Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States

Abstract

IMPORTANCE Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant.OBJECTIVE To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities. DESIGN, SETTING, AND PARTICIPANTSThis study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022. MAIN OUTCOMES AND MEASURES Hospitals' likelihood of adopting stroke care certification.RESULTS A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51). CONCLUSIONS AND RELEVANCEIn this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.

Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence

“…Given the highly technical and interdisciplinary nature of thrombectomy care, the benefit of specialized and certified stroke center care is likely to be even greater in the modern thrombectomy era where shorter time to treatment is associated with better outcomes. We found that a substantial proportion of hospitals treating patients with AIS are not stroke-certified by leading certifying organizations even though overall stroke certification has grown 83.5% from 2009 to 2019 18…”

Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care

“…50 Further differences exist between certified stroke centers and nonstroke centers; hospitals certified as stroke centers tend to be located in higher income service areas, have higher profit margins, and are less likely to be located in rural areas, demonstrating the impact of economic characteristics of patient populations on certification. 54,55 Finally, globally, stroke center certification is more established in highincome countries and regions compared with low-and middle-income countries. 56,57 Integration of Prehospital and Hospital Data Timely feedback is a vital part of continuously improving diagnostic skills and treatment decisions; yet this is uncommonly and inconsistently delivered to frontline EMS practitioners.…”

Changing Health Care Markets Have the Potential to Undermine Stroke Systems of Care

“…Hospitals in rural and poorer communities are less likely to become stroke centers, 6 urban hospitals serving racial and ethnic minority communities and rural hospitals have disproportionately closed, and safety net hospitals are also more likely to close their EDs or close entirely. 7 The impact of these closures on stroke care has not been quantified, but they are likely driving widening disparities in stroke outcomes given the timesensitive nature of reperfusion and differential loss of stroke care in vulnerable communities.…”