Does Exposure to Certified Stroke Centers Affect All Communities Equitably? Stroke Patient Outcomes by Community Socioeconomic Status.

Abstract

To determine how access, treatment, and outcomes change for patients after their community is exposed to a newly certified stroke center based on a community's disadvantage status. In this retrospective observational study, we included Medicare Fee-for-Service patients from a national claims-based database admitted to hospitals between January 2009 and December 2019 whose primary diagnosis was acute ischemic stroke. We implemented linear probability models with community fixed effects to compare changes in outcomes when communities were exposed to newly certified stroke centers nearby relative to similar communities that did not experience stroke center expansion, controlling for patient demographics and comorbid conditions and secular trends. Outcomes included admission to a certified stroke center, receipt of thrombolytic therapy or mechanical thrombectomy, and 1-year mortality. We analyzed 2,807,763 patients with acute ischemic stroke. Only 68% of those in disadvantaged communities had exposure to a newly certified stroke center nearby during the study period, whereas 92% of those in advantaged communities had the same exposure. In disadvantaged communities, new stroke centers were associated with a 23.1 percentage point (pp) increase in admission to a stroke center, a 0.3 pp increase in "drip-and-ship" thrombolytic therapy, a 0.2 pp decrease in thrombectomy, and no statistically significant changes in "drip-and-stay" thrombolytic therapy or 1-year mortality. In advantaged communities, new stroke centers were associated with a 4.2 pp increase in admission to a stroke center, a 0.6 pp decrease in "drip-and-ship" thrombolytic therapy, a 0.8 pp increase in "drip-and-stay" thrombolytic therapy, a 0.2 pp increase in thrombectomy, and a small reduction in 1-year mortality of 0.6 pp. Stroke center expansion has been uneven, and its effects on patient care differ by a community's socioeconomic status. These findings should guide stroke center initiatives to improve care in disadvantaged communities.