Growth of Regional Acute Stroke Systems of Care in the United States in the First Decade of the 21st Century

Introduction : Stroke is a leading cause of morbidity, mortality and healthcare spending in the United States. Acute management of ischemic stroke is time‐dependent and evidence suggests improved clinical outcomes for patients treated at designated certified stroke centers. There is an increasing trend among hospitals to obtain certification as designated stroke centers. A common source or integrated tool providing both information and location of all available stroke centers in the US irrespective of the certifying organization is not readily available. The objective of our research is to generate a comprehensive and interactive electronic resource with combined data on all geographically‐coded certified stroke centers to assist in pre‐hospital triage and study healthcare disparities in stroke including availability and access to acute stroke care by location and population. Methods : Data on stroke center certification was primarily obtained from each of the three main certifying organizations: The Joint Commission (TJC), Det Norske Veritas (DNV) and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of all stroke center locations was performed using the ArcGIS Pro application. The most current data on stroke centers is presented in an interactive electronic format and the information is frequently updated to represent newly certified centers. Utility of the tool and its analytics are shown. Role of the tool in improving pre‐hospital triage in the stroke systems of care, studying healthcare disparities and implications for public health policy are discussed. Results : Aggregate data analysis at the time of submission revealed 1,806 total certified stroke centers. TJC‐certified stroke centers represent the majority with 106 Acute Stroke Ready (ASR), 1,040 Primary Stroke Centers (PSCs), 49 Thrombectomy Capable Centers (TSCs) and 197 Comprehensive Stroke Centers (CSCs). A total of 341 DNV‐certified programs including 36 ASRs, 162 PSCs, 16 PSC Plus (thrombectomy capable) and 127 CSCs were identified. HFAP‐certified centers (75) include 16 ASRs, 49 PSCs, 2 TSCs and 8 CSCs. A preliminary map of all TJC‐certified CSCs and TSCs is shown in the figure (1). Geospatial analysis reveals distinct areas with currently limited access to certified stroke centers and currently, access to certified stroke centers is extremely limited to non‐existent in fe States (for example: Idaho, Montana, Wyoming, New Mexico and South Dakota). Conclusions : Stroke treatment and clinical outcomes are time‐dependent and prompt assessment and triage by EMS directly to appropriate designated stroke centers is therefore critical. A readily available electronic platform providing location and treatment capability for all nearby certified centers will enhance regional stroke systems of care, including enabling more rapid inter‐hospital transfers for advanced intervention. Identifying geographic areas of limited access to treatment can also help improve policy and prioritize the creation of a more equitable and well‐distributed network of stroke care in the United States.

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Abstract P278: Improving Stroke Systems of Care in Nebraska

Stroke ◽

10.1161/str.52.suppl_1.p278 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Marco A Gonzalez Castellon ◽

James A BOBENHOUSE ◽

David Franco ◽

Beth L Malina ◽

Mindy Cook ◽

...

Keyword(s):

Acute Stroke ◽

Rural Areas ◽

Systems Of Care ◽

Stroke Care ◽

The United States ◽

Advisory Council ◽

Management Tool ◽

Acute Stroke Care ◽

Stroke Systems Of Care ◽

Get With The Guidelines

Introduction: Stroke is a leading cause of disability in the United States. Disparities in stroke care between metropolitan and rural areas have long been recognized. Access to high-level timely stroke expertise improves outcomes, but in rural areas this is limited by sparse availability of stroke specialists. Since 2006, the Nebraska Stroke Advisory Council, a statewide coalition of stroke experts and stakeholders, began implementing strategies to improve stroke care. In 2016, the Nebraska legislature approved Bill 722, mandating the development of stroke systems of care. In 2018, the AHA and the Helmsley Charitable Trust launched Mission: Lifeline Stroke, a coordinated 3-year program to enhance stroke systems of care in Nebraska. Purpose: To assess advances in acute stroke care in Nebraska after implementing a statewide stroke system of care focused on rural areas. Methods: The Council joined with AHA to expand public and professional stroke education offerings including workshops, conferences, and EMS trainings. They developed state specific treatment guidelines and created educational reinforcement materials. From 2016 to 2019 Get With The Guidelines® (GWTG) was used for stroke data collection and quality improvement in Nebraska. GWTG participating hospitals expanded from 7 to 40 sites (21 critical access). Results: The number of stroke and Transient Ischemic Attack cases reported more than doubled from 2016 to 2019 (1848 to 3987 cases). The door to CT initiated in < 25 minutes improved by 13%. IV alteplase therapy gains included: utilization increased from 8.7% to 11.3%; median door to drug time reduced from 54 to 42 minutes; and door to drug within 60 minutes of arrival increased from 67% to 80.4%.The number of alteplase monitored patients doubled and mechanical thrombectomy cases increased from 77 in 2017 to 138 in 2019. Conclusion: Implementation of strategies in Nebraska, with an emphasis on rural critical access hospitals, led to significant improvements in acute stroke care. This work represents the authors’ independent analysis of local or multicenter data gathered using the AHA Get With The Guidelines® Patient Management Tool but is not an analysis of the national GWTG dataset and does not represent findings from the AHA GWTG National Program

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Abstract WP292: Changing Landscape of Stroke Systems of Care: Increase in Inter Hospital Transfer in the United States

Stroke ◽

10.1161/str.49.suppl_1.wp292 ◽

2018 ◽

Vol 49 (Suppl_1) ◽

Author(s):

Shreyansh Shah ◽

Shubin Sheng ◽

Ying Xian ◽

Kori S Zachrison ◽

Kevin N Sheth ◽

...

Keyword(s):

United States ◽

Systems Of Care ◽

The United States ◽

Hospital Transfer ◽

Stroke Systems Of Care

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Digital Health Strategies to Improve Care and Continuity Within Stroke Systems of Care in the United States

Circulation ◽

10.1161/circulationaha.117.029234 ◽

2019 ◽

Vol 139 (2) ◽

pp. 149-151 ◽

Cited By ~ 3

Author(s):

Lee H. Schwamm

Keyword(s):

United States ◽

Systems Of Care ◽

Digital Health ◽

The United States ◽

Stroke Systems Of Care

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Abstract 1122‐000163: Stroke Center Accessibility Study in the U.S. Using Geospatial Analysis and Machine Learning

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000163 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Ahsan Ali ◽

Randall Edgell

Keyword(s):

United States ◽

Machine Learning ◽

Acute Stroke ◽

Gulf Coast ◽

Systems Of Care ◽

The United States ◽

Geospatial Analysis ◽

Stroke Mortality ◽

Stroke Center ◽

Zip Code

Introduction : Background: Several accrediting bodies certify the level of stroke care hospitals provide. The Joint Commission on Hospital Accreditation (JC) is the largest accrediting body in the United States. There is no open source Geographic Information Systems (GIS) dataset showing the distribution of JC accredited centers by ZIP code. Objective: to create a stroke center accessibility and stroke center desert system using geospatial analysis and machine learning which provides real‐time assessment of stroke center availability, distribution and access to care. Methods : Geospatial data layers of JC accredited stroke centers were compiled using data sources including U.S. Census Bureau and CDC. Map layers corresponding to the levels of JC accredited stroke hospitals geolocated using ZIP code were created as follows: 1) Acute Stroke Ready 2) Primary 3) Thrombectomy Capable 4) Comprehensive Stroke Center. A GIS dataset displaying stroke mortality by region was obtained from the ArcGIS Living Atlas. Stroke center deserts are analyzed using a 4.5 hour drive map along with population and diversity. Machine learning models were implemented to estimate stroke mortality as a function of distance to care centers and capability levels of the stroke centers. Results : Stroke centers are highly concentrated within large urban centers. There are geographic regions that have poor access to stroke centers. Such regions include the Gulf Coast States of Louisiana, Mississippi, and Alabama that have large areas with poor stroke center access while having some of the highest stroke mortality in the country. (Figure 1 ‐ Stroke Center Distribution in the United States) Dot Symbols: Blue = Acute Stroke Ready; Green = Primary; Yellow = Thrombectomy Capable; Red = Comprehensive Raster Data: Stroke Mortality by ZIP Code; White to Purple Scale with Purple = Highest Mortality Conclusions : There are regional variations in stroke center availability. There are certain regions with high stroke mortality with very little stroke center access. Geospatial AI tools can be utilized to improve stroke systems of care.

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Abstract WP321: Enhancing Stroke Systems of Care in the United States through Evidence-Informed State Policy Interventions

Stroke ◽

10.1161/str.50.suppl_1.wp321 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Sharada Shantharam ◽

Aunima Bhuiya ◽

Farah M Chowdhury ◽

Colleen Barbero ◽

Lauren Taylor ◽

...

Keyword(s):

United States ◽

State Policy ◽

Systems Of Care ◽

The United States ◽

Policy Interventions ◽

Stroke Systems Of Care

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Abstract 185: Trends in Care Delivery and Outcomes for Acute Stroke and Transient Ischemic Attacks Among Rural and Urban Medicare Beneficiaries, 2008-2017

Stroke ◽

10.1161/str.51.suppl_1.185 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Kori S Zachrison ◽

Andrew D Wilcock ◽

Lee H Schwamm ◽

Lori Uscher-Pines ◽

Jose R Zubizarreta ◽

...

Keyword(s):

Acute Stroke ◽

Systems Of Care ◽

Care Delivery ◽

The United States ◽

Medicare Beneficiaries ◽

Rural And Urban ◽

Using Data ◽

Stroke Systems Of Care ◽

Stroke Center ◽

First 90 Days

Introduction: Over the last decade substantial investments have been made in implementing stroke systems of care to improve access and quality of care. We sought to determine if these interventions have narrowed the rural-urban disparities in care over time for patients with acute stroke or transient ischemic attack (TIA). Methods: Descriptive observational study using data from all traditional Medicare beneficiaries in the United States from 2008-17 who presented to a hospital emergency department and were admitted either under observation stay or inpatient admission. Patients were classified as rural or urban based on home zip code. The main outcomes were rates of presentation to a certified stroke center, neurology consultation during admission, IV altepase, 90-day mortality, days living independently in the first 90 days post stroke, and 90-day spending. Results: We identified 3.31 million hospital stays for TIA and stroke in the study period. Rural and urban patients had similar age, race, gender, Medicaid status and presence of chronic conditions. In 2008, 24.4% and 60.4% of rural and urban patients respectively were cared for at a certified stroke center (disparity -36.1%). By 2017 this disparity had narrowed by 8.6% points (95% CI 6.6%,10.7%) (Fig). Between 2008 and 2017, the disparity in neurologist evaluation during admission narrowed by 7.4% (5.2%, 9.6%). However, there was no substantive change in disparity in alteplase use -0.1% (95% CI -0.5%,0.3%), mortality at 90 days 0.4% (95% CI 0.1%, 0.7%), or days living independently within 90 days -0.7 days (95% CI -1.1, 0.2). Spending in the first 90 days differentially increased among rural patients by $867 (95% CI 85, 1649). Conclusions: In the last decade, rural residents are more likely to receive care at a certified stroke center and receive neurologist consultation. However, disparities in outcomes are persistent, highlighting more work is needed to equitably extend stroke expertise to all Americans.

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Trends in acute ischemic stroke treatments and mortality in the United States from 2012 to 2018

Neurosurgical FOCUS ◽

10.3171/2021.4.focus21117 ◽

2021 ◽

Vol 51 (1) ◽

pp. E2

Author(s):

Sharath Kumar Anand ◽

William J. Benjamin ◽

Arjun Rohit Adapa ◽

Jiwon V. Park ◽

D. Andrew Wilkinson ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Systems Of Care ◽

Temporal Trends ◽

The United States ◽

Tissue Type ◽

Type Plasminogen Activator ◽

Stroke Systems Of Care ◽

The Relationship

OBJECTIVE The establishment of mechanical thrombectomy (MT) as a first-line treatment for select patients with acute ischemic stroke (AIS) and the expansion of stroke systems of care have been major advancements in the care of patients with AIS. In this study, the authors aimed to identify temporal trends in the usage of tissue-type plasminogen activator (tPA) and MT within the AIS population from 2012 to 2018, and the relationship to mortality. METHODS Using a nationwide private health insurance database, 117,834 patients who presented with a primary AIS between 2012 and 2018 in the United States were identified. The authors evaluated temporal trends in tPA and MT usage and clinical outcomes stratified by treatment and age using descriptive statistics. RESULTS Among patients presenting with AIS in this population, the mean age was 69.1 years (SD ± 12.3 years), and 51.7% were female. Between 2012 and 2018, the use of tPA and MT increased significantly (tPA, 6.3% to 11.8%, p < 0.0001; MT, 1.6% to 5.7%, p < 0.0001). Mortality at 90 days decreased significantly in the overall AIS population (8.7% to 6.7%, p < 0.0001). The largest reduction in 90-day mortality was seen in patients treated with MT (21.4% to 14.1%, p = 0.0414) versus tPA (11.8% to 7.0%, p < 0.0001) versus no treatment (8.3% to 6.3%, p < 0.0001). Age-standardized mortality at 90 days decreased significantly only in patients aged 71–80 years (11.4% to 7.8%, p < 0.0001) and > 81 years (17.8% to 11.6%, p < 0.0001). Mortality at 90 days stagnated in patients aged 18 to 50 years (3.0% to 2.2%, p = 0.4919), 51 to 60 years (3.8% to 3.9%, p = 0.7632), and 61 to 70 years (5.5% to 5.2%, p = 0.2448). CONCLUSIONS From 2012 to 2018, use of tPA and MT increased significantly, irrespective of age, while mortality decreased in the entire AIS population. The most dramatic decrease in mortality was seen in the MT-treated population. Age-standardized mortality improved only in patients older than 70 years, with no change in younger patients.

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