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Volume 8: No. 4, July 2011

ORIGINAL RESEARCH
Geographic and Sociodemographic Disparities in Drive Times to Joint Commission–Certified Primary Stroke Centers in North Carolina, South Carolina, and Georgia


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Abstract
Introduction
Methods
Results
Discussion
Acknowledgments
Author Information
References
Tables


Jenna A. Khan, MPH; Michele Casper, PhD; Andrew W. Asimos, MD; Lydia Clarkson, MPH; Dianne Enright, GISP; Laura J. Fehrs, MD; Mary George, MD, MSPH; Khosrow Heidari, MA, MS; Sara L. Huston, PhD; Laurie H. Mettam, MEd; G. Ishmael Williams, Jr, MA; Linda Schieb, MSPH; Sophia Greer, MPH

Suggested citation for this article: Khan JA, Casper M, Asimos AW, Clarkson L, Enright D, Fehrs LJ, et al. Geographic and sociodemographic disparities in drive times to Joint Commission–certified primary stroke centers in North Carolina, South Carolina, and Georgia. Prev Chronic Dis 2011;8(4):A79. http://www.cdc.gov/pcd/issues/2011/jul/10_0178.htm. Accessed [date].

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Abstract

Introduction
Timely access to facilities that provide acute stroke care is necessary to reduce disabilities and death from stroke. We examined geographic and sociodemographic disparities in drive times to Joint Commission–certified primary stroke centers (JCPSCs) and other hospitals with stroke care quality improvement initiatives in North Carolina, South Carolina, and Georgia.

Methods
We defined boundaries for 30- and 60-minute drive-time areas to JCPSCs and other hospitals  by  using geographic information systems (GIS) mapping technology and calculated the proportions of the population living in these drive-time areas by sociodemographic characteristics. Age-adjusted county-level stroke death rates were overlaid onto the drive-time areas.

Results
Approximately 55% of the population lived within a 30-minute drive time to a JCPSC; 77% lived within a 60-minute drive time. Disparities in percentage of the population within 30-minute drive times were found by race/ethnicity, education, income, and urban/rural status; the disparity was largest between urban areas (70% lived within 30-minute drive time) and rural areas (26%). The rural coastal plains had the largest concentration of counties with high stroke death rates and the fewest JCPSCs.

Conclusion
Many areas in this tri-state region lack timely access to JCPSCs. Alternative strategies are needed to expand provision of quality acute stroke care in this region. GIS modeling is valuable for examining and strategically planning the distribution of hospitals providing acute stroke care.

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Introduction

Timely acute stroke care is necessary to substantially reduce disabilities that affect stroke patients (1,2). For ischemic stroke, the Food and Drug Administration has approved the use of intravenous tissue plasminogen activator (tPA) within 3 hours of symptom onset. One study suggests that the window of treatment benefit can be as long as 4.5 hours (3). However, many studies have shown that the sooner ischemic stroke patients receive tPA the greater the benefit, particularly if the treatment is initiated within 90 minutes of symptom onset, and, conversely, that delay in tPA delivery or failure to deliver tPA results in significantly worse ischemic stroke outcomes (1-5). For hemorrhagic stroke, therapeutic strategies to attenuate early hemorrhage expansion, such as early treatment for anticoagulation reversal in warfarin-related hemorrhagic strokes, are also time-sensitive (6).

Expeditious transport to hospitals capable of administering quality stroke care is an essential component of timely acute stroke care. Given that long delays can occur between onset of stroke symptoms and arrival at an emergency department (7-9) and that emergency department procedures for stroke patients often take longer than the 1 hour maximum set by the relevant National Quality Forum performance measure (8,10), drive times should be as short as possible. At least 1 state (Maryland) has already incorporated a 30-minute drive-time threshold into the destination bypass protocol for emergency medical services for patients with a suspected stroke (11).

Recommendations for the Establishment of Stroke Systems of Care (12), published by the American Stroke Association Task Force on the Development of Stroke Systems, recommends that “all patients having signs or symptoms of stroke be transported to the nearest primary stroke center or hospital with an equivalent designation.” Joint Commission primary stroke center (JCPSC) certification is the leading nationally recognized primary stroke center designation program. Established in 2003 in response to recommendations from the Brain Attack Coalition and the American Stroke Association, JCPSC certification requires that hospitals demonstrate compliance with stroke care standards, including standardized methods for delivering clinical care based on appropriate clinical guidelines or evidence-based practice and a commitment to performance measurement and improvement of care (13). However, JCPSCs are not evenly distributed geographically; market forces and degree of local interest are among the main determinants of whether hospitals seek JCPSC certification. Reliance on JCPSCs as the sole destination facilities for acute stroke care presents challenges for developing robust stroke systems of care. Therefore, we wished to examine scenarios that could expand the number of hospitals recognized as capable of providing quality acute stroke care. The Paul Coverdell National Acute Stroke Registry (PCNASR, funded by the Centers for Disease Control and Prevention) (14) and the Get With the Guidelines–Stroke program (GWTG–Stroke, managed by the American Stroke Association) (15) are the 2 nationally recognized stroke care quality improvement initiatives. Hospitals participating in these initiatives may already have all or many of the resources needed to provide quality acute stroke care and therefore may be well positioned to be officially designated as stroke care centers with minimal additional resources.

The primary objective of this study was to document the geographic disparities in timely access to JCPSCs in the tri-state region of North Carolina, South Carolina, and Georgia, a region with a historically high burden of stroke. In addition, we examined the disparities in population access to JCPSCs by sociodemographic group. Finally, we explored the extent to which timely access to acute stroke care would improve if hospitals currently participating in nationally recognized stroke care quality initiatives (PCNASR and GWTG–Stroke) were able to meet criteria for designation as a primary stroke center.

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Methods

We conducted a drive-time analysis to determine proportions of the population living within 30- and 60-minute drive times to primary stroke centers and to hospitals participating in stroke care quality improvement programs.

We obtained 2000 population data by census tract for the tri-state region from the US Census (16). The study population for this region totaled 20,247,778 (North Carolina: 8,049,313; South Carolina: 4,012,012; and Georgia: 8,186,453). We included in our analysis all hospitals in the region, along with hospitals just across the state boundaries, that were certified as JCPSCs as of September 27, 2010 (n = 88). We also identified all hospitals that were not certified as JCPSCs but that participated in either PCNASR or GWTG–Stroke (n = 72). Participation in these programs indicates a hospital’s commitment to improve the quality of stroke care. We classified and analyzed PCNASR and GWTG–Stroke hospitals that were also certified as JCPSCs only. No PCNASR hospitals were in South Carolina.

We used Network Analyst 9.3 (Environmental Systems Research Institute [ESRI], Redlands, California) and StreetMap Pro 2007 road network software (ESRI) to create drive-time areas of 30 and 60 minutes to JCPSCs. We used the geographic information system (GIS) method of aerial interpolation to estimate the population residing within 30- and 60-minute drive-time areas. We first calculated the proportion of each census tract in 30- and 60-minute drive-time areas. Next, we used that proportion to calculate the percentage of the population residing within 30- and 60-minute drive-time areas by sociodemographic characteristics. We performed χ2 analyses using SAS version 9.1 (SAS Institute, Inc, Cary, North Carolina).

We obtained sociodemographic data from the 2000 US Census (17). We based categories of race (black or white) and ethnicity (Hispanic or non-Hispanic) on self-reported census data. We defined urban (urbanized areas or urban clusters), rural (all nonurban areas), and poverty (income below the poverty level in 1999) on the basis of census definitions.

We overlaid drive time areas onto county-level, age-adjusted stroke death rates aggregated for the years 2001 through 2005. We defined stroke deaths as those for which the underlying cause of death on the death certificate was coded as I60-I64, I67, or I69 from the International Statistical Classification of Diseases, 10th Revision (18). We calculated stroke death rates per 100,000, directly age-adjusted to the 2000 US standard population. We categorized the county-level stroke death rates into quartiles and mapped them as 3 categories: bottom quartile, 2 middle quartiles, and top quartile. We did not show stroke death rates for counties with fewer than 5 stroke deaths because these rates do not meet statistical standards of reliability (19).

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Results

In the tri-state region, approximately 55% of the population resided within a 30-minute drive time to a JCPSC, and 77% resided within a 60-minute drive time to a JCPSC (Table). Stratification by age group showed a slight inverse association (ie, population percentages for both drive times decreased monotonically with increasing age group). We found variations in the proportion of the population living within a 30-minute or 60-minute drive time by race/ethnicity, education level, poverty status, and urban/rural status. We found that higher proportions of Hispanics (vs non-Hispanic blacks and non-Hispanic whites), people with more than a high school education (vs those with a high school education or less), people living in urban areas (vs those in rural areas), and people at or above the poverty level (vs those living in poverty) lived within either a 30-minute or 60-minute drive time to a JCPSC. Twenty-six percent of people living in rural areas lived within a 30-minute drive time to a JCPSC compared with 70% of those living in urban areas.

Most JCPSCs in the region were in the northwest section along the Interstate 85 corridor (Figure 1). Few JCPSCs were in the rural, coastal plains. Stroke death rates also varied geographically in the region. Counties in the top quartile for stroke deaths (78-136 stroke deaths/100,000) were primarily in the rural coastal plains, and counties in the lowest quartile (<58 stroke deaths/100,000) were found predominantly in the piedmont and mountain areas. Many of the counties with the highest stroke death rates were outside the 30-minute drive-time areas (Figure 2). Twenty-eight PCNASR and GWTG–Stroke hospitals that are not JCPSCs were in or near these areas of high stroke death rates (Figure 3). Most of the tri-state population was within 30-minute (75%) and 60-minute (95%) drive times to either a JCPSC, PCNASR, or GWTG–Stroke hospital (Table). The sociodemographic disparities in the population distribution within 30- and 60-minute drive times were maintained after the inclusion of PCNASR and GWTG–Stroke hospitals (Table).

Map

Figure 1. Thirty-minute and 60-minute drive time areas to a Joint Commission–Certified Primary Stroke Center (JCPSC), North Carolina, South Carolina, and Georgia. [A text description of this figure is also available.]

Map

Figure 2. Age-adjusted stroke death rates by county and 30-minute drive-time areas to a Joint Commission–Certified Primary Stroke Center (JCPSC), North Carolina, South Carolina, and Georgia. [A text description of this figure is also available.]

Map

Figure 3. Age-adjusted stroke death rates by county, 30-minute drive-time areas to a Joint Commission–Certified Primary Stroke Center (JCPSC), and location of hospitals that participate in the Paul Coverdell National Acute Stroke Registry (PCNASR) or the Get With the Guidelines–Stroke (GWTG–Stroke) program, North Carolina, South Carolina, and Georgia. [A text description of this figure is also available.]

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Discussion

We found substantial geographic and sociodemographic disparities in drive times to JCPSCs in the tri-state region of North Carolina, South Carolina, and Georgia. Overall, approximately 55% of the population in the tri-state region lived within a 30-minute drive time to a JCPSC and 77% lived within a 60-minute drive time. For 30-minute and 60-minute drive times, people in younger age groups, with higher education levels, living in urban areas, and not living in poverty had more timely access to a JCPSC. When hospitals currently engaged in stroke care quality improvement initiatives (ie, the PCNASR and GWTG–Stroke hospitals) were included in the analysis, we observed substantial increases in percentage of the population within 30-minute and 60-minute drive times, suggesting that these hospitals are well located to serve populations that do not have timely access to JCSPCs.

These results highlight opportunities to strengthen stroke systems of care by including hospitals that may not meet the criteria for designation as a JCPSC but have the potential to provide acute stroke treatment services. The 2 main avenues for expanding the role of these hospitals are 1) establishment of an additional set of evidence-based criteria for acute stroke treatment center designation that complements but does not replace the JCPSC criteria (not unlike the multilevel trauma center designation) and 2) enhancement of telestroke networks.

An additional set of evidence-based stroke center criteria to complement the existing JCPSC criteria would enhance stroke systems of care by recognizing the vital role that smaller hospitals fill in treating stroke patients, especially in rural areas such as those in the tri-state region of North Carolina, South Carolina, and Georgia. Healthcare Facilities Accreditation Program is 1 example of an additional stroke center certification program that has certified 13 primary stroke centers nationwide (www.hfap.org/AccreditationPrograms/acute.aspx).

Several states have already begun to develop alternative stroke center designation programs. However, many of these programs lack the infrastructure to verify (with onsite inspection) whether hospitals or facilities can appropriately be classified as stroke centers. Hospitals relying on remote survey techniques to self-report their stroke treatment capabilities may overestimate their stroke service capabilities (20). An additional set of evidence-based criteria established by stroke experts that would be rigorously verified would provide regional, state, and local organizations an opportunity to continue their collaborative efforts of enhancing stroke systems of care by strategically identifying where stroke centers are most needed and what resources would be needed to enable existing hospitals to perform key functions for acute stroke care.

Telestroke refers to the application of telemedicine in stroke care, in which consultation is performed by a remotely located expert through the use of high-quality videoconferencing. This type of remote evaluation of stroke patients is increasingly being used and strengthens state and regional stroke systems of care (21,22). The American Heart Association recognizes the importance of telemedicine for improving stroke care, especially in rural areas where facilities are scarce and emergency medical services transport can be inadequate (12,23). Telestroke networks exist in North Carolina, South Carolina, and Georgia, and Georgia plans to expand the scope of its telestroke networks (24-26). The existing telestroke networks are unable to provide telestroke services to some of the high-risk areas identified in this study (ie, most of the coastal plains of North Carolina and South Carolina that are outside a 60-minute drive time to a JCPSC and have high rates of stroke death).

Two other studies have estimated the percentage of the population living within a 60-minute drive time to stroke centers, with results similar to those of this study. In Canada, 67% of the total population lived within a 60-minute drive time to a hospital capable of administering tPA (27). In the United States, a report by the Northwest Regional Stroke Network found that 69% of its population was within a 60-minute drive time to a JCPSC (28). These studies suggest that although the rural areas of the tri-state region are neither as vast nor as remote as rural areas in the Northwest and Canada, a liberal 60-minute travel window around existing JCPSCs still leaves a similar percentage of the population (more than 30%) without timely access to JCPSCs. Other studies of drive times to acute stroke care have used different time frames or travel distances. In Georgia, 69% of the population was determined to be living within 20 miles of a stroke-ready hospital and in North Carolina, 21% of stroke deaths were among patients who lived within a 20-minute drive to a JCPSC (29,30).

The use of Network Analyst provides a more accurate representation of drive times than the more commonly used uniform distance buffers. However, drive-time analyses are limited because neither approach is able to account for changes in the elevation of the terrain or faster driving speed by emergency medical services. Consequently, the drive times in mountainous areas may be underestimated and may be overestimated in settings where emergency medical services are readily available and traffic patterns allow higher speeds. Another limitation of our study is the use of death certificate data for calculating stroke death rates. Geographic variations in reporting practices could introduce bias into the geographic patterns of stroke death rates. However, past studies have not documented a systematic geographic bias in the accuracy of reporting stroke deaths (31).

In summary, many geographic areas in the tri-state region of North Carolina, South Carolina, and Georgia, an area of the country with a historically high stroke death rate, lack timely access to JCPSCs. The results of this study highlight the need for alternative strategies to expand provision of quality acute stroke care in the tri-state region, particularly to underserved populations. Application of the GIS technique used in this study visually portrays the population effect of selected scenarios for improving access to timely acute stroke care.

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Acknowledgments

We thank Randall Young for his assistance with the analysis; the American Heart Association affiliates in North Carolina, South Carolina, and Georgia for their collaboration on this project; and Tiffany N. Bailey for editing assistance.

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Author Information

Corresponding Author: Michele Casper, PhD, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mailstop K-47, Atlanta, GA 30341. Telephone: 770-488-2571. E-mail: mcasper@cdc.gov.

Author Affiliations: Jenna A. Khan, University of Illinois at Chicago School of Public Health, Chicago, Illinois; Andrew W. Asimos, Carolinas Medical Center, Charlotte, North Carolina; Lydia Clarkson, Laura J. Fehrs, Georgia Department of Community Health, Atlanta, Georgia; Dianne Enright, North Carolina State Center for Health Statistics, Raleigh, North Carolina; Mary George, G. Ishmael Williams Jr, Linda Schieb, Sophia Greer, Centers for Disease Control and Prevention, Atlanta, Georgia; Khosrow Heidari, South Carolina Department of Health and Environmental Control, Columbia, South Carolina; Sara L. Huston, Maine Center for Disease Control and Prevention, Augusta, Maine, and University of Southern Maine, Portland, Maine; Laurie H. Mettam, Tri-State Stroke Network, Raleigh, North Carolina. At the time of the study, Ms Khan was affiliated with the Centers for Disease Control and Prevention, Atlanta, Georgia, and Dr Huston was affiliated with the University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, and Tri-State Stroke Network, Raleigh, North Carolina.

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References

  1. Hacke W, Donnan G, Fieschi C, Kaste M, von Krummer R, Broderick JP, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363(9411):768-74.
  2. Marler JR, Tilley BC, Lu M, Brott TG, Lyden PC, Grotta JC, et al. Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology 2000;55(11):1649-55.
  3. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al, for the European Cooperative Acute Stroke Study (ECASS) investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359(13):1317-29.
  4. Saver JL, Yafeh B. Confirmation of tPA treatment effect by baseline severity-adjusted end point reanalysis of the NINDS-tPA stroke trials. Stroke 2007;38(2):414-6.
  5. Goldstein JN, Thomas SH, Frontiero V, Joseph A, Engel C, Snider R, et al. Timing of fresh frozen plasma administration and rapid correction of coagulopathy in warfarin-related intracerebral hemorrhage. Stroke 2006;37(1):151-5.
  6. Centers for Disease Control and Prevention. Awareness of stroke warning symptoms — 13 states and the District of Columbia, 2005. MMWR Morb Mortal Wkly Rep 2008;57(18):481-5.
  7. Morris DL, Rosamond W, Madden K, Schultz C, Hamilton S. Prehospital and emergency department delays after acute stroke: the Genentech Stroke Presentation Survey. Stroke 2000;31(11):2585-90.
  8. Schroeder EB, Rosamond WD, Morris DL, Evenson KR, Hinn AR. Determinants of use of emergency medical services in a population with stroke symptoms: the Second Delay in Accessing Stroke Healthcare (DASH II) Study. Stroke 2000;31(11):2591-6.
  9. Rose KM, Rosamond WD, Huston SL, Murphy CV, Tegeler CH. Predictors of time from hospital arrival to initial brain-imaging among suspected stroke patients: the North Carolina Collaborative Stroke Registry. Stroke 2008;39(12):3262-7.
  10. Maryland medical protocols for emergency medical services providers. Baltimore (MD): Maryland Institute for Emergency Medical Services Systems; 2010.
  11. Schwamm LH, Pancioli A, Acker JE III, Goldstein LB, Zorowitz RD, Shephard TJ, et al. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association’s Task Force on the Development of Stroke Systems. Circulation 2005;111(8):1078-91.
  12. Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg MR, et al. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA 2000;283(23):3102-9.
  13. George MG, Tong X, McGruder H, Yoon P, Rosamond W, Winquist A, et al; Centers for Disease Control and Prevention (CDC). Paul Coverdell National Acute Stroke Registry surveillance — four states, 2005-2007. MMWR Surveill Summ 2009;58(7):1-23.
  14. Fonarow G, Reeves M, Smith E, Saver JL, Zhao X, Olson DW, et al, GWTG-Stroke Steering Committee and Investigators. Characteristics, performance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in Get With the Guidelines-Stroke. Circ Cardiovasc Qual Outcomes 2010;3:291-302.
  15. Census 2000 summary file 1 [Georgia, North Carolina, South Carolina]. US Census Bureau; 2007. http://factfinder.census.gov/servlet/DatasetMainPageServlet?_ds_name=D. Accessed March 7, 2011.
  16. Census 2000 summary file 3 [Georgia, North Carolina, South Carolina]. US Census Bureau; 2002. http://factfinder.census.gov/servlet/DatasetMainPageServlet?_ds_name=D. Accessed March 7, 2011.
  17. World Health Organization. International statistical classification of diseases and related health problems 10th revision version for 2007. http://apps.who.int/classifications/apps/icd/icd10online/. Updated on May 4, 2006. Accessed October 3, 2010.
  18. Buescher PA. Problems with rates based on small numbers. Statistical primer series, No. 12. North Carolina Department of Health and Human Services, Division of Public Health, State Center for Health Statistics; 2008. http://www.schs.state.nc.us/SCHS/pdf/primer12_2.pdf. Accessed February 22, 2011.
  19. Kidwell CS, Shephard T, Tonn S, Lawyer B, Murdock M, Koroshetz W, et al. Establishment of primary stroke centers: a survey of physician attitudes and hospital resources. Neurology 2003;60(9):1452-6.
  20. Audebert HJ, Kukla C, Vatankhah B, Gotzler B, Schenkel J, Hofer S, et al. Comparison of tissue plasminogen activator administration management between Telestroke Network hospitals and academic stroke centers: the Telemedical Pilot Project for Integrative Stroke Care in Bavaria/Germany. Stroke 2006;37(7):1822-7.
  21. Hess DC, Wang S, Hamilton W, Lee S, Pardue C, Waller JL, et al. REACH: clinical feasibility of a rural telestroke network. Stroke 2005;36(9):2018-20.
  22. Schwamm LH, Holloway RG, Amarenco P, Audebert HJ, Bakas T, Chumbler NR, et al. A review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the American Heart Association/American Stroke Association. Stroke 2009;40(7):2616-34.
  23. Tele-stroke network launched by Wake Forest University Baptist Medical Center. The Medical News; 2009. http://www.news-medical.net/news/20091029/Tele-stroke-network-launched-by-Wake-Forest-University-Baptist-Medical-Center.aspx. Accessed July 30, 2010.
  24. Comprehensive Stroke and Cerebrovascular Center: REACH MUSC program - telestroke program. Medical University of South Carolina. http://www.muschealth.com/stroke/reach.htm. Accessed February 28, 2011.
  25. Hess DC, Wang S, Gross H, Nichols FT, Hall CE, Adams RJ. Telestroke: extending stroke expertise into underserved areas. Lancet Neurol 2006;5(3):275-8.
  26. Scott PA, Temovsky CJ, Lawrence K, Gudaitis E, Lowell MJ. Analysis of Canadian population with potential geographic access to intravenous thrombolysis for acute ischemic stroke. Stroke 1998;29(11):2304-10.
  27. Service areas for Joint Commission Primary Stroke Centers. Northwest Regional Stroke Network. Olympia (WA): Washington State Department of Health; 2009.
  28. Blaney DD, Hallisey EJ, Zhou Y, Huston SL, Frankel MR. Stroke mortality is related to hospital readiness in a stroke belt state. 2007 International Stroke Conference. Stroke 2007;38(2):573 (abstract).
  29. Asimos A, Huston S, Mettam L, Enright D. JCAHO stroke center certification as a strategy for a statewide system of acute stroke care in North Carolina. Society for Academic Emergency Medicine Meeting. Acad Emerg Med 2007;14(5 Suppl 1):S31 (abstract).
  30. Lanska DJ, Peterson PM. Geographic variation in reporting of stroke deaths to underlying or contributing causes in the United States. Stroke 1995;26(11):1999-2003.

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Table

Return to your place in the textTable. Population Within Specified Drive Times to Hospitals With a Primary Stroke Center or a Stroke Care Quality Improvement Initiative, by Demographic Characteristics, North Carolina, South Carolina, and Georgiaa 
Characteristic Nb % Within Drive Time to
JCPSCs Onlyc
% Within Drive Time to
JCPSC, PCNASR, or
GWTG
Stroke Hospitalsd
30 min 60 min 30 min 60 min
Total 20,247,778 54.8 77.3 75.3 94.7
Age, y
<40 11,937,561 56.5 78.3 76.9 95.1
40-49 3,028,225 55.6 77.9 75.9 94.8
50-64 3,042,336 51.9 75.7 72.7 93.8
≥65 2,239,656 48.9 73.7 70.0 93.1
Sex
Female 10,329,041 54.9 77.3 75.3 94.6
Male 9,918,737 54.8 77.3 75.3 94.7
Race/ethnicity
Non-Hispanic black 5,272,303 53.9 73.8 75.4 94.8
Hispanic 909,266 68.3 85.3 83.5 96.8
Non-Hispanic white 13,827,497 54.3 78.1 74.6 94.4
Education (age ≥25 y)
<High school 2,880,352 46.0 73.9 67.7 94.2
High school graduate 3,767,038 48.8 74.9 70.8 94.1
>High school 6,417,579 62.1 80.3 80.6 94.8
Regione
Urban 13,140,663 70.4 84.0 87.7 96.1
Rural 7,107,115 26.2 65.0 52.4 91.9
Incomef
<Poverty level 2,540,329 47.3 71.0 69.1 93.4
≥Poverty level 17,107,997 56.2 78.5 76.3 94.8

Abbreviations: JCPSC, Joint Commission–Certified Primary Stroke Center; PCNASR, Paul Coverdell National Acute Stroke Registry; GWTG–Stroke, Get With the Guidelines–Stroke program.
a Source: US Census 2000 Summary File 1 and Summary File 3 (16,17).
b Values for each category may not add to total because of missing data.
c All characteristics are significant at P < .001 except sex. Calculated by using χ2 test.
d All characteristics are significant at P < .001 except sex for 30-minute drive times. Calculated by using χ2 test.
e Urban defined as urbanized areas (densely settled territories with ≥50,000 people) and urban clusters (densely settled territories with >2,500 people but <50,000 people). Rural defined as all other areas.
f 1999 poverty level derived from 2000 US Census (17). 

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The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.


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