title: Reassessing the Stroke Belt: Using Small Area Spatial Statistics to Identify Clusters of High Stroke Mortality in the United States.
abstract: The stroke belt is described as an 8-state region with high stroke mortality across the southeastern United States. Using spatial statistics, we identified clusters of high stroke mortality (hot spots) and adjacent areas of low stroke mortality (cool spots) for US counties and evaluated for regional differences in county-level risk factors.
  
  
  
  A cross-sectional study of stroke mortality was conducted using Multiple Cause of Death data (Centers for Disease Control and Prevention) to compute age-adjusted adult stroke mortality rates for US counties. Local indicators of spatial association statistics were used for hot-spot mapping. County-level variables were compared between hot and cool spots.
  
  
  
  Between 2008 and 2010, there were 393 121 stroke-related deaths. Median age-adjusted adult stroke mortality was 61.7 per 100 000 persons (interquartile range=51.4-74.7). We identified 705 hot-spot counties (22.4%) and 234 cool-spot counties (7.5%); 44.5% of hot-spot counties were located outside of the stroke belt. Hot spots had greater proportions of black residents, higher rates of unemployment, chronic disease, and healthcare utilization, and lower median income and educational attainment.
  
  
  
  Clusters of high stroke mortality exist beyond the 8-state stroke belt, and variation exists within the stroke belt. Reconsideration of the stroke belt definition and increased attention to local determinants of health underlying small area regional variability could inform targeted healthcare interventions.
authors.affiliation: From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.).
authors.forename: David N
authors.initials: DN
authors.lastname: Karp
authors.affiliation: From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.).
authors.forename: Catherine S
authors.initials: CS
authors.lastname: Wolff
authors.affiliation: From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.).
authors.forename: Douglas J
authors.initials: DJ
authors.lastname: Wiebe
authors.affiliation: From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.).
authors.forename: Charles C
authors.initials: CC
authors.lastname: Branas
authors.affiliation: From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.).
authors.forename: Brendan G
authors.initials: BG
authors.lastname: Carr
authors.affiliation: From the Department of Biostatistics and Epidemiology (D.N.K., D.J.W., C.C.B.), Leonard Davis Institute of Health Economics (D.J.W., C.C.B., M.T.M.), and Department of Neurology (M.T.M.), University of Pennsylvania, Philadelphia; Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.); and Duke University School of Medicine, Duke University, Durham, NC (C.S.W.). Michael.mullen@uphs.upenn.edu.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Mullen
mesh_terms: D000368:Aged; D016000:Cluster Analysis; D003430:Cross-Sectional Studies; D003920:Diabetes Mellitus / Q000453:epidemiology; D005006:Ethnicity / Q000706:statistics & numerical data; D005260:Female; D062306:Geography, Medical; D006296:Health Services / Q000706:statistics & numerical data; D006801:Humans; D006973:Hypertension / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000453:epidemiology; D015995:Prevalence; D012307:Risk Factors; D012959:Socioeconomic Factors; D015144:Southeastern United States / Q000453:epidemiology; D020521:Stroke / Q000401:mortality*
keywords: attention; cause of death; chronic disease; risk factors; stroke