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Dhand A, Reeves MJ, Mu Y, Rosner BA, Rothfeld-Wehrwein ZR, Nieves A, Dhongade VA, Jarman M, Bergmark RW, Semco RS, Ader J, Marshall BDL, Goedel WC, Fonarow GC, Smith EE, Saver JL, Schwamm LH, Sheth KN. Mapping the Ecological Terrain of Stroke Prehospital Delay: A Nationwide Registry Study. Stroke 2024; 55:1507-1516. [PMID: 38787926 DOI: 10.1161/strokeaha.123.045521] [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: 10/12/2023] [Accepted: 04/12/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Delays in hospital presentation limit access to acute stroke treatments. While prior research has focused on patient-level factors, broader ecological and social determinants have not been well studied. We aimed to create a geospatial map of prehospital delay and examine the role of community-level social vulnerability. METHODS We studied patients with ischemic stroke who arrived by emergency medical services in 2015 to 2017 from the American Heart Association Get With The Guidelines-Stroke registry. The primary outcome was time to hospital arrival after stroke (in minutes), beginning at last known well in most cases. Using Geographic Information System mapping, we displayed the geography of delay. We then used Cox proportional hazard models to study the relationship between community-level factors and arrival time (adjusted hazard ratios [aHR] <1.0 indicate delay). The primary exposure was the social vulnerability index (SVI), a metric of social vulnerability for every ZIP Code Tabulation Area ranging from 0.0 to 1.0. RESULTS Of 750 336 patients, 149 145 met inclusion criteria. The mean age was 73 years, and 51% were female. The median time to hospital arrival was 140 minutes (Q1: 60 minutes, Q3: 458 minutes). The geospatial map revealed that many zones of delay overlapped with socially vulnerable areas (https://harvard-cga.maps.arcgis.com/apps/webappviewer/index.html?id=08f6e885c71b457f83cefc71013bcaa7). Cox models (aHR, 95% CI) confirmed that higher SVI, including quartiles 3 (aHR, 0.96 [95% CI, 0.93-0.98]) and 4 (aHR, 0.93 [95% CI, 0.91-0.95]), was associated with delay. Patients from SVI quartile 4 neighborhoods arrived 15.6 minutes [15-16.2] slower than patients from SVI quartile 1. Specific SVI themes associated with delay were a community's socioeconomic status (aHR, 0.80 [95% CI, 0.74-0.85]) and housing type and transportation (aHR, 0.89 [95% CI, 0.84-0.94]). CONCLUSIONS This map of acute stroke presentation times shows areas with a high incidence of delay. Increased social vulnerability characterizes these areas. Such places should be systematically targeted to improve population-level stroke presentation times.
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Affiliation(s)
- Amar Dhand
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Department of Neurology (A.D., Z.R.R.-W., V.A.D.), Brigham and Women's Hospital, Boston, MA
- Network Science Institute, Northeastern University, Boston, MA (A.D.)
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Yi Mu
- Department of Biostatistics, Channing Laboratory, Harvard T.H. Chan School of Public Health, Boston, MA (Y.M., B.A.R.)
| | - Bernard A Rosner
- Department of Biostatistics, Channing Laboratory, Harvard T.H. Chan School of Public Health, Boston, MA (Y.M., B.A.R.)
| | - Zachary R Rothfeld-Wehrwein
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Department of Neurology (A.D., Z.R.R.-W., V.A.D.), Brigham and Women's Hospital, Boston, MA
| | - Amber Nieves
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (A.N.)
| | - Vrushali A Dhongade
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Department of Neurology (A.D., Z.R.R.-W., V.A.D.), Brigham and Women's Hospital, Boston, MA
| | - Molly Jarman
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Department of Otolaryngology-Head and Neck Surgery (M.J., R.W.B.), Brigham and Women's Hospital, Boston, MA
| | - Regan W Bergmark
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Center for Surgery and Public Health (R.W.B., R.S.S.), Brigham and Women's Hospital, Boston, MA
- Department of Otolaryngology-Head and Neck Surgery (M.J., R.W.B.), Brigham and Women's Hospital, Boston, MA
| | - Robert S Semco
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Center for Surgery and Public Health (R.W.B., R.S.S.), Brigham and Women's Hospital, Boston, MA
| | - Jeremy Ader
- Department of Neurology, Columbia University Irving Medical Center, New York, NY (J.A.)
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI (B.D.L.M., W.C.G.)
| | - William C Goedel
- Department of Epidemiology, Brown University School of Public Health, Providence, RI (B.D.L.M., W.C.G.)
| | - Gregg C Fonarow
- Department of Cardiology (G.C.F.), University of California, Los Angeles David Geffen School of Medicine
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, AB, Canada (E.E.S.)
| | - Jeffrey L Saver
- Department of Neurology (J.L.S.), University of California, Los Angeles David Geffen School of Medicine
| | - Lee H Schwamm
- Harvard Medical School Boston, MA (A.D., Z.R.R.-W., V.A.D., M.J., R.W.B., R.S.S., L.H.S.)
- Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.)
| | - Kevin N Sheth
- Department of Neurology & Neurosurgery, Yale School of Medicine, New Haven, CT (K.N.S.)
- Yale Center for Brain & Mind Health, New Haven, CT (K.N.S.)
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Denny MC, Rosendale N, Gonzales NR, Leslie-Mazwi TM, Middleton S. Addressing Disparities in Acute Stroke Management and Prognosis. J Am Heart Assoc 2024; 13:e031313. [PMID: 38529656 DOI: 10.1161/jaha.123.031313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/03/2024] [Indexed: 03/27/2024]
Abstract
There are now abundant data demonstrating disparities in acute stroke management and prognosis; however, interventions to reduce these disparities remain limited. This special report aims to provide a critical review of the current landscape of disparities in acute stroke care and highlight opportunities to use implementation science to reduce disparities throughout the early care continuum. In the prehospital setting, stroke symptom recognition campaigns that have been successful in reducing prehospital delays used a multilevel approach to education, including mass media, culturally tailored community education, and professional education. The mobile stroke unit is an organizational intervention that has the potential to provide more equitable access to timely thrombolysis and thrombectomy treatments. In the hospital setting, interventions to address implicit biases among health care providers in acute stroke care decision-making are urgently needed as part of a multifaceted approach to advance stroke equity. Implementing stroke systems of care interventions, such as evidence-based stroke care protocols at designated stroke centers, can have a broader public health impact and may help reduce geographic, racial, and ethnic disparities in stroke care, although further research is needed. The long-term impact of disparities in acute stroke care cannot be underestimated. The consistent trend of longer time to treatment for Black and Hispanic people experiencing stroke has direct implications on long-term disability and independence after stroke. A learning health system model may help expedite the translation of evidence-based interventions into clinical practice to reduce disparities in stroke care.
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Affiliation(s)
- M Carter Denny
- Department of Neurology Georgetown University School of Medicine Washington DC USA
- Department of Neurology, MedStar Health Washington DC USA
| | - Nicole Rosendale
- Department of Neurology University of California San Francisco San Francisco CA USA
- Weill Institute for Neurosciences, University of California San Francisco San Francisco CA USA
| | - Nicole R Gonzales
- Department of Neurology University of Colorado Anschutz Medical Campus Aurora CO USA
| | | | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University Darlinghurst Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University Darlinghurst Australia
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Skolarus LE, Lin CC, Bi R, Bailey S, Corches CL, Sales AE, Springer MV, Burke JF. Reduction in Racial Differences in Stroke Thrombolytics in Flint, Michigan. Stroke 2024; 55:e24-e26. [PMID: 38152959 PMCID: PMC10872391 DOI: 10.1161/strokeaha.123.044663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Affiliation(s)
- Lesli E. Skolarus
- Northwestern University, Davee Department of Neurology, Chicago IL
- University of Michigan, Department of Neurology, Ann Arbor, MI
| | - Chun Chieh Lin
- Ohio State University, Department of Neurology, Columbus, OH
| | - Ran Bi
- Ohio State University, Department of Neurology, Columbus, OH
| | | | | | - Anne E. Sales
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri
- VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - James F. Burke
- Ohio State University, Department of Neurology, Columbus, OH
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