title: Green space and mortality following ischemic stroke.
abstract: BACKGROUND
  Residential proximity to green space has been associated with physical and mental health benefits, but whether green space is associated with post-stroke survival has not been studied.
  
  
  METHODS
  Patients ≥ 21 years of age admitted to the Beth Israel Deaconess Medical Center (BIDMC) between 1999 and 2008 with acute ischemic stroke were identified. Demographics, presenting symptoms, medical history and imaging results were abstracted from medical records at the time of hospitalization for stroke onset. Addresses were linked to average Normalized Difference Vegetation Index, distance to roadways with more than 10,000 cars/day, and US census block group. Deaths were identified through June 2012 using the Social Security Death Index.
  
  
  RESULTS
  There were 929 deaths among 1645 patients with complete data (median follow up: 5 years). In multivariable Cox models adjusted for indicators of medical history, demographic and socioeconomic factors, the hazard ratio for patients living in locations in the highest quartile of green space compared to the lowest quartile was 0.78 (95% Confidence Interval: 0.63-0.97) (p-trend = 0.009). This association remained statistically significant after adjustment for residential proximity to a high traffic road.
  
  
  CONCLUSIONS
  Residential proximity to green space is associated with higher survival rates after ischemic stroke in multivariable adjusted models. Further work is necessary to elucidate the underlying mechanisms for this association, and to better understand the exposure-response relationships and susceptibility factors that may contribute to higher mortality in low green space areas.
authors.affiliation: Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Boston, MA 02215 USA; Department of Environmental Health, Harvard School of Public Health, Boston, MA, USA. Electronic address: ewilker@bidmc.harvard.edu.
authors.forename: Elissa H
authors.initials: EH
authors.lastname: Wilker
authors.affiliation: Department of Environmental Health, Harvard School of Public Health, Boston, MA, USA; Department of Forestry and Natural Resources, College of Agriculture, National Chiayi University, Chiayi, Taiwan.
authors.forename: Chih-Da
authors.initials: CD
authors.lastname: Wu
authors.affiliation: Department of Environmental Health, Harvard School of Public Health, Boston, MA, USA.
authors.forename: Eileen
authors.initials: E
authors.lastname: McNeely
authors.affiliation: Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Boston, MA 02215 USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Mostofsky
authors.affiliation: Department of Environmental Health, Harvard School of Public Health, Boston, MA, USA.
authors.forename: John
authors.initials: J
authors.lastname: Spengler
authors.affiliation: Department of Epidemiology, Brown University, Providence, RI, USA.
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Wellenius
authors.affiliation: Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Boston, MA 02215 USA; Department of Environmental Health, Harvard School of Public Health, Boston, MA, USA.
authors.forename: Murray A
authors.initials: MA
authors.lastname: Mittleman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001336:Automobiles / Q000191:economics / Q000706:statistics & numerical data; D001900:Boston / Q000453:epidemiology / Q000208:ethnology; D002545:Brain Ischemia / Q000191:economics / Q000208:ethnology / Q000401:mortality*; D004781:Environmental Exposure / Q000191:economics / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019368:Nature; D016016:Proportional Hazards Models; D011633:Public Facilities / Q000191:economics; D020521:Stroke / Q000191:economics / Q000208:ethnology / Q000401:mortality*; D016019:Survival Analysis; D055815:Young Adult
keywords: Environment; Green space; Mortality