title: Disparities in accessibility of certified primary stroke centers.
abstract: OBJECTIVE
  We examine whether the proportion of the US population with ≤60 minute access to Primary Stroke Centers (PSCs) varies based on geographic and demographic factors.
  
  
  METHODS
  Population level access to PSCs within 60 minutes was estimated using validated models of prehospital time accounting for critical prehospital time intervals and existing road networks. We examined the association between geographic factors, demographic factors, and access to care. Multivariable models quantified the association between demographics and PSC access for the entire United States and then stratified by urbanicity.
  
  
  RESULTS
  Of the 309 million people in the United States, 65.8% had ≤60 minute PSC access by ground ambulance (87% major cities, 59% minor cities, 9% suburbs, and 1% rural). PSC access was lower in stroke belt states (44% versus 69%). Non-whites were more likely to have access than whites (77% versus 62%), and Hispanics were more likely to have access than non-Hispanics (78% versus 64%). Demographics were not meaningfully associated with access in major cities or suburbs. In smaller cities, there was less access in areas with lower income, less education, more uninsured, more Medicare and Medicaid eligibles, lower healthcare utilization, and healthcare resources.
  
  
  CONCLUSIONS
  There are significant geographic disparities in access to PSCs. Access is limited in nonurban areas. Despite the higher burden of cerebrovascular disease in stroke belt states, access to care is lower in these areas. Selecting demographic and healthcare factors is strongly associated with access to care in smaller cities, but not in other areas, including major cities.
authors.affiliation: From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.). michael.mullen@uphs.upenn.edu.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Mullen
authors.affiliation: From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.).
authors.forename: Douglas J
authors.initials: DJ
authors.lastname: Wiebe
authors.affiliation: From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.).
authors.forename: Ariel
authors.initials: A
authors.lastname: Bowman
authors.affiliation: From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.).
authors.forename: Catherine S
authors.initials: CS
authors.lastname: Wolff
authors.affiliation: From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.).
authors.forename: Karen C
authors.initials: KC
authors.lastname: Albright
authors.affiliation: From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.).
authors.forename: Jason
authors.initials: J
authors.lastname: Roy
authors.affiliation: From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.).
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Balcer
authors.affiliation: From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.).
authors.forename: Charles C
authors.initials: CC
authors.lastname: Branas
authors.affiliation: From the Department of Neurology (M.T.M.), Center for Clinical Epidemiology and Biostatistics (D.J.W., J.R., C.C.B., B.G.C.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., B.G.C.), and Department of Emergency Medicine, School of Medicine (B.G.C.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, University of Southern California, Los Angeles (A.B.); School of Medicine, Duke University, Durham, NC (C.S.W.); Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham (K.C.A.); Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham (K.C.A.); and Department of Neurology, New York University (L.J.B.).
authors.forename: Brendan G
authors.initials: BG
authors.lastname: Carr
mesh_terms: D003430:Cross-Sectional Studies; D005260:Female; D006297:Health Services Accessibility / Q000639:trends*; D054625:Healthcare Disparities / Q000639:trends*; D006761:Hospitals / Q000639:trends; D006801:Humans; D008297:Male; D011320:Primary Health Care / Q000639:trends*; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy*; D061665:Time-to-Treatment / Q000639:trends; D014481:United States / Q000453:epidemiology
keywords: health services geographic accessibility; health services research; stroke