The distance a stroke patient must travel to reach the nearest certified stroke center differs by race, age, income and insurance status, according to a study that analyzed nationwide U.S. census data and road maps, published in June 2021 in Stroke. The greatest distances traveled to receive stroke care were found among rural residents and American Indians. A stroke occurs when the flow of blood to the brain is either blocked by a clot or ruptures. Since blood carries oxygen and nutrients to the brain, brain cells start to die when blood flow is disrupted, making rapid treatment critical. Olajide Williams, MD, professor of neurology at Columbia University Irving Medical Center in New York City and American Heart Association volunteer expert, says, “There’s a mantra in stroke neurology that time is brain: 1.9 million neurons are lost every minute of a stroke, so the longer we delay treating a stroke the more neurons we lose.” This time delay could result in complications like paralysis, memory loss or cognitive difficulty. “We know the sooner we treat patients with stroke the better the clinical outcomes” says Dr. Williams.
Demographic Disparities in Proximity to Certified Stroke Care
But what about when some stroke patients face longer hospital distances than others? Not every American has the same risk of stroke and not every American can get stroke care at the same time, says lead study author Akash Kansagra, MD, an associate professor of radiology, neurological surgery, and neurology at Washington University School of Medicine in St. Louis. “I see patients who encounter all sorts of barriers. We need to understand those factors.” Dr. Kansagra and his team, including lead researcher Cathy Yu, a medical student at Washington University School of Medicine, spent a year examining distance disparities. The team used a public mapping service along with data from the U.S. Census Bureau. This census data surveyed age, race, ethnicity, medical insurance status, income and population density in each census tract from 2014–2018. A census tract is a small geographic unit defined for the U.S. Census. Using regression modeling, the team then examined the relationship between the demographic characteristics of census tracts and the distance to the nearest certified stroke center, or a hospital certified to treat stroke patients. Not surprisingly, the study found a significant difference in the distance to the nearest stroke center between rural and urban locations. The model found that a theoretical urban census tract with average demographics was located 6.2 kilometers (km) away from the nearest stroke center, while a theoretical rural one was 30.2 km away — a 24 km difference. “There is a striking divide in access to stroke care between rural and nonrural America,” says Kansagra. He notes that although there is a general awareness of this difference, even for someone like him in the field, these figures are eye-opening. The study also found that in rural areas, census tracts with a higher population of residents aged 65 or older, were farther from stroke centers. Since stroke risk increases with age, this is a concerning find. In both urban and rural areas, researchers also found that American Indian residents have to travel farther to reach stroke care facilities. This was more pronounced in rural locations. According to the model, each 1 percent increase in the proportion of American Indians represented a 0.06 mile longer travel distance in urban areas, and a 0.66 mile longer travel distance in rural areas. Kansagra says, “This result is not surprising given the long history of health inequalities that affect these Americans, but it is especially alarming since many American Indian populations are at particularly high risk for developing stroke.” According to the study, higher income levels also meant greater distances to stroke care in urban areas, while lesser distances in rural ones. This likely speaks to the wealth concentration in suburbs. However, in both urban and rural areas, more uninsured people were located farther from stroke centers.
Limitations to the Study
In an accompanying editorial, Williams and Michael T. Mullen, MD, an assistant professor of neurology at the Hospital of the University of Pennsylvania in Philadelphia, commended the study for highlighting geographic disparities. Both authors also noted the study’s limitations, including not differentiating between primary and comprehensive stroke centers and using measures of distance but not travel time. For example, although the distance to reach a stroke center in an urban area may be shorter, traffic congestion could delay hospital arrival. Williams also emphasizes that although distance is a significant barrier, it is not the only barrier to health equity. “Other factors are known barriers to stroke care and care-seeking behaviors, like issues around insurance, and social determinants of health, like race and ethnicity. We need to take all factors into account, look at the modifiable components, and have strategies to address them,” says Williams.
Addressing Geographic Disparities
The study’s findings underscore the need for communities to address gaps in stroke care. “The study highlights the need for increasing stroke-certified hospitals in rural areas,” says Kansagra. He also emphasizes how transportation can alleviate the problem. “While we can’t build a hospital overnight, we can get an ambulance or helicopter to a patient in time.” Mobile stroke centers, state of the art ambulances equipped to treat patients before they arrive at a hospital, may be part of the solution. “Some communities have really benefited from them, like in Houston,” says Kansagra. However, he emphasizes that as stroke care becomes increasingly sophisticated, it’s difficult to make some of this technology portable. Alongside these structural changes, Williams highlights the importance of stroke literacy, like knowing the cardinal signs and symptoms of a stroke. Kansagra adds that it’s also essential to know where to get care. “A family member is always in a position to ask whether the patient is being taken to a certified stroke center,” he says. “This is a good way to advocate for your loved one.”
