurations could be explored.
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Affiliation(s)
- Shrey Mathur
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
- Neuroscience Unit, Faculty of Medicine, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Iris Q. Grunwald
- Neuroscience Unit, Faculty of Medicine, Anglia Ruskin University, Chelmsford, United Kingdom
- Department of Medicine, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, United Kingdom
| | - Stefan A. Helwig
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Martin Lesmeister
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
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33
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Kapral MK, Austin PC, Jeyakumar G, Hall R, Chu A, Khan AM, Jin AY, Martin C, Manuel D, Silver FL, Swartz RH, Tu JV. Rural-Urban Differences in Stroke Risk Factors, Incidence, and Mortality in People With and Without Prior Stroke. Circ Cardiovasc Qual Outcomes 2019; 12:e004973. [DOI: 10.1161/circoutcomes.118.004973] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Moira K. Kapral
- Division of General Internal Medicine, Department of Medicine (M.K.K., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Peter C. Austin
- Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Geerthana Jeyakumar
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland (G.J.)
| | - Ruth Hall
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Anna Chu
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Anam M. Khan
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Albert Y. Jin
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada (A.Y.J.)
| | - Cally Martin
- Kingston Health Sciences Centre, Kingston, Ontario, Canada (C.M.)
| | - Doug Manuel
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.M.)
| | - Frank L. Silver
- Division of Neurology, Department of Medicine (F.L.S., R.H.S.), University of Toronto, Toronto, Ontario, Canada
| | - Richard H. Swartz
- Division of Neurology, Department of Medicine (F.L.S., R.H.S.), University of Toronto, Toronto, Ontario, Canada
| | - Jack V. Tu
- Division of General Internal Medicine, Department of Medicine (M.K.K., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
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Ruiz-Pérez I, Bastos Á, Serrano-Ripoll MJ, Ricci-Cabello I. Effectiveness of interventions to improve cardiovascular healthcare in rural areas: a systematic literature review of clinical trials. Prev Med 2019; 119:132-144. [PMID: 30597226 DOI: 10.1016/j.ypmed.2018.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 12/11/2018] [Accepted: 12/16/2018] [Indexed: 12/16/2022]
Abstract
The objective of this systematic literature review is to examine the impact of interventions to improve cardiovascular disease healthcare provided to people living in rural areas. Systematic electronic searches were conducted in Medline, CINAHL, Embase, Scopus, and Web of Knowledge in July 2018. We included clinical trials assessing the effectiveness of interventions to improve cardiovascular disease healthcare in rural areas. Study eligibility assessment, data extraction, and critical appraisal were undertaken by two reviewers independently. We identified 18 trials (18 interventions). They targeted myocardial infarction (five interventions), stroke (eight), and heart failure (five). All the interventions for myocardial infarction were based on organizational changes (e.g. implementation of mobile coronary units). They consistently reduced time to treatment and decreased mortality. All the interventions for heart failure were based on the provision of patient education. They consistently improved patient knowledge and self-care behaviour, but mortality reductions were reported in only some of the trials. Among the interventions for stroke, those based on the implementation of telemedicine (tele-stroke systems or tele-consultations) improved monitoring of stroke survivors; those based on new or enhanced rehabilitation services did not consistently improve mortality or physical function; whereas educational interventions effectively improved patient knowledge and behavioural outcomes. In conclusion, a number of different strategies (based on enhancing structures and providing patient education) have been proposed to improve cardiovascular disease healthcare in rural areas. Although available evidence show that these interventions can improve healthcare processes, their impact on mortality and other important health outcomes still remains to be established.
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Affiliation(s)
- Isabel Ruiz-Pérez
- Andalusian School of Public Health, Cuesta del Observatorio, 4, 18011 Granada, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Spain; Ibs. Instituto de Investigación Biosanitaria de Granada, Spain.
| | - Ángel Bastos
- Andalusian School of Public Health, Cuesta del Observatorio, 4, 18011 Granada, Spain
| | - Maria Jesús Serrano-Ripoll
- Balearic Islands Health Research Institute (IdISBa), Spain; Atención Primaria Mallorca, IB-Salut, Spain; Universitat de les Illes Balears (UIB), Departament de Psicologia, Spain
| | - Ignacio Ricci-Cabello
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Spain; Balearic Islands Health Research Institute (IdISBa), Spain; Atención Primaria Mallorca, IB-Salut, Spain
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35
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Dodson ZM, Enki Yoo EH, Martin-Gill C, Roth R. Spatial Methods to Enhance Public Health Surveillance and Resource Deployment in the Opioid Epidemic. Am J Public Health 2018; 108:1191-1196. [PMID: 30024793 DOI: 10.2105/ajph.2018.304524] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To improve public health surveillance and response by using spatial optimization. METHODS We identified cases of suspected nonfatal opioid overdose events in which naloxone was administered from April 2013 through December 2016 treated by the city of Pittsburgh, Pennsylvania, Bureau of Emergency Medical Services. We used spatial modeling to identify areas hardest hit to spatially optimize naloxone distribution among pharmacies in Pittsburgh. RESULTS We identified 3182 opioid overdose events with our classification approach, which generated spatial patterns of opioid overdoses within Pittsburgh. We then used overdose location to spatially optimize accessibility to naloxone via pharmacies in the city. Only 24 pharmacies offered naloxone at the time, and only 3 matched with our optimized solution. CONCLUSIONS Our methodology rapidly identified communities hardest hit by the opioid epidemic with standard public health data. Naloxone accessibility can be optimized with established location-allocation approaches. Public Health Implications. Our methodology can be easily implemented by public health departments for automated surveillance of the opioid epidemic and has the flexibility to optimize a variety of intervention strategies.
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Affiliation(s)
- Zan M Dodson
- Zan M. Dodson is with the Public Health Dynamics Laboratory, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Eun-Hye Enki Yoo is with the Department of Geography, State University of New York at Buffalo. Christian Martin-Gill and Ronald Roth are with the Department of Emergency Medicine, University of Pittsburgh
| | - Eun-Hye Enki Yoo
- Zan M. Dodson is with the Public Health Dynamics Laboratory, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Eun-Hye Enki Yoo is with the Department of Geography, State University of New York at Buffalo. Christian Martin-Gill and Ronald Roth are with the Department of Emergency Medicine, University of Pittsburgh
| | - Christian Martin-Gill
- Zan M. Dodson is with the Public Health Dynamics Laboratory, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Eun-Hye Enki Yoo is with the Department of Geography, State University of New York at Buffalo. Christian Martin-Gill and Ronald Roth are with the Department of Emergency Medicine, University of Pittsburgh
| | - Ronald Roth
- Zan M. Dodson is with the Public Health Dynamics Laboratory, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Eun-Hye Enki Yoo is with the Department of Geography, State University of New York at Buffalo. Christian Martin-Gill and Ronald Roth are with the Department of Emergency Medicine, University of Pittsburgh
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36
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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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37
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Bernetti L, Nuzzaco G, Muscia F, Gamboni A, Zedde M, Eusebi P, Zampolini M, Corea F. Stroke networks and telemedicine: An Italian national survey. Neurol Int 2018; 10:7599. [PMID: 29844893 PMCID: PMC5937223 DOI: 10.4081/ni.2018.7599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 02/19/2018] [Accepted: 02/24/2018] [Indexed: 11/23/2022] Open
Abstract
Stroke is the leading cause of disability and death. Nowadays, clinical benefits of stroke units and thrombolysis in ischemic stroke are evidence-based. Also the benefit of endovascular treatment for acute ischemic stroke has been established. Telemedicine has been used to improve access to care by allowing a neurologist at a remote location to interact with the patient and their family members. Prior studies have shown that the use of telemedicine for acute ischemic stroke is not only safe and effective, but it also increases the utilization of tPA, improving patient outcomes. This study aimed to investigate the diffusion of telemedicine in Italian stroke networks with an online questionnaire to assess: type of stroke care setting, Volume of thrombolysis- thrombectomy/year, access to stroke care between different hospitals, the presence of imaging sharing protocols within the network or patients dispatchment screening; type of network solutions. We have interviewed 24 Italian neurologists, working in large urban areas, from north southward, including Italian islands. In particular, these neurologists represented 14 different regions and 20 countries. A majority of neurologists replying to the survey (47.83%) worked in large general hospitals or smaller general hospitals (26%) and a smaller number of physicians (17.3%) were committed in University Hospital or (8.7%) independent foundation hospitals. The 60.87% of stroke networks involved in the survey had a low thrombolysis/year volume while the 30.43% had a thrombolysis/year volume above 100. According to the survey a local stroke network was established in 87.50% of cases. In the 45.83% of cases, the hospitals care is not homogeneous within the network. A network for the consultation of neuroimaging between hospitals is available in 33.33% of cases. Whitin those describing an active network for Teleconsult the 57.14% used personal devices, while only the 25 % use professional teleconference system, and in 25% of cases used medical devices. Our findings demonstrated a relevant diffusion of Teleconsult in Italian stroke networks. The systems adopted are mostly individual solutions not integrated in protocolled pathways. These findings may encourage a systematization of Telemedicine medical curricula to increase larger access to neurological consults.
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Affiliation(s)
- Laura Bernetti
- Neurologic Clinic, Department of Medicine, University of Perugia.,Stroke and Neurology Units, San Giovanni Battista Hospital, Foligno
| | | | | | - Alessio Gamboni
- Emergency Department, San Giovanni Battista Hospital, Foligno
| | | | - Paolo Eusebi
- Neurologic Clinic, Department of Medicine, University of Perugia
| | - Mauro Zampolini
- Stroke and Neurology Units, San Giovanni Battista Hospital, Foligno
| | - Francesco Corea
- Stroke and Neurology Units, San Giovanni Battista Hospital, Foligno
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Freyssenge J, Renard F, Schott AM, Derex L, Nighoghossian N, Tazarourte K, El Khoury C. Measurement of the potential geographic accessibility from call to definitive care for patient with acute stroke. Int J Health Geogr 2018; 17:1. [PMID: 29329535 PMCID: PMC5767021 DOI: 10.1186/s12942-018-0121-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/06/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The World Health Organization refers to stroke, the second most frequent cause of death in the world, in terms of pandemic. Present treatments are only effective within precise time windows. Only 10% of thrombolysis patients are eligible. Late assessment of the patient resulting from admission and lack of knowledge of the symptoms is the main explanation of lack of eligibility. METHODS The aim is the measurement of the time of access to treatment facilities for stroke victims, using ambulances (firemen ambulances or EMS ambulances) and private car. The method proposed analyses the potential geographic accessibility of stroke care infrastructure in different scenarios. The study allows better considering of the issues inherent to an area: difficult weather conditions, traffic congestion and failure to respect the distance limits of emergency transport. RESULTS Depending on the scenario, access times vary considerably within the same commune. For example, between the first and the second scenario for cities in the north of Rhône county, there is a 10 min difference to the nearest Primary Stroke Center (PSC). For the first scenario, 90% of the population is 20 min away of the PSC and 96% for the second scenario. Likewise, depending on the modal vector (fire brigade or emergency medical service), overall accessibility from the emergency call to admission to a Comprehensive Stroke Center (CSC) can vary by as much as 15 min. CONCLUSIONS The setting up of the various scenarios and modal comparison based on the calculation of overall accessibility makes this a new method for calculating potential access to care facilities. It is important to take into account the specific pathological features and the availability of care facilities for modelling. This method is innovative and recommendable for measuring accessibility in the field of health care. This study makes possible to highlight the patients' extension of care delays. Thus, this can impact the improvement of patient care and rethink the healthcare organization. Stroke is addressed here but it is applicable to other pathologies.
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Affiliation(s)
- J. Freyssenge
- Univ. Lyon, University Claude Bernard Lyon 1, HESPER EA 7425, 69008 Lyon, France
- Emergency Department and RESCUe Network, Lucien Hussel Hospital, Vienne, 38200 France
- UMR 5600 Environnement Ville Société CNRS, University Jean Moulin Lyon 3, 18, rue Chevreul, 69007 Lyon, France
| | - F. Renard
- UMR 5600 Environnement Ville Société CNRS, University Jean Moulin Lyon 3, 18, rue Chevreul, 69007 Lyon, France
| | - A. M. Schott
- Univ. Lyon, University Claude Bernard Lyon 1, HESPER EA 7425, 69008 Lyon, France
- Pôle IMER, Hospices Civils de Lyon, 69003 Lyon, France
| | - L. Derex
- Univ. Lyon, University Claude Bernard Lyon 1, HESPER EA 7425, 69008 Lyon, France
- Department of Stroke Medicine, Hospices Civils de Lyon, 69003 Lyon, France
| | - N. Nighoghossian
- Department of Stroke Medicine, Hospices Civils de Lyon, 69003 Lyon, France
- Department of Neuroradiology, Hospices Civils de Lyon, 69003 Lyon, France
- CREATIS, CNRS-UMR5220 INSERM-U1044, Lyon, 69008 France
- INSA-Lyon, Lyon, 69008 France
| | - K. Tazarourte
- Univ. Lyon, University Claude Bernard Lyon 1, HESPER EA 7425, 69008 Lyon, France
- Emergency Department, Hospices Civils de Lyon, 69003 Lyon, France
| | - C. El Khoury
- Univ. Lyon, University Claude Bernard Lyon 1, HESPER EA 7425, 69008 Lyon, France
- Emergency Department and RESCUe Network, Lucien Hussel Hospital, Vienne, 38200 France
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Freyssenge J, Renard F, Schott AM, Derex L, Nighoghossian N, Tazarourte K, El Khoury C. Measurement of the potential geographic accessibility from call to definitive care for patient with acute stroke. Int J Health Geogr 2018. [PMID: 29329535 DOI: 10.1186/s12942-018-0153-9/figures/11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The World Health Organization refers to stroke, the second most frequent cause of death in the world, in terms of pandemic. Present treatments are only effective within precise time windows. Only 10% of thrombolysis patients are eligible. Late assessment of the patient resulting from admission and lack of knowledge of the symptoms is the main explanation of lack of eligibility. METHODS The aim is the measurement of the time of access to treatment facilities for stroke victims, using ambulances (firemen ambulances or EMS ambulances) and private car. The method proposed analyses the potential geographic accessibility of stroke care infrastructure in different scenarios. The study allows better considering of the issues inherent to an area: difficult weather conditions, traffic congestion and failure to respect the distance limits of emergency transport. RESULTS Depending on the scenario, access times vary considerably within the same commune. For example, between the first and the second scenario for cities in the north of Rhône county, there is a 10 min difference to the nearest Primary Stroke Center (PSC). For the first scenario, 90% of the population is 20 min away of the PSC and 96% for the second scenario. Likewise, depending on the modal vector (fire brigade or emergency medical service), overall accessibility from the emergency call to admission to a Comprehensive Stroke Center (CSC) can vary by as much as 15 min. CONCLUSIONS The setting up of the various scenarios and modal comparison based on the calculation of overall accessibility makes this a new method for calculating potential access to care facilities. It is important to take into account the specific pathological features and the availability of care facilities for modelling. This method is innovative and recommendable for measuring accessibility in the field of health care. This study makes possible to highlight the patients' extension of care delays. Thus, this can impact the improvement of patient care and rethink the healthcare organization. Stroke is addressed here but it is applicable to other pathologies.
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Affiliation(s)
- J Freyssenge
- Univ. Lyon, University Claude Bernard Lyon 1, HESPER EA 7425, 69008, Lyon, France. .,Emergency Department and RESCUe Network, Lucien Hussel Hospital, Vienne, 38200, France. .,UMR 5600 Environnement Ville Société CNRS, University Jean Moulin Lyon 3, 18, rue Chevreul, 69007, Lyon, France.
| | - F Renard
- UMR 5600 Environnement Ville Société CNRS, University Jean Moulin Lyon 3, 18, rue Chevreul, 69007, Lyon, France
| | - A M Schott
- Univ. Lyon, University Claude Bernard Lyon 1, HESPER EA 7425, 69008, Lyon, France.,Pôle IMER, Hospices Civils de Lyon, 69003, Lyon, France
| | - L Derex
- Univ. Lyon, University Claude Bernard Lyon 1, HESPER EA 7425, 69008, Lyon, France.,Department of Stroke Medicine, Hospices Civils de Lyon, 69003, Lyon, France
| | - N Nighoghossian
- Department of Stroke Medicine, Hospices Civils de Lyon, 69003, Lyon, France.,Department of Neuroradiology, Hospices Civils de Lyon, 69003, Lyon, France.,CREATIS, CNRS-UMR5220 INSERM-U1044, Lyon, 69008, France.,INSA-Lyon, Lyon, 69008, France
| | - K Tazarourte
- Univ. Lyon, University Claude Bernard Lyon 1, HESPER EA 7425, 69008, Lyon, France.,Emergency Department, Hospices Civils de Lyon, 69003, Lyon, France
| | - C El Khoury
- Univ. Lyon, University Claude Bernard Lyon 1, HESPER EA 7425, 69008, Lyon, France.,Emergency Department and RESCUe Network, Lucien Hussel Hospital, Vienne, 38200, France
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Seabury S, Bognar K, Xu Y, Huber C, Commerford SR, Tayama D. Regional disparities in the quality of stroke care. Am J Emerg Med 2017; 35:1234-1239. [DOI: 10.1016/j.ajem.2017.03.046] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/17/2017] [Accepted: 03/18/2017] [Indexed: 11/24/2022] Open
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Howard G, Kleindorfer DO, Cushman M, Long DL, Jasne A, Judd SE, Higginbotham JC, Howard VJ. Contributors to the Excess Stroke Mortality in Rural Areas in the United States. Stroke 2017; 48:1773-1778. [PMID: 28626048 PMCID: PMC5502731 DOI: 10.1161/strokeaha.117.017089] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/11/2017] [Accepted: 04/27/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stroke mortality is 30% higher in the rural United States. This could be because of either higher incidence or higher case fatality from stroke in rural areas. METHODS The urban-rural status of 23 280 stroke-free participants recruited between 2003 and 2007 in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) was classified using the Rural-Urban Commuting Area scheme as residing in urban, large rural town/city, or small rural town or isolated areas. The risk of incident stroke was assessed using proportional hazards analysis, and case fatality (death within 30 days of stroke) was assessed using logistic regression. Models were adjusted for demographics, traditional stroke risk factors, and measures of socioeconomic status. RESULTS After adjustment for demographic factors and relative to urban areas, stroke incidence was 1.23-times higher (95% confidence intervals, 1.01-1.51) in large rural town/cities and 1.30-times higher (95% confidence intervals, 1.03-1.62) in small rural towns or isolated areas. Adjustment for risk factors and socioeconomic status only modestly attenuated this association, and the association became marginally nonsignificant (P=0.071). There was no association of rural-urban status with case fatality (P>0.47). CONCLUSIONS The higher stroke mortality in rural regions seemed to be attributable to higher stroke incidence rather than case fatality. A higher prevalence of risk factors and lower socioeconomic status only modestly contributed to the increased risk of incident stroke risk in rural areas. There was no evidence of higher case fatality in rural areas.
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Affiliation(s)
- George Howard
- From the Department of Biostatistics (G.H., D.L.L., S.E.J.) and Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology, University of Cincinnati, OH (D.O.K., A.J.); Department of Medicine, University of Vermont, Burlington (M.C.); and College of Community Health Sciences, University of Alabama, Tuscaloosa (J.C.H.).
| | - Dawn O Kleindorfer
- From the Department of Biostatistics (G.H., D.L.L., S.E.J.) and Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology, University of Cincinnati, OH (D.O.K., A.J.); Department of Medicine, University of Vermont, Burlington (M.C.); and College of Community Health Sciences, University of Alabama, Tuscaloosa (J.C.H.)
| | - Mary Cushman
- From the Department of Biostatistics (G.H., D.L.L., S.E.J.) and Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology, University of Cincinnati, OH (D.O.K., A.J.); Department of Medicine, University of Vermont, Burlington (M.C.); and College of Community Health Sciences, University of Alabama, Tuscaloosa (J.C.H.)
| | - D Leann Long
- From the Department of Biostatistics (G.H., D.L.L., S.E.J.) and Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology, University of Cincinnati, OH (D.O.K., A.J.); Department of Medicine, University of Vermont, Burlington (M.C.); and College of Community Health Sciences, University of Alabama, Tuscaloosa (J.C.H.)
| | - Adam Jasne
- From the Department of Biostatistics (G.H., D.L.L., S.E.J.) and Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology, University of Cincinnati, OH (D.O.K., A.J.); Department of Medicine, University of Vermont, Burlington (M.C.); and College of Community Health Sciences, University of Alabama, Tuscaloosa (J.C.H.)
| | - Suzanne E Judd
- From the Department of Biostatistics (G.H., D.L.L., S.E.J.) and Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology, University of Cincinnati, OH (D.O.K., A.J.); Department of Medicine, University of Vermont, Burlington (M.C.); and College of Community Health Sciences, University of Alabama, Tuscaloosa (J.C.H.)
| | - John C Higginbotham
- From the Department of Biostatistics (G.H., D.L.L., S.E.J.) and Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology, University of Cincinnati, OH (D.O.K., A.J.); Department of Medicine, University of Vermont, Burlington (M.C.); and College of Community Health Sciences, University of Alabama, Tuscaloosa (J.C.H.)
| | - Virginia J Howard
- From the Department of Biostatistics (G.H., D.L.L., S.E.J.) and Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology, University of Cincinnati, OH (D.O.K., A.J.); Department of Medicine, University of Vermont, Burlington (M.C.); and College of Community Health Sciences, University of Alabama, Tuscaloosa (J.C.H.)
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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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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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Bauer J, Müller P, Maier W, Groneberg DA. Orthopedic workforce planning in Germany - an analysis of orthopedic accessibility. PLoS One 2017; 12:e0171747. [PMID: 28178335 PMCID: PMC5298336 DOI: 10.1371/journal.pone.0171747] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 01/25/2017] [Indexed: 11/19/2022] Open
Abstract
In Germany, orthopedic workforce planning relies on population-to-provider-ratios represented by the 'official degree of care provision'. However, with geographic information systems (GIS), more sophisticated measurements are available. By utilizing GIS-based technologies we analyzed the current state of demand and supply of the orthopedic workforce in Germany (orthopedic accessibility) with the integrated Floating Catchment Area method. The analysis of n = 153,352,220 distances revealed significant geographical variations on national scale: 5,617,595 people (6.9% of total population) lived in an area with significant low orthopedic accessibility (average z-score = -4.0), whereas 31,748,161 people (39.0% of total population) lived in an area with significant high orthopedic accessibility (average z-score = 8.0). Accessibility was positively correlated with the degree of urbanization (r = 0.49; p<0.001) and the official degree of care provision (r = 0.33; p<0.001) and negatively correlated with regional social deprivation (r = -0.47; p<0.001). Despite advantages of simpler measures regarding implementation and acceptance in health policy, more sophisticated measures of accessibility have the potential to reduce costs as well as improve health care. With this study, significant geographical variations were revealed that show the need to reduce oversupply in less deprived urban areas in order to enable adequate care in more deprived rural areas.
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Affiliation(s)
- Jan Bauer
- Institute of Occupational, Social and Environmental Medicine, Goethe University, Germany
| | - Peter Müller
- Public Health Foundation (‘Stiftung Gesundheit’), Hamburg, Germany
| | - Werner Maier
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Ingolstädter Landstr. 1, Neuherberg, Germany
| | - David A. Groneberg
- Institute of Occupational, Social and Environmental Medicine, Goethe University, Germany
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Gonzales S, Mullen MT, Skolarus L, Thibault DP, Udoeyo U, Willis AW. Progressive rural-urban disparity in acute stroke care. Neurology 2017; 88:441-448. [PMID: 28053009 DOI: 10.1212/wnl.0000000000003562] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 10/10/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore rural-urban differences and trends in tissue plasminogen activator (tPA) utilization among acute ischemic stroke (AIS) patients and examine the association between primary stroke center (PSC) growth and geographic disparity in tPA use. METHODS We used hospital discharge data from the National Inpatient Sample (NIS) from 2000 to 2010 and indicators of tPA utilization and describe temporal trends in geographic disparities in AIS care during PSC growth. The Gini coefficient was used to quantify rural-urban inequity in tPA use at the state level (from 0% to 100% of maximum potential rural-urban inequity) in tPA use. RESULTS Of 914,500 cases of AIS between 2001 and 2010, 2.3% (n = 21, 190) received tPA. The rural-urban disparity in tPA worsened: tPA use in urban hospitals quadrupled (1.17%-4.87%) compared to rural hospitals (0.87%-1.59%). Of 33 states with NIS data, 15 reached at least 75% of the maximum rural-urban inequality from 2004 to 2010. CONCLUSIONS Geographic disparities in tPA use for AIS are increasing. Greater understanding of the effectors of tPA utilization is necessary to ensure that access to tPA treatment is equitable for all communities in the United States.
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Affiliation(s)
- Sergio Gonzales
- From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA
| | - Michael T Mullen
- From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA
| | - Lesli Skolarus
- From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA
| | - Dylan P Thibault
- From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA
| | - Uduak Udoeyo
- From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA
| | - Allison W Willis
- From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA.
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Leira EC, Phipps MS, Jasne AS, Kleindorfer DO. Time to treat stroke patients in rural locations as an underserved minority. Neurology 2017; 88:422-423. [PMID: 28053007 DOI: 10.1212/wnl.0000000000003560] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Enrique C Leira
- From the Departments of Neurology and Epidemiology (E.C.L.), Carver College of Medicine and College of Public Health, University of Iowa, Iowa City; the Departments of Neurology and Epidemiology and Public Health (M.S.P.), University of Maryland School of Medicine, Baltimore; and the Department of Neurology (A.S.J., D.O.K.), University of Cincinnati, OH.
| | - Michael S Phipps
- From the Departments of Neurology and Epidemiology (E.C.L.), Carver College of Medicine and College of Public Health, University of Iowa, Iowa City; the Departments of Neurology and Epidemiology and Public Health (M.S.P.), University of Maryland School of Medicine, Baltimore; and the Department of Neurology (A.S.J., D.O.K.), University of Cincinnati, OH
| | - Adam S Jasne
- From the Departments of Neurology and Epidemiology (E.C.L.), Carver College of Medicine and College of Public Health, University of Iowa, Iowa City; the Departments of Neurology and Epidemiology and Public Health (M.S.P.), University of Maryland School of Medicine, Baltimore; and the Department of Neurology (A.S.J., D.O.K.), University of Cincinnati, OH
| | - Dawn O Kleindorfer
- From the Departments of Neurology and Epidemiology (E.C.L.), Carver College of Medicine and College of Public Health, University of Iowa, Iowa City; the Departments of Neurology and Epidemiology and Public Health (M.S.P.), University of Maryland School of Medicine, Baltimore; and the Department of Neurology (A.S.J., D.O.K.), University of Cincinnati, OH
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Bekelis K, Marth N, Wong K, Zhou W, Birkmeyer J, Skinner J. Primary Stroke Center Hospitalization for Elderly Patients With Stroke: Implications for Case Fatality and Travel Times. JAMA Intern Med 2016; 176:1361-8. [PMID: 27455403 PMCID: PMC5434865 DOI: 10.1001/jamainternmed.2016.3919] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Physicians often must decide whether to treat patients with acute stroke locally or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of a specialized PSC care. OBJECTIVES To examine the association of case fatality with receiving care in PSCs vs other hospitals for patients with stroke and to identify whether prolonged travel time offsets the effect of PSCs. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of Medicare beneficiaries with stroke admitted to a hospital between January 1, 2010, and December 31, 2013. Drive times were calculated based on zip code centroids and street-level road network data. We used an instrumental variable analysis based on the differential travel time to PSCs to control for unmeasured confounding. The setting was a 100% sample of Medicare fee-for-service claims. EXPOSURES Admission to a PSC. MAIN OUTCOMES AND MEASURES Seven-day and 30-day postadmission case-fatality rates. RESULTS Among 865 184 elderly patients with stroke (mean age, 78.9 years; 55.5% female), 53.9% were treated in PSCs. We found that admission to PSCs was associated with 1.8% (95% CI, -2.1% to -1.4%) lower 7-day and 1.8% (95% CI, -2.3% to -1.4%) lower 30-day case fatality. Fifty-six patients with stroke needed to be treated in PSCs to save one life at 30 days. Receiving treatment in PSCs was associated with a 30-day survival benefit for patients traveling less than 90 minutes, but traveling at least 90 minutes offset any benefit of PSC care. CONCLUSIONS AND RELEVANCE Hospitalization of patients with stroke in PSCs was associated with decreased 7-day and 30-day case fatality compared with noncertified hospitals. Traveling at least 90 minutes to receive care offset the 30-day survival benefit of PSC admission.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Nancy Marth
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Kendrew Wong
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Weiping Zhou
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - John Birkmeyer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Jonathan Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Department of Economics, Dartmouth College, Hanover, NH
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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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49
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Chin HB, Kramer MR, Mertens AC, Spencer JB, Howards PP. Differences in Women's Use of Medical Help for Becoming Pregnant by the Level of Urbanization of County of Residence in Georgia. J Rural Health 2016; 33:41-49. [PMID: 26769080 DOI: 10.1111/jrh.12172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE Our goal was to determine if there are differences by place of residence in visiting a doctor for help getting pregnant in a population-based study. METHODS Using data from the Furthering Understanding of Cancer, Health, and Survivorship in Adult (FUCHSIA) Women's Study, a cohort study of fertility outcomes in reproductive-aged women in Georgia, we fit models to estimate the association between geographic type of residence and seeking help for becoming pregnant. FINDINGS The prevalence of visiting a doctor for help getting pregnant ranged from 13% to 17% across geographic groups. Women living in suburban counties were most likely to seek medical care for help getting pregnant compared with women living in urbanized counties (adjusted prevalence ratio (aPR) = 1.14, 95% CI: 0.74-1.75); among women who reported infertility this difference was more pronounced (aPR = 1.59, 95% CI: 1.00-2.53). Women living in rural counties were equally likely to seek fertility care compared with women in urbanized counties in the full sample and among women who experienced infertility. CONCLUSIONS Women living in urban and rural counties were least likely to seek infertility care, suggesting that factors including but not limited to physical proximity to providers are influencing utilization of this type of care. Increased communication about reproductive goals and infertility care available to meet these goals by providers who women see for regular care may help address these barriers.
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Affiliation(s)
- Helen B Chin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Michael R Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ann C Mertens
- Aflac Cancer Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jessica B Spencer
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
| | - Penelope P Howards
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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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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