Parth Upadhyaya, DO

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.

In recent years, the widened net for time-dependent interventions of acute stroke finds a counterpoint with irregular geographic distribution of capable certified stroke centers. With this comes unequal access for varied demographics. The authors aim to identify these gaps to better focus resources on disparities as stroke care continues to evolve.

By using United States Census Bureau data, the authors first determined the location of population density centroids of each census tract (U.S. Census Bureau) and the three nearest certified stroke centers by linear distance. The shortest road distance designated the nearest stroke center to each given census tract. Age, race, ethnicity, insurance status and income for each census tract, in addition to urban versus nonurban location, were identified in relation to stroke centers. Urban was defined by population density of 1000 people per square mile with a minimum of 2,500 people. By creating a hypothetical urban and nonurban reference tract, confounding factors were controlled, and before-mentioned characteristics elucidated.

71,929 census tracts, 2388 stroke hospitals and 316,995,649 people were included — 610 tracts were excluded due to population of 0. For urban tracts, American Indian and uninsured populations had increased distance to stroke hospitals, while Black, Asian and Other races were decreased. Increases in distance to hospitals were associated with increases in median annual income — each $10,000.00 increased distance by 0.166 km. Nonurban tracts found increased distance associated with >65 years, American Indian, and uninsured demographics, while shorter distance was associated with representation of Black race. Increase in median annual income by $10,000.00 decreased distance by 5.04 km.

As expected, certified stroke centers were localized to urban areas, linking known notions of rural lack of access. American Indian, elderly, and uninsured populations find themselves with greater median distances to certified stroke centers, while increasing median annual income and population density decreased that distance. The differences in demographics are most pronounced in nonurban census tracts, leaving a population who, at baseline, have a greater risk of stroke to travel the greatest distance.

The current paradigm of stroke care may involve transfers to higher level of care, but this does not remedy the raw mileage a patient must traverse. Ideally, using time in place of distance would help reveal variations in ground travel, e.g., urban traffic congestion and ambulance rerouting. This limitation, along with possibly missed certified centers and aggregated nature of data, are addressed in the study.

One may assume that stroke center designation favors large urban centers due to availability of resources and more favorable cost benefit ratios. The authors ask certifying bodies to encourage nonurban centers to build the needed infrastructure to obtain “stroke certified” designations. Identifying barriers to certification, whether cost or availability of a neurologist, may become a fork in the road for net community benefit and solvency for smaller centers.

As more medical centers reach for stroke certified designation, future studies may compare clinical outcomes of newly designated or nonurban stroke centers head-to-head. One should question whether a push for quantity risks quality for our most at-risk populations. In the future, the issue may not be an irregular geographic distribution, but rather asymmetric outcomes to accessible certified centers.