Does Exposure to Certified Stroke Centers Affect All Communities Equitably? Stroke Patient Outcomes by Community Socioeconomic Status - 02/07/25

Doi : 10.1016/j.annemergmed.2025.05.015

Yu-Chu Shen, PhD ^a,^b, Anthony S. Kim, MD, MAS ^c, Renee Y. Hsia, MD, MSc ^d,^e,^⁎
^a Department of Defense Management, Naval Postgraduate School, Monterey, CA
^b National Bureau of Economic Research, Cambridge, MA
^c Weill Institute of Neurosciences, Department of Neurology, University of California, San Francisco, CA
^d Department of Emergency Medicine, University of California, San Francisco, CA
^e Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA

^∗Corresponding Author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Wednesday 02 July 2025

Abstract

Study objective

To determine how access, treatment, and outcomes change for patients after their community is exposed to a newly certified stroke center based on a community’s disadvantage status.

Methods

In this retrospective observational study, we included Medicare Fee-for-Service patients from a national claims-based database admitted to hospitals between January 2009 and December 2019 whose primary diagnosis was acute ischemic stroke. We implemented linear probability models with community fixed effects to compare changes in outcomes when communities were exposed to newly certified stroke centers nearby relative to similar communities that did not experience stroke center expansion, controlling for patient demographics and comorbid conditions and secular trends. Outcomes included admission to a certified stroke center, receipt of thrombolytic therapy or mechanical thrombectomy, and 1-year mortality.

Results

We analyzed 2,807,763 patients with acute ischemic stroke. Only 68% of those in disadvantaged communities had exposure to a newly certified stroke center nearby during the study period, whereas 92% of those in advantaged communities had the same exposure. In disadvantaged communities, new stroke centers were associated with a 23.1 percentage point (pp) increase in admission to a stroke center, a 0.3 pp increase in “drip-and-ship” thrombolytic therapy, a 0.2 pp decrease in thrombectomy, and no statistically significant changes in “drip-and-stay” thrombolytic therapy or 1-year mortality. In advantaged communities, new stroke centers were associated with a 4.2 pp increase in admission to a stroke center, a 0.6 pp decrease in “drip-and-ship” thrombolytic therapy, a 0.8 pp increase in “drip-and-stay” thrombolytic therapy, a 0.2 pp increase in thrombectomy, and a small reduction in 1-year mortality of 0.6 pp.

Conclusion

Stroke center expansion has been uneven, and its effects on patient care differ by a community’s socioeconomic status. These findings should guide stroke center initiatives to improve care in disadvantaged communities.

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Keywords : Stroke, Acute ischemic, Treatment outcome, Certification

Plan

Introduction

Background

Importance

Goals of This Investigation

Methods

Study Design and Setting

Selection of Participants

Characteristics of Study Subjects

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor: Richelle J. Cooper, MD, MPH. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: YCS, ASK, and RYH planned and designed the study. YCS, ASK, and RYH are responsible for the acquisition, analysis, and interpretation of data. YCS and RYH drafted the manuscript. YCS, ASK, RYH did critical review of the manuscript for important intellectual content. YCS completed statistical analysis. YCS and RYH obtained funding. YCS takes responsibility for the paper as a whole.
	Data sharing statement: The dataset analyzed in the study is not publicly available due to legal and privacy regulations concerning patient-level data.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This project was supported by the Pilot Project Award from the NBER Center for Aging and Health Research, funded by the National Institute on Aging Grant (P30AG012810) and the National Institute on Minority Health and Health Disparities (R01MD017482). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Drs. Hsia and Shen report grant funding from NIA and NIMHD. Dr. Kim reports grant funding from NINDS, NCATS, NIMHD, AHA, and PCORI.