Abstract
The increased number of stroke centers in the United States may not be equitably distributed across all populations. Anecdotal reports suggest there may be differential proliferation in wealthier and urban communities. To examine hospital characteristics and economic conditions of communities surrounding hospitals with and without stroke centers. This cohort study included all general, short-term, acute hospitals in the continental United States and used merged data from the Joint Commission, Det Norske Veritas, Healthcare Facilities Accreditation Program, state health departments, the Centers for Medicare & Medicaid Services, the American Hospital Association, the Dartmouth Atlas of Health Care, and the US Census Bureau from January 1, 2009, to September 30, 2017, to compare hospital and community characteristics of stroke-certified and non-stroke-certified hospitals and assessed characteristics of early and late adopters of stroke certification. Stroke center certification was the primary outcome. Risk factors were grouped into 3 categories: economic and financial, hospital, and community characteristics. Survival analyses were performed using a Cox proportional hazards regression model. The study included 4546 US hospitals. During the study period, 1689 hospitals (37.2%) were stroke certified (961 adopted certification on or before January 1, 2009, 728 afterward). After controlling for other area and hospital characteristics, hospitals in low-income hospital service areas and the lower tertile of profit-margin distribution were less likely to adopt stroke certification (hazard ratio [HR], 0.62; 95% CI, 0.52-0.74 and HR, 0.87; 95% CI, 0.78-0.98, respectively). Urban hospitals had a higher likelihood of stroke certification than rural hospitals (HR, 12.79; 95% CI, 10.64-15.37). This study found that stroke centers have proliferated unevenly across geographic localities, where hospitals in high-income hospital service areas and with higher profit margins have a greater likelihood of being stroke certified. These findings suggest that market-driven factors may be associated with stroke center certification.
Highlights
As the fifth leading cause of death and the leading cause of long-term disability in the United States, stroke has been a health care priority in the United States across the past 2 decades
After controlling for other area and hospital characteristics, hospitals in low-income hospital service areas and the lower tertile of profit-margin distribution were less likely to adopt stroke certification
Urban hospitals had a higher likelihood of stroke certification than rural hospitals (HR, 12.79; 95% CI, 10.64-15.37)
Summary
As the fifth leading cause of death and the leading cause of long-term disability in the United States, stroke has been a health care priority in the United States across the past 2 decades. In June 2000, the Brain Attack Coalition recommended the establishment of primary stroke centers.[1] In 2003, the Joint Commission, along with the American Heart Association and American Stroke Association, Open Access. For many years there was substantial concern that a considerable proportion of the population lacked adequate access to stroke centers,[4,5,6,7] the number of stroke centers has increased during the past decade.[8] Numerous early studies showed that, compared with non–stroke unit care, organized stroke unit care reduced the risk of death in patients with stroke by 14%, decreased the risk of death or institutionalized care of patients with stroke by 18%, and reduced the risk of death or dependency among patients with stroke by 18%.3 for many years there was substantial concern that a considerable proportion of the population lacked adequate access to stroke centers,[4,5,6,7] the number of stroke centers has increased during the past decade.[8]
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