title: Association of a higher density of specialist neuroscience providers with fewer deaths from stroke in the United States population.
abstract: OBJECTIVE
  Stroke is a leading cause of death and disability. Given that neurologists and neurosurgeons have special expertise in this area, the authors hypothesized that the density of neuroscience providers is associated with reduced mortality rates from stroke across US counties.
  
  
  METHODS
  This is a retrospective review of the Area Resource File 2009-2010, a national county-level health information database maintained by the US Department of Health and Human Services. The primary outcome variable was the 3-year (2004-2006) average in cerebrovascular disease deaths per million population for each county. The primary independent variable was the combined density of neurosurgeons and neurologists per million population in the year 2006. Multiple regression analysis was performed, adjusting for density of general practitioners (GPs), urbanicity of the county, and socioeconomic status of the residents of the county.
  
  
  RESULTS
  In the 3141 counties analyzed, the median number of annual stroke deaths was 586 (interquartile range [IQR] 449-754), the median number of neuroscience providers was 0 (IQR 0-26), and the median number of GPs was 274 (IQR 175-410) per million population. On multivariate adjusted analysis, each increase of 1 neuroscience provider was associated with 0.38 fewer deaths from stroke per year (p < 0.001) per million population. Rural location (p < 0.001) and increased density of GPs (p < 0.001) were associated with increases in stroke-related mortality.
  
  
  CONCLUSIONS
  Higher density of specialist neuroscience providers is associated with fewer deaths from stroke. This suggests that the availability of specialists is an important factor in survival after stroke, and underlines the importance of promoting specialist education and practice throughout the country.
authors.affiliation: Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA. atman.desai@hitchcock.org
authors.forename: Atman
authors.initials: A
authors.lastname: Desai
authors.forename: Kimon
authors.initials: K
authors.lastname: Bekelis
authors.forename: Wenyan
authors.initials: W
authors.lastname: Zhao
authors.forename: Perry A
authors.initials: PA
authors.lastname: Ball
authors.forename: Kadir
authors.initials: K
authors.lastname: Erkmen
mesh_terms: D000328:Adult; D004522:Educational Status; D005260:Female; D058006:General Practice / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D009462:Neurology / Q000706:statistics & numerical data*; D009493:Neurosurgery / Q000706:statistics & numerical data*; D011203:Poverty / Q000706:statistics & numerical data; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D019035:Rural Health Services / Q000706:statistics & numerical data; D020521:Stroke / Q000401:mortality* / Q000628:therapy*; D014481:United States / Q000453:epidemiology; D014483:United States Dept. of Health and Human Services / Q000706:statistics & numerical data; D019037:Urban Health Services / Q000706:statistics & numerical data