title: Progressive rural-urban disparity in acute stroke care.
abstract: To explore rural-urban differences and trends in tissue plasminogen activator (tPA) utilization among acute ischemic stroke (AIS) patients and examine the association between primary stroke center (PSC) growth and geographic disparity in tPA use.
  
  
  
  We used hospital discharge data from the National Inpatient Sample (NIS) from 2000 to 2010 and indicators of tPA utilization and describe temporal trends in geographic disparities in AIS care during PSC growth. The Gini coefficient was used to quantify rural-urban inequity in tPA use at the state level (from 0% to 100% of maximum potential rural-urban inequity) in tPA use.
  
  
  
  Of 914,500 cases of AIS between 2001 and 2010, 2.3% (n = 21, 190) received tPA. The rural-urban disparity in tPA worsened: tPA use in urban hospitals quadrupled (1.17%-4.87%) compared to rural hospitals (0.87%-1.59%). Of 33 states with NIS data, 15 reached at least 75% of the maximum rural-urban inequality from 2004 to 2010.
  
  
  
  Geographic disparities in tPA use for AIS are increasing. Greater understanding of the effectors of tPA utilization is necessary to ensure that access to tPA treatment is equitable for all communities in the United States.
authors.affiliation: From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA.
authors.forename: Sergio
authors.initials: S
authors.lastname: Gonzales
authors.affiliation: From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Mullen
authors.affiliation: From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA.
authors.forename: Lesli
authors.initials: L
authors.lastname: Skolarus
authors.affiliation: From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA.
authors.forename: Dylan P
authors.initials: DP
authors.lastname: Thibault
authors.affiliation: From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA.
authors.forename: Uduak
authors.initials: U
authors.lastname: Udoeyo
authors.affiliation: From the Leonard Davis Institute of Health Economics (S.G., M.T.M., A.W.W.), Center for Clinical Epidemiology and Biostatistics (D.P.T., A.W.W.), and Department of Biostatistics and Epidemiology (A.W.W.), University of Pennsylvania; Department of Neurology (S.G., M.T.M., D.P.T., A.W.W.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (L.S., A.W.W.), University of Michigan, Ann Arbor; and Dorsnsife School of Public Health (U.U.), Drexel University, Philadelphia, PA. allison.willis@uphs.upenn.edu.
authors.forename: Allison W
authors.initials: AW
authors.lastname: Willis
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy* / Q000453:epidemiology; D003430:Cross-Sectional Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D054625:Healthcare Disparities / Q000639:trends*; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D012424:Rural Population / Q000706:statistics & numerical data; D020521:Stroke / Q000188:drug therapy* / Q000453:epidemiology; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014481:United States / Q000453:epidemiology; D014505:Urban Population / Q000706:statistics & numerical data
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator