title: Geographic access to acute stroke care in the United States.
abstract: OBJECTIVE
  Only 3% to 5% of patients with acute ischemic stroke receive intravenous recombinant tissue-type plasminogen activator (r-tPA) and <1% receive endovascular therapy. We describe access of the US population to all facilities that actually provide intravenous r-tPA or endovascular therapy for acute ischemic stroke.
  
  
  METHODS
  We used US demographic data and intravenous r-tPA and endovascular therapy rates in the 2011 US Medicare Provider and Analysis Review data set. International Classification of Diseases-Ninth Revision codes 433.xx, 434.xx and 436 identified acute ischemic stroke cases. International Classification of Diseases-Ninth Revision code 99.10 defined intravenous r-tPA treatment and International Classification of Diseases-Ninth Revision code 39.74 defined endovascular therapy. We estimated ambulance response times using arc-Geographic Information System's network analyst and helicopter transport times using validated models. Population access to care was determined by summing the population contained within travel sheds that could reach capable hospitals within 60 and 120 minutes.
  
  
  RESULTS
  Of 370,351 acute ischemic stroke primary diagnosis discharges, 14,926 (4%) received intravenous r-tPA and 1889 (0.5%) had endovascular therapy. By ground, 81% of the US population had access to intravenous-capable hospitals within 60 minutes and 56% had access to endovascular-capable hospitals. By air, 97% had access to intravenous-capable hospitals within 60 minutes and 85% had access to endovascular hospitals. Within 120 minutes, 99% of the population had access to both intravenous and endovascular hospitals.
  
  
  CONCLUSIONS
  More than half of the US population has geographic access to hospitals that actually deliver acute stroke care but treatment rates remain low. These data provide a national perspective on acute stroke care and should inform the planning and optimization of stroke systems in the United States.
authors.affiliation: From the University of Cincinnati Neuroscience Institute, OH (O.A., T.A., A.R., P.K., D.K.); Department of Emergency Medicine (O.A.), Department of Neurosurgery (O.A., T.A., A.R.), and Department of Neurology (P.K., D.K.), University of Cincinnati, OH; Department of Neurology, University of Alabama at Birmingham (K.C.A.); and Department of Biostatistics and Epidemiology (B.G.C., C.W., C.B.), Department of Emergency Medicine (B.G.C.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia. Opeolu.Adeoye@uc.edu.
authors.forename: Opeolu
authors.initials: O
authors.lastname: Adeoye
authors.affiliation: From the University of Cincinnati Neuroscience Institute, OH (O.A., T.A., A.R., P.K., D.K.); Department of Emergency Medicine (O.A.), Department of Neurosurgery (O.A., T.A., A.R.), and Department of Neurology (P.K., D.K.), University of Cincinnati, OH; Department of Neurology, University of Alabama at Birmingham (K.C.A.); and Department of Biostatistics and Epidemiology (B.G.C., C.W., C.B.), Department of Emergency Medicine (B.G.C.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia.
authors.forename: Karen C
authors.initials: KC
authors.lastname: Albright
authors.affiliation: From the University of Cincinnati Neuroscience Institute, OH (O.A., T.A., A.R., P.K., D.K.); Department of Emergency Medicine (O.A.), Department of Neurosurgery (O.A., T.A., A.R.), and Department of Neurology (P.K., D.K.), University of Cincinnati, OH; Department of Neurology, University of Alabama at Birmingham (K.C.A.); and Department of Biostatistics and Epidemiology (B.G.C., C.W., C.B.), Department of Emergency Medicine (B.G.C.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia.
authors.forename: Brendan G
authors.initials: BG
authors.lastname: Carr
authors.affiliation: From the University of Cincinnati Neuroscience Institute, OH (O.A., T.A., A.R., P.K., D.K.); Department of Emergency Medicine (O.A.), Department of Neurosurgery (O.A., T.A., A.R.), and Department of Neurology (P.K., D.K.), University of Cincinnati, OH; Department of Neurology, University of Alabama at Birmingham (K.C.A.); and Department of Biostatistics and Epidemiology (B.G.C., C.W., C.B.), Department of Emergency Medicine (B.G.C.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia.
authors.forename: Catherine
authors.initials: C
authors.lastname: Wolff
authors.affiliation: From the University of Cincinnati Neuroscience Institute, OH (O.A., T.A., A.R., P.K., D.K.); Department of Emergency Medicine (O.A.), Department of Neurosurgery (O.A., T.A., A.R.), and Department of Neurology (P.K., D.K.), University of Cincinnati, OH; Department of Neurology, University of Alabama at Birmingham (K.C.A.); and Department of Biostatistics and Epidemiology (B.G.C., C.W., C.B.), Department of Emergency Medicine (B.G.C.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia.
authors.forename: Micheal T
authors.initials: MT
authors.lastname: Mullen
authors.affiliation: From the University of Cincinnati Neuroscience Institute, OH (O.A., T.A., A.R., P.K., D.K.); Department of Emergency Medicine (O.A.), Department of Neurosurgery (O.A., T.A., A.R.), and Department of Neurology (P.K., D.K.), University of Cincinnati, OH; Department of Neurology, University of Alabama at Birmingham (K.C.A.); and Department of Biostatistics and Epidemiology (B.G.C., C.W., C.B.), Department of Emergency Medicine (B.G.C.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia.
authors.forename: Todd
authors.initials: T
authors.lastname: Abruzzo
authors.affiliation: From the University of Cincinnati Neuroscience Institute, OH (O.A., T.A., A.R., P.K., D.K.); Department of Emergency Medicine (O.A.), Department of Neurosurgery (O.A., T.A., A.R.), and Department of Neurology (P.K., D.K.), University of Cincinnati, OH; Department of Neurology, University of Alabama at Birmingham (K.C.A.); and Department of Biostatistics and Epidemiology (B.G.C., C.W., C.B.), Department of Emergency Medicine (B.G.C.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia.
authors.forename: Andrew
authors.initials: A
authors.lastname: Ringer
authors.affiliation: From the University of Cincinnati Neuroscience Institute, OH (O.A., T.A., A.R., P.K., D.K.); Department of Emergency Medicine (O.A.), Department of Neurosurgery (O.A., T.A., A.R.), and Department of Neurology (P.K., D.K.), University of Cincinnati, OH; Department of Neurology, University of Alabama at Birmingham (K.C.A.); and Department of Biostatistics and Epidemiology (B.G.C., C.W., C.B.), Department of Emergency Medicine (B.G.C.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia.
authors.forename: Pooja
authors.initials: P
authors.lastname: Khatri
authors.affiliation: From the University of Cincinnati Neuroscience Institute, OH (O.A., T.A., A.R., P.K., D.K.); Department of Emergency Medicine (O.A.), Department of Neurosurgery (O.A., T.A., A.R.), and Department of Neurology (P.K., D.K.), University of Cincinnati, OH; Department of Neurology, University of Alabama at Birmingham (K.C.A.); and Department of Biostatistics and Epidemiology (B.G.C., C.W., C.B.), Department of Emergency Medicine (B.G.C.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia.
authors.forename: Charles
authors.initials: C
authors.lastname: Branas
authors.affiliation: From the University of Cincinnati Neuroscience Institute, OH (O.A., T.A., A.R., P.K., D.K.); Department of Emergency Medicine (O.A.), Department of Neurosurgery (O.A., T.A., A.R.), and Department of Neurology (P.K., D.K.), University of Cincinnati, OH; Department of Neurology, University of Alabama at Birmingham (K.C.A.); and Department of Biostatistics and Epidemiology (B.G.C., C.W., C.B.), Department of Emergency Medicine (B.G.C.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia.
authors.forename: Dawn
authors.initials: D
authors.lastname: Kleindorfer
mesh_terms: D016208:Databases, Factual; D057510:Endovascular Procedures; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D061185:Mechanical Thrombolysis; D020521:Stroke / Q000628:therapy*; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014481:United States
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: access to health care; endovascular procedures; tissue-type plasminogen activator