Optimization modeling to maximize population access to comprehensive stroke centers.
OBJECTIVE
The location of comprehensive stroke centers (CSCs) is critical to ensuring rapid access to acute stroke therapies; we conducted a population-level virtual trial simulating change in access to CSCs using optimization modeling to selectively convert primary stroke centers (PSCs) to CSCs.


METHODS
Up to 20 certified PSCs per state were selected for conversion to maximize the population with 60-minute CSC access by ground and air. Access was compared across states based on region and the presence of state-level emergency medical service policies preferentially routing patients to stroke centers.


RESULTS
In 2010, there were 811 Joint Commission PSCs and 0 CSCs in the United States. Of the US population, 65.8% had 60-minute ground access to PSCs. After adding up to 20 optimally located CSCs per state, 63.1% of the US population had 60-minute ground access and 86.0% had 60-minute ground/air access to a CSC. Across states, median CSC access was 55.7% by ground (interquartile range 35.7%-71.5%) and 85.3% by ground/air (interquartile range 59.8%-92.1%). Ground access was lower in Stroke Belt states compared with non-Stroke Belt states (32.0% vs 58.6%, p = 0.02) and lower in states without emergency medical service routing policies (52.7% vs 68.3%, p = 0.04).


CONCLUSIONS
Optimal system simulation can be used to develop efficient care systems that maximize accessibility. Under optimal conditions, a large proportion of the US population will be unable to access a CSC within 60 minutes.
From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA. michael.mullen@uphs.upenn.edu.
Michael T
MT
Mullen
From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA.
Charles C
CC
Branas
From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA.
Scott E
SE
Kasner
From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA.
Catherine
C
Wolff
From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA.
Justin C
JC
Williams
From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA.
Karen C
KC
Albright
From the Department of Neurology, School of Medicine (M.T.M., S.E.K.), and Department of Biostatistics and Epidemiology (C.C.B., B.G.C.), University of Pennsylvania, Philadelphia; School of Medicine (C.W.), Duke University, Durham, NC; Department of Geography and Environmental Engineering (J.C.W.), Johns Hopkins University, Baltimore, MD; Department of Epidemiology, School of Public Health (K.C.A.), Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (K.C.A.), and Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center (K.C.A.), University of Alabama at Birmingham; and Department of Emergency Medicine (B.G.C.), School of Medicine, Thomas Jefferson University, Philadelphia, PA.
Brendan G
BG
Carr
D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006302:Health Services Research / Q000379:methods*; D006782:Hospitals, Special / Q000706:statistics & numerical data*; D006801:Humans; D017146:Models, Organizational; D020521:Stroke / Q000628:therapy*; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D014187:Transportation of Patients / Q000706:statistics & numerical data*; D014481:United States