Background Injury is a major contributor to morbidity and mortality in the United States. Accordingly, expanding access to trauma care is a Healthy People priority. The extent to which disparities in access to trauma care exist in the US is unknown. Our objective was to describe geographic, demographic, and socioeconomic disparities in access to trauma care in the United States. Methods Cross-sectional study of the US population in 2010 using small units of geographic analysis and validated estimates of population access to a Level I or II trauma center within 60 minutes via ambulance or helicopter. We examined the association between geographic, demographic, and socioeconomic factors and trauma center access, with subgroup analyses of urban-rural disparities. Results Of the 309 million people in the US in 2010, 29.7 million lacked access to trauma care. Across the country, areas with higher income were significantly more likely to have access (OR 1.30, 95% CI 1.12–1.50), as were major cities (OR 2.13, 95% CI 1.25–3.62) and suburbs (OR 1.27, 95% CI 1.02–1.57). Areas with higher rates of uninsured (OR 0.09, 95% CI 0.07–0.11) and Medicaid or Medicare eligible patients (OR 0.69, 95% CI 0.59–0.82) were less likely to have access. Areas with higher proportions of blacks and non-whites were more likely to have access (OR 1.37, 95% CI 1.19–1.58), as were areas with higher proportions of Hispanics and foreign-born persons (OR 1.51, 95% CI 1.13–2.01). Overall, rurality was associated with significantly lower access to trauma care (OR 0.20, 95% CI 0.18–0.23). Conclusion While the majority of the United States has access to trauma care within an hour, almost 30 million US residents do not. Significant disparities in access were evident for vulnerable populations defined by insurance status, income, and rurality.
Background and Purpose-Only 3% to 5% of patients with acute ischemic stroke receive intravenous recombinant tissuetype plasminogen activator (r-tPA) and <1% receive endovascular therapy. We describe access of the US population to all facilities that actually provide intravenous r-tPA or endovascular therapy for acute ischemic stroke. Methods-We used US demographic data and intravenous r-tPA and endovascular therapy rates in the 2011 US Medicare Provider and Analysis Review data set. We estimated ambulance response times using arc-Geographic Information System's network analyst and helicopter transport times using validated models. Population access to care was determined by summing the population contained within travel sheds that could reach capable hospitals within 60 and 120 minutes. Results-Of 370 351 acute ischemic stroke primary diagnosis discharges, 14 926 (4%) received intravenous r-tPA and 1889 (0.5%) had endovascular therapy. By ground, 81% of the US population had access to intravenous-capable hospitals within 60 minutes and 56% had access to endovascular-capable hospitals. By air, 97% had access to intravenous-capable hospitals within 60 minutes and 85% had access to endovascular hospitals. Within 120 minutes, 99% of the population had access to both intravenous and endovascular hospitals. Conclusions-More than half of the US population has geographic access to hospitals that actually deliver acute stroke care but treatment rates remain low. These data provide a national perspective on acute stroke care and should inform the planning and optimization of stroke systems in the United States. (Stroke. 2014;45:3019-3024.)
Background and Purpose We examine whether the proportion of the US population with ≤ 60 minute access to PSCs varies based on geographic and demographic factors. Methods Population level access to PSCs within 60 minutes was estimated using validated models of prehospital time accounting for critical prehospital time intervals and existing road networks. We examined the association between geographic factors, demographic factors, and access to care. Multivariable models quantified the association between demographics and PSC access for the entire US and then stratified by urbanicity. Results Of the 309 million people in the US, 65.8% had ≤ 60 minute PSC access by ground ambulance (87% major cities, 59% minor cities, 9% suburbs, and 1% rural). PSC access was lower in stroke belt states (44% vs. 69%). Non-Whites were more likely to have access than Whites (77% vs. 62%) and Hispanics were more likely to have access than non-Hispanics (78% vs. 64%). Demographics were not meaningfully associated with access in major cities or suburbs. In smaller cities there was less access in areas with lower income, less education, more uninsured, more Medicare and/or Medicaid eligibles, lower healthcare utilization and healthcare resources... Conclusions There are significant geographic disparities in access to PSCs. Access is limited in non-urban areas. Despite the higher burden of cerebrovascular disease in stroke belt states, access to care is lower in these areas. Select demographic and healthcare factors are strongly associated with access to care in smaller cities, but not in other areas, including major cities.
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.
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