Abstract 2585: Disparities in Evaluation by Certified Primary Stroke Centers within the REGARDS cohort

Abstract

Background: There are known disparities in stroke incidence and mortality on the basis of race, income, region, and population density. Disparate access to specialized stroke care may contribute to these disparities. We sought to evaluate access to Joint Commission certified primary stroke centers (PSC) by race, education, income, population density, and region within the REGARDS cohort. Methods: The REasons for Geographic and Racial Differences in Stroke (REGARDS) study is a prospective population-based cohort of adults 45 years or older. 30,239 participants were recruited between 1 2003 and October 2007. Participants are contacted at 6 month intervals to ascertain suspected stroke events. The analysis was limited to the first suspected stroke event for each subject between 12/9/2005 and 1/6/2011. Medical records were retrieved and we determined if the evaluating hospital was a certified PSC at the time of the event. Region was dichotomized to stroke-belt or non-belt. Population density was dichotomized to urban or non-urban. Subjects evaluated at a PSC were compared to those evaluated at a non-PSC. Multivariable regression was used to determine independent predictors of PSC evaluation. Results: There were 1000 suspected stroke events during the study interval, of which 204 were evaluated at a certified PSC. Women were less likely to be evaluated at a PSC than men, 17.8% vs 23.0% (p=0.04). Subjects with a history of stroke were less likely to be evaluated at a PSC than those without a history of stroke, 15.1% vs 21.6% (p=0.04). Subjects who reside in non-urban locations were less likely to be evaluated at a PSC than those in urban areas, 9.1% vs 23.9% (p<0.001). Subjects residing within the stroke belt were less likely to be evaluated at a PSC than those living in other regions, 14.7% vs 27.3% (p<0.001). In the univariate analyses, no disparities were found on the basis of race, education, or income. In the multivariable analysis, living in non-urban areas (OR 2.6, 95% CI 1.5-4.5), living within the stroke belt (OR 1.9, 95% CI: 1.3-2.7), and having a prior history of stroke (OR 2.2, 95% CI 1.3-3.7) predicted evaluation at non-certified hospitals. Conclusion: Disparities in evaluation by certified PSC’s are related to geographic factors, region and population density, but not to most individual characteristics including race, education, or income. Despite an increased burden of cerebrovascular disease in the stroke belt and in rural areas, subjects in these areas were less likely to be treated at certified hospitals. This may be attributable to a reduced number of stroke centers in these locations. Public policy and systems planning should ensure specialized stroke care is rapidly accessible in areas with the greatest need.