Rural residents, American Indians travel farthest for certified stroke care

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The distance a stroke patient must travel to be treated at a certified stroke center varies by race, age, income, and insurance status, with the greatest differences between rural residents and Native Americans found, according to a combined analysis of U.S. census data and street maps published today in Stroke.

Treatment for ischemic stroke, a blockage in an artery that supplies blood to the brain, restores blood flow to the brain. Rapid treatment is essential to reduce the disability. Blood flow can be restored by intravenous administration of clot-dissolving medication within 4.5 hours of the onset of stroke symptoms and ideally within one hour of hospital arrival. All certified stroke centers offer treatment with anticoagulant drugs, are staffed by doctors trained in stroke care, and implement further measures to improve stroke care.

“Every day those of us who treat stroke face the reality that our desire to help everyone competes with the fact that millions of Americans can’t get to us in time,” said lead study author Akash Kansagra, MD, MS , Associate Professor of Radiology. neurological surgery and neurology at Washington University School of Medicine in St. Louis. “Stroke patients have a much better chance of recovery if they can go to a stroke hospital quickly. The question we wanted to answer was whether certain Americans need to travel further than others to get the expertise that could save them if they had a stroke. “

The American Heart Association / American Stroke Association’s 2019 guidelines recommend that emergency services take stroke patients to the nearest stroke-capable hospital, as well as using interactive video conferencing on acute stroke care, also known as “telestroke,” for patients in remote areas using the settings.

The American Heart Association and the Joint Commission are working together to provide hospitals with Acute Stroke Certification, Primary Stroke Certification, Thrombectomized Stroke Certification, and Comprehensive Stroke Certification for Qualified Hospitals.

Researchers used a public map service to compare the road distance to the nearest certified stroke center for each census district (small geographic areas defined for the U.S. census) in the 48 contiguous states and the District of Columbia. For each census district, they collected data from the US Census Bureau’s 2014-2018 American Community Survey on age, race, ethnicity, health insurance status, income, and population density. The analysis covered 98% of all US census areas, which includes more than 316 million people and more than 2,300 stroke certified hospitals.

The researchers found that the longest distances to stroke-certified centers were for people in rural areas, rural areas with more elderly people, areas with less health insurance, census areas with lower household incomes, and higher proportions of American Indians.


  • In rural areas, census counts with more elderly residents were farther from stroke centers, with every 1% increase representing 0.31 mile longer travel distance for people 65 years of age or older. There was no clear association between the density of the elderly population and the distance to stroke care in urban areas.
  • In both urban and rural areas, the census areas with higher proportions of Native American residents were farther from certified stroke care centers, with every 1% increase in the proportion of American Indians traveling 0.06 mile longer in urban areas and a Miles longer distance in rural areas.
  • In both urban and rural areas, the areas with more uninsured were further away from stroke centers; Each 1% increase in the proportion of patients uninsured represented a 0.01 mile difference between driving in urban areas and 0.17 mile longer driving distance in rural areas.
  • The relationship between income and distance to a certified stroke center was reversed between urban and rural areas. In urban areas, every $ 10,000 increase in median household income meant a 0.10 mile increase in travel distance. In rural areas, every $ 10,000 increase in household income meant a 3.13 mile reduction in travel distance.

“Aside from the actual differences in geographic proximity to stroke care between urban and non-urban areas, our analysis found notable differences in the relationships between demographics and proximity to stroke care in urban and rural settings,” said Kansagra.

Kansagra said it is unclear why people over 65 in rural areas are further from certified stroke centers, “but the trend is worrying. While stroke can happen at any age, older adults are at higher risk. People who are most likely to have a stroke are also more likely to live far from a stroke hospital. “

The researchers said the finding that higher income levels meant greater distance to stroke care in urban areas, but closer distance to travel in rural areas likely reflects the concentration of wealth in the suburbs. “What surprised me was that there was no such reversal in areas where more residents had no health insurance,” said Kansagra. “No matter where we looked, areas with low health insurance were further removed from stroke care than areas with high insurance.”

The researchers said that institutions that certify stroke-enabled hospitals “must continue to promote the development and certification of stroke centers in non-urban areas and emphasize the return on investment in terms of health benefits for citizens rather than financial benefits for hospitals.” . At the same time, state governments can develop more integrated and coordinated care systems, including emergency services, that enable stroke patients to be quickly triaged and moved to the most appropriate stroke center.

The study results also highlight the importance of knowing about the stroke care centers in your community. “Not all hospitals have the resources to provide stroke care. Patients and their families can advocate for their wellbeing by insisting on being taken to a qualified stroke hospital, ”he said.

The current study is constrained by its reliance in part on government websites to identify stroke centers and the inability to follow guidelines that can direct emergency services to bypass certain hospitals. Since traffic jams can increase travel time in certain areas, the study is also limited by distance measurements, but not by travel time.

An accompanying editorial by Michael T. Mullen, MD, MS, and Olajide A. Williams, MDMS, recognized that this study builds on previous work but did not distinguish between primary stroke centers and comprehensive centers that provide different levels of stroke care.

In addition, Mullen and Williams write that distance to a stroke hospital is only part of a much larger series of problems: “Geographical accessibility is not the same as actual access to care and may not translate into improved stroke outcomes. … Systematic differences in hospital characteristics in relation to actual performance can also affect stroke outcomes regardless of distance barriers. Even so, removing the barriers posed by physical distance from stroke centers is a necessary and important endeavor, as highlighted in this study. “

Kansagra and his co-researchers are currently analyzing how far Americans have to travel to have a mechanical thrombectomy, a surgical procedure used to remove blood clots in patients suffering from a severe stroke caused by blood clots.

To identify stroke symptoms that require immediate treatment, the American Stroke Association recommends everyone remember the acronym FAST for Face Drooping, Arm Weakness, Speech Difficulty, Call Time 9-1-1.

According to the American Heart Association’s Heart Disease and Stroke Statistics – 2021 Update, stroke ranks 5th among all causes of death in the United States, separated from other cardiovascular diseases, and is a leading cause of severe disability in adults. A stroke occurs when a blood vessel to or in the brain either becomes blocked or ruptured, preventing blood and oxygen from reaching the entire brain.

Mayo Clinic Minute: African Americans at Higher Risk of Stroke

More information:
Stroke (2021). DOI: 10.1161 / STROKEAHA.121.034493 Provided by the American Heart Association

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