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. Author manuscript; available in PMC: 2016 Sep 22.
Published in final edited form as: J Health Dispar Res Pract. 2016 Spring;9(1):5.

Sex Disparities in Access to Acute Stroke Care: Can Telemedicine Mitigate this Effect?

Catherine Wolff 1, Amelia K Boehme 2, Karen C Albright 3, Tzu-Ching Wu 4, Michael T Mullen 5, Charles C Branas 6, James C Grotta 7, Sean I Savitz 8, Brendan G Carr 9
PMCID: PMC5032905  NIHMSID: NIHMS800098  PMID: 27668134

Abstract

Background

Women have more frequent and severe ischemic strokes than men, and are less likely to receive treatment for acute stroke. Primary stroke centers (PSCs) have been shown to utilize treatment more frequently. Further, as telemedicine (TM) has expanded access to acute stroke care we sought to investigate the association between PSC, TM and access to acute stroke care in the state of Texas.

Methods

Texas hospitals and resources were identified from the 2009 American Hospital Association Annual Survey. Hospitals were categorized as: (1) stand-alone PSCs not using telemedicine for acute stroke care, (2) PSCs using telemedicine for acute stroke care (PSC-TM), (3) non-PSC hospitals using telemedicine for acute stroke care, or (4) non-PSC hospitals not using telemedicine for acute stroke care. The proportion of the population who could reach a PSC within 60 minutes was determined for stand-alone PSCs, PSC-TM, and non-PSCs using TM for stroke care.

Results

Overall, women were as likely to have 60-minute access to a PSC or PSC-TM as their male counterparts (POR 1.02, 95% CI 1.02-1.03). Women were also just as likely to have access to acute stroke care via PSC or PSC-TM or TM as men (POR 1.03, 95% CI 1.02-1.04).

Discussion

Our study found no sex disparities in access to stand alone PSCs or to hospitals using TM in the state of Texas. The results of this study suggest that telemedicine can be used as part of an inclusive strategy to improve access to care equally for men and women.

Keywords: stroke, health disparities, telemedicine, acute stroke care

INTRODUCTION

Stroke is the leading cause of disability and fourth leading cause of death in the United States.(Towfighi & Saver, 2011) Stroke can be acutely treated with tissue plasminogen activator (tPA), significantly improving functional outcome when given to appropriately selected acute ischemic stroke (AIS) patients within 4.5 hours.(Hacke et al., 2008; “Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group,” 1995) However, national tPA treatment rates remain low (3-7%) despite the known benefits of treatment.(M. J. Reeves et al., 2005; Schwamm et al., 2013) Patients presenting to primary stroke centers are more likely to receive tPA and have better outcomes, but only two-thirds of Americans live within an hour of a Joint Commission Primary Stroke Center (PSC).(Albright et al., 2010; B. Carr & Branas; Lichtman et al., 2011; Prabhakaran, McNulty, O'Neill, & Ouyang, 2012)

Telemedicine has been used to improve access to care by allowing a neurologist at a remote location to interact with the patient and their family members.(Hess et al., 2006) Prior studies have shown that the use of telemedicine for treatment of AIS is not only safe and effective, but it also increases the utilization of tPA, thereby improving patient care and outcomes.(Choi et al., 2006; Meyer et al., 2008; Switzer et al., 2009) Prior research has shown that a way to increase access to acute neurological expertise is through telemedicine (TM).(Miley et al., 2009; Saler, Switzer, & Hess, 2011; Switzer & Hess, 2008) TM is the use of telecommunication technologies to provide medical information and services.(Perednia & Allen, 1995) Telemedicine uses the direct audiovisual connections between a location that does not have expert medical care and provides a remote physician, TM delivers quality health care from a distance.(Demaerschalk et al., 2009) Previous research has shown that acute stroke care provided through audio/video TM is safe with acceptable clinical outcomes and, in many instances, can improve utilization of IV t-PA.(Adams et al., 2012; Audebert et al., 2006; Audebert et al., 2009; Choi et al., 2006; Demaerschalk et al., 2010; Meyer et al., 2008; Stewart & Switzer, 2011; Switzer et al., 2013; Switzer et al., 2009) The American Stroke Association recommends that networks of telestroke be developed to provide acute neurological expertise to locations that lack on-site resources to improve access to acute stroke care.(Higashida et al., 2013; Schwamm et al., 2009)

Stroke disproportionately impacts women, leading to a sex disparity that is increasingly being recognized in the literature.(Kapral et al., 2005) More strokes occur in women than men, partially due to the fact that women have longer lifespans than men and have historically received poorer quality care.(M. J. Reeves, Fonarow, Zhao, Smith, & Schwamm, 2009; Roger et al., 2012) Women who experience stroke are known to present with more severe neurological and functional impairments, though they are less likely to receive tPA acutely and antithrombotics on discharge.(Hachinski et al., 2010; M. Reeves, Bhatt, Jajou, Brown, & Lisabeth, 2009) These differences may explain the significant disparities in functional outcome between the sexes, as female stroke patients are known to have a worse functional outcome (modified Rankin Scale ≥3) at both 30 days and one year following hospitalization for a first-time stroke.(Dougu et al., 2011; Roth et al., 2011) With the graying of America, there are more women over the age of 65 than men, because women tend to live longer than men. In addition to this, women tend to remain in the shared marital home after the passing of their spouse and therefore do not move. We believe that these factors combined increase the risk of women living in areas without access to acute stroke care. The purpose of this study is to determine whether the differences exist in access to acute stroke care for men and women and to examine the effect that telemedicine has had on eliminating disparities in access to care in this devastating, time-sensitive disease.

METHODS

Study Population

Data from the US Census Bureau and the 2010 Neilson Claritas Demographic Estimation Program were used to obtain population demographic information and geographic locations.(USCensusBureau, 2010) The primary unit of analysis was the block group; a small unit of geographic analysis that is contained within the boundaries of a census tract and comprised of a population of 600-3000 adults. Calculations were conducted from the block group centroid, a point closest to the most residents within each block group. Sex composition of each block group was determined.

Hospital Survey

The details of the survey methodology have been previously described. (Wu et al., 2014) Briefly, hospitals in Texas were identified through publicly available data from the American Hospital Association (AHA).(Association) Acute Care Facilities were defined as registered facilities with emergency departments capable of managing adult patients. Within this group, hospitals certified as stroke centers within the state of Texas were identified.(Services, 2013) The Texas Department of State Health Services accepts Comprehensive or Primary Stroke certification issued by either The Joint Commission (TJC) or Det Norske Veritas (DNV) Healthcare to receive Comprehensive Stroke Center and Primary Stroke Center state designation.(TJC, 2013; Veritas, 2013) These centers meet guidelines set forth by the Brain Attack Coalition and American Stroke Association and demonstrate appropriate patient management and outcomes in stroke care.(Alberts et al., 2000; Services, 2009) For the purposes of this study, state designated Comprehensive Stroke Centers and Primary Stroke Centers were combined into a single category—Primary Stroke Centers.

Using a standardized questionnaire, a three question telephone survey was administered to the emergency department coordinator or charge nurse in 556 hospitals to determine if each hospital was (1) an acute care hospital, (2) a TJC, DNV or the state of Texas certified Primary Stroke Center, or (3) utilizing telemedicine (TM) to provide acute stroke care. The questions asked during the telephone survey were (1) Is your hospital an acute care hospital?, (2) Is your hospital a primary stroke center?, and (3) Does your hospital use telemedicine for stroke?. After verification of the information obtained from the telephone survey, hospitals were designated into 4 categories: stand-alone Primary Stroke Centers (stand-alone PSC: hospitals that were Primary Stroke Centers and were not using telemedicine for acute stroke care), Primary Stroke Centers using telemedicine (PSC-TM: hospitals that were Primary Stroke Centers and were using telemedicine for acute stroke care), telemedicine for stroke care (TM-only: hospitals that were not Primary Stroke Centers but were using telemedicine for acute stroke care) or none (hospitals that were not Primary Stroke Centers and were not using telemedicine for acute stroke care).

Access to Care Calculations

Each block group was classified as having access within 60 minutes to either a stand-alone PSC, a PSC-TM, or a TM-only facility. Time estimates for each block group were calculated using the distance from the block group centroid to the closest hospital of each type (i.e., stand-alone PSC, PSC-TM, TM-only), with the addition of validated ambulance prehospital time intervals. The population of the block groups within these catchment areas was summed to determine total population with 60-minute access. Calculations were restricted to only consider the population and facilities residing within Texas state borders.

The Network Analyst functionality in ESRI ArcMap 10.1 was used to determine the shortest road distance between each centroid and the nearest hospital.(Love & Morris, 1979; Love & Wesolowsky, 1988) Each block group was linked exclusively with one hospital of each type and no block group was counted more than once. Transport times were calculated based on posted speed limits with 10 mph added to the speed limit for the roads in each path to the linked hospital. Key pre-hospital ambulance time intervals, adjusted based on rurality, were added to the transport time to estimate the total prehospital travel time. The 911 activation to ambulance dispatch interval was estimated as 1.4, 1.4 and 2.9 minutes for urban, suburban and rural areas, respectively.(B. G. Carr, Caplan, Pryor, & Branas, 2006) The time from ambulance dispatch until arrival at the scene was determined by multiplying the drive time from the scene to the hospital (as described above) by 1.6, 1.5 and 1.4 for urban, suburban and rural drives, respectively.(B. G. Carr et al., 2006) Lastly, 13.5, 13.5 and 15.1 minutes were added to account for time spent by emergency medical services (EMS) on the scene prior to transport.(Branas et al., 2005; B. G. Carr, Branas, Metlay, Sullivan, & Camargo, 2009) We calculated the difference between the population who could reach a PSC within 60 minutes (60-minute access) and the population who could reach a TM spoke (PSC-TM or TM-Only) within 60 minutes to determine the contribution of TM to access to acute stroke care. Using Census data, we were then able to determine if sex differences exist in access to acute stroke care through TM.

Statistics

Given the proportion with access to a stand-alone PSC was greater than 20% in all groups we elected to use modified Poisson regression to produce prevalence odds ratios (POR) to illustrate the association between sex and access to acute stroke care.(Zou, 2004) This decision was made in an attempt to prevent the overestimation often seen when using logistic regression (odds ratios) in situations with prevalent outcomes. (Zou, 2004) In addition to crude models, models were adjusted for urbanization.

RESULTS

In 2009 the population of Texas was 23.8 million residents. Of these, approximately 50% were women. A total of 578 Texas hospitals were identified in the American Hospital Association database, of which 96% (556/578) completed the survey. There were 22 hospitals who did not participate (18 could not be reached by phone). Of the 556 hospitals completing the survey, 395 (71%) were identified as acute care facilities. One hundred and three (26%) acute care facilities were identified as stroke centers; the minority of these were PSC-TMs (21%, 22/103).

Over 75% (18 million) of the Texas population had 60-minute in-state ground access to a stand-alone PSC. Sixty-minute access increased to 82% with an additional 478,000 (2%) people being served by PSC-TMs. Although PSC-TMs increased access to acute stroke care, nearly 4 million Texans still do not have 60-minute access.

There was no difference in the proportion of men and women with 60-minute access to stand-alone PSCs, PSC-TMs, and TM-only (Table 1). Approximately 16% of Texas had did not have 60-minute access to acute stroke care (16.2% men, 15.9% women). Overall, women were equally likely to have 60-minute access to acute stroke care at a stand-alone PSC or PSC-TM (POR 1.02, 95% CI 1.02- 1.03) when compared to their male counterparts. Women remained just as likely to have 60-minute access to acute stroke care at a stand-alone PSC or PSC-TM or TM-only as men (POR 1.03, 95% CI 1.02-1.04).

Table 1.

Current Access to Acute Stroke Care in Texas by Sex

Men (n= 11,871,925) Women (n= 11,929,515)
Stand-alone PSC 8,950,514 (75.4%) 9,003,888 (75.5%)
PSC-TM 755,100 (6.4%) 792,268 (6.6%)
TM-only 237,974 (2.0%) 240,674 (2.0%)
None 1,928,337 (16.2%) 1,892,685 (15.9%)
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Discussion

Stroke is an unplanned time-sensitive critical illness and, as such, requires rapid access to hospitals prepared to treat acute stroke. Delayed presentation on the part of women has been thought to play a role in the 30% lower likelihood of women receiving acute stroke treatment (i.e., tPA) when compared to men.(Dougu et al., 2011; M. Reeves et al., 2009) This lack of acute treatment has been thought to contribute to the worse functional outcome seen in women following a stroke.(Dougu et al., 2011; M. Reeves et al., 2009) While it has been previously demonstrated that telemedicine increases both access to acute stroke care and tPA utilization, no study has investigated the association between sex and access to acute stroke care—with and without the use of telemedicine. We found no sex disparities in access to stand-alone PSCs, PSCs utilizing telemedicine, or hospitals using telemedicine for acute stroke care in the state of Texas. Our findings do not explain the delayed presentation and low tPA treatment rates that have been reported in women with acute stroke.(Hachinski et al., 2010; M. Reeves et al., 2009)

Telemedicine has the potential to increase access to PSCs and has been shown to increase use of tPA.(Choi et al., 2006),(Mullen, Kasner, et al., 2013) If our findings for Texas are generalizable nationally, then this raises the question of whether potential access to acute stroke care for women translates to realized access.(Andersen & Aday, 1978; Sibley & Weiner, 2011) Our study examined potential access (i.e., availability, accessibility) via travel time from place of residence to the nearest acute stroke care facility. In contrast, Mullen et al. examined where patients were actually treated for their acute stroke (i.e., realized access) using a national cohort study.(Mullen, Judd, et al., 2013) Our divergent findings raise important questions about acute stroke care for women. Are there other variables that facilitate or impede women in receiving acute stroke care at PSCs?(Andersen & Aday, 1978; Sibley & Weiner, 2011) What is the role of Emergency Medical Services (EMS) in selecting the hospital to which a patient will be transported?(Grotta, Savitz, & Persse, 2013) While longer EMS transport times have been reported for women with suspected acute coronary syndrome, reasons for this delay are understudied and not well understood.(Concannon et al., 2009; Ornato, 2009)

Our study is not without limitations. Our design does not account for patients who are transported across state lines. Additionally, our analysis was based on where people live, which may not be where every patient experiences stroke symptoms, although previous research has demonstrated that most strokes occur at home.(Kelly-Hayes et al., 1995) The drive times used in this study are calculated from trauma systems; stroke patients may have drive times that are 6 to 11 minutes longer.(Ramanujam et al., 2009; Wojner-Alexandrov, Alexandrov, Rodriguez, Persse, & Grotta, 2005) The drive time calculations do not account for traffic or geographic boundaries. Our definition of a stand-alone PSC included both primary stroke centers and comprehensive stroke centers certified by TJC, DNV, and the state of Texas, centers certified national quality improvement projects were not included in this definition.(Gropen et al., 2009) This study only accounts for access to PSCs or telemedicine facilities. It does not account for each individual hospital's ability to safely deliver tPA or employ other acute care strategies through existing transfer agreements (i.e., drip and ship).(Kleindorfer et al., 2009; Qureshi et al., 2012) Finally, this is an ecological study. Observations at the aggregate level do not necessarily represent associations at the individual level. This study is limited by its ecological nature and thus we are only able to report on two of the five domains of access to care: availability and accessibility. We acknowledge that accommodation, affordability, and accessibility are equally as important domains of access to care, but this data was not readily available.(Penchansky & Thomas, 1981)

Although women have more frequent and more severe strokes, they are less often treated with tPA which may result in the higher levels of poor functional outcomes seen in women after stroke. Our study found that men and women have equal potential access to all three types of hospitals that reported providing acute stroke care. While increasing access to stroke care has been an important public health endeavor with a focus on increasing access for groups that have historically been underserved, our study failed to show a sex disparity in potential access to acute stroke care. Further the results of this study suggest that telemedicine can be used as part of an inclusive strategy to improve access to care equally for men and women.

ACKNOWLEDGEMENTS

Dr. Boehme is supported by NINDS NIH T32 NS007153-31. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NINDS or the NIH.

Contributor Information

Catherine Wolff, University of Pennsylvania and Duke University.

Amelia K. Boehme, Columbia University.

Karen C. Albright, University of Alabama at Birmingham.

Tzu-Ching Wu, University of Texas-Houston Memorial Herman Medical Center.

Michael T. Mullen, University of Pennsylvania.

Charles C. Branas, University of Pennsylvania.

James C. Grotta, University of Texas-Houston Memorial Herman Medical Center.

Sean I. Savitz, University of Texas-Houston Memorial Herman Medical Center.

Brendan G. Carr, University of Pennsylvania.

REFERENCES

  1. Adams RJ, Debenham E, Chalela J, Chimowitz M, Hays A, Hill C, Turan TN. REACH MUSC: A Telemedicine Facilitated Network for Stroke: Initial Operational Experience. Front Neurol. 2012;3:33. doi: 10.3389/fneur.2012.00033. doi: 10.3389/fneur.2012.00033. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg MR, Walker MD. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA. 2000;283(23):3102–3109. doi: 10.1001/jama.283.23.3102. [DOI] [PubMed] [Google Scholar]
  3. Albright KC, Branas CC, Meyer BC, Matherne-Meyer DE, Zivin JA, Lyden PD, Carr BG. ACCESS: acute cerebrovascular care in emergency stroke systems. Arch Neurol. 2010;67(10):1210–1218. doi: 10.1001/archneurol.2010.250. doi: 10.1001/archneurol.2010.250. [DOI] [PubMed] [Google Scholar]
  4. Andersen R, Aday LA. Access to Medical Care in the U.S.: Realized and Potential. Medical Care. 1978;16(7):533–546. doi: 10.1097/00005650-197807000-00001. doi: 10.2307/3763653. [DOI] [PubMed] [Google Scholar]
  5. Association, A. H. AHA Guide. [10/2/2013];AHA Data and Directories. from http://www.aha.org/research/rc/stat-studies/data-and-directories.shtml.
  6. Audebert HJ, Schenkel J, Heuschmann PU, Bogdahn U, Haberl RL, Telemedic Pilot Project for Integrative Stroke Care, G. Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. Lancet Neurol. 2006;5(9):742–748. doi: 10.1016/S1474-4422(06)70527-0. doi: 10.1016/S1474-4422(06)70527-0. [DOI] [PubMed] [Google Scholar]
  7. Audebert HJ, Schultes K, Tietz V, Heuschmann PU, Bogdahn U, Haberl RL, Telemedical Project for Integrative Stroke, C. Long-term effects of specialized stroke care with telemedicine support in community hospitals on behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS). Stroke. 2009;40(3):902–908. doi: 10.1161/STROKEAHA.108.529255. doi: 10.1161/STROKEAHA.108.529255. [DOI] [PubMed] [Google Scholar]
  8. Bone RC, Sibbald WJ, Sprung CL. The ACCP-SCCM consensus conference on sepsis and organ failure. Chest. 1992;101(6):1481–1483. doi: 10.1378/chest.101.6.1481. [DOI] [PubMed] [Google Scholar]
  9. Branas CC, MacKenzie EJ, Williams JC, Schwab CW, Teter HM, Flanigan MC, ReVelle CS. Access to trauma centers in the United States. JAMA. 2005;293(21):2626–2633. doi: 10.1001/jama.293.21.2626. doi: 10.1001/jama.293.21.2626. [DOI] [PubMed] [Google Scholar]
  10. Carr B, Branas C. StrokeMaps.org Available from: www.strokemaps.org.
  11. Carr BG, Branas CC, Metlay JP, Sullivan AF, Camargo CA., Jr. Access to emergency care in the United States. Ann Emerg Med. 2009;54(2):261–269. doi: 10.1016/j.annemergmed.2008.11.016. doi: 10.1016/j.annemergmed.2008.11.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Carr BG, Caplan JM, Pryor JP, Branas CC. A meta-analysis of prehospital care times for trauma. Prehosp Emerg Care. 2006;10(2):198–206. doi: 10.1080/10903120500541324. doi: 10.1080/10903120500541324. [DOI] [PubMed] [Google Scholar]
  13. Choi JY, Porche NA, Albright KC, Khaja AM, Ho VS, Grotta JC. Using telemedicine to facilitate thrombolytic therapy for patients with acute stroke. Jt Comm J Qual Patient Saf. 2006;32(4):199–205. doi: 10.1016/s1553-7250(06)32025-9. [DOI] [PubMed] [Google Scholar]
  14. Concannon TW, Griffith JL, Kent DM, Normand SL, Newhouse JP, Atkins J, Selker HP. Elapsed time in emergency medical services for patients with cardiac complaints: are some patients at greater risk for delay? Circ Cardiovasc Qual Outcomes. 2009;2(1):9–15. doi: 10.1161/CIRCOUTCOMES.108.813741. doi: 10.1161/circoutcomes.108.813741. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Demaerschalk BM, Bobrow BJ, Raman R, Kiernan TE, Aguilar MI, Ingall TJ, Investigators, S. T. D. A. T. Stroke team remote evaluation using a digital observation camera in Arizona: the initial mayo clinic experience trial. Stroke. 2010;41(6):1251–1258. doi: 10.1161/STROKEAHA.109.574509. doi: 10.1161/STROKEAHA.109.574509. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Demaerschalk BM, Miley ML, Kiernan TE, Bobrow BJ, Corday DA, Wellik KE, Coinvestigators S. Stroke telemedicine. Mayo Clin Proc. 2009;84(1):53–64. doi: 10.4065/84.1.53. doi: 10.1016/S0025-6196(11)60808-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Dougu N, Takashima S, Sasahara E, Taguchi Y, Toyoda S, Hirai T, Inoue H. Predictors of poor outcome in patients with acute cerebral infarction. J Clin Neurol. 2011;7(4):197–202. doi: 10.3988/jcn.2011.7.4.197. doi: 10.3988/jcn.2011.7.4.197. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Gropen T, Magdon-Ismail Z, Day D, Melluzzo S, Schwamm LH, Group NA. Regional implementation of the stroke systems of care model: recommendations of the northeast cerebrovascular consortium. Stroke. 2009;40(5):1793–1802. doi: 10.1161/STROKEAHA.108.531053. doi: 10.1161/STROKEAHA.108.531053. [DOI] [PubMed] [Google Scholar]
  19. Grotta JC, Savitz SI, Persse D. Stroke severity as well as time should determine stroke patient triage. Stroke. 2013;44(2):555–557. doi: 10.1161/STROKEAHA.112.669721. doi: 10.1161/strokeaha.112.669721. [DOI] [PubMed] [Google Scholar]
  20. Hachinski V, Donnan GA, Gorelick PB, Hacke W, Cramer SC, Kaste M, Tuomilehto J. Stroke: working toward a prioritized world agenda. Stroke. 2010;41(6):1084–1099. doi: 10.1161/STROKEAHA.110.586156. doi: 10.1161/STROKEAHA.110.586156 41/6/1084 [pii] [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, Investigators E. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317–1329. doi: 10.1056/NEJMoa0804656. doi: 10.1056/NEJMoa0804656. [DOI] [PubMed] [Google Scholar]
  22. Hess DC, Wang S, Gross H, Nichols FT, Hall CE, Adams RJ. Telestroke: extending stroke expertise into underserved areas. Lancet Neurol. 2006;5(3):275–278. doi: 10.1016/S1474-4422(06)70377-5. doi: 10.1016/S1474-4422(06)70377-5. [DOI] [PubMed] [Google Scholar]
  23. Higashida R, Alberts MJ, Alexander DN, Crocco TJ, Demaerschalk BM, Derdeyn CP, American Heart Association Advocacy Coordinating, C. Interactions within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association. Stroke. 2013;44(10):2961–2984. doi: 10.1161/STR.0b013e3182a6d2b2. doi: 10.1161/STR.0b013e3182a6d2b2. [DOI] [PubMed] [Google Scholar]
  24. Kapral MK, Fang J, Hill MD, Silver F, Richards J, Jaigobin C, Cheung AM. Sex differences in stroke care and outcomes: results from the Registry of the Canadian Stroke Network. Stroke. 2005;36(4):809–814. doi: 10.1161/01.STR.0000157662.09551.e5. doi: 01.STR.0000157662.09551.e5 [pii] 10.1161/01.STR.0000157662.09551.e5. [DOI] [PubMed] [Google Scholar]
  25. Kelly-Hayes M, Wolf PA, Kase CS, Brand FN, McGuirk JM, D'Agostino RB. Temporal patterns of stroke onset. The Framingham Study. Stroke. 1995;26(8):1343–1347. doi: 10.1161/01.str.26.8.1343. [DOI] [PubMed] [Google Scholar]
  26. Kleindorfer D, Xu Y, Moomaw CJ, Khatri P, Adeoye O, Hornung R. US geographic distribution of rt-PA utilization by hospital for acute ischemic stroke. Stroke. 2009;40(11):3580–3584. doi: 10.1161/STROKEAHA.109.554626. doi: 10.1161/STROKEAHA.109.554626. [DOI] [PubMed] [Google Scholar]
  27. Lichtman JH, Jones SB, Wang Y, Watanabe E, Leifheit-Limson E, Goldstein LB. Outcomes after ischemic stroke for hospitals with and without Joint Commission-certified primary stroke centers. Neurology. 2011;76(23):1976–1982. doi: 10.1212/WNL.0b013e31821e54f3. doi: 10.1212/WNL.0b013e31821e54f3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Love RF, Morris JG. Mathematical Models of Road Travel Distances. Management Science. 1979;25(2):130–139. doi: 10.1287/mnsc.25.2.130. [Google Scholar]
  29. Love RF, Wesolowsky GO. Facilities Location: Models and Methods. North- Holland Publishers; New York: 1988. [Google Scholar]
  30. Meyer BC, Raman R, Hemmen T, Obler R, Zivin JA, Rao R, Lyden PD. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study. Lancet Neurol. 2008;7(9):787–795. doi: 10.1016/S1474-4422(08)70171-6. doi: 10.1016/S1474-4422(08)70171-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Miley ML, Demaerschalk BM, Olmstead NL, Kiernan TE, Corday DA, Chikani V, Bobrow BJ. The state of emergency stroke resources and care in rural Arizona: a platform for telemedicine. Telemed J E Health. 2009;15(7):691–699. doi: 10.1089/tmj.2009.0018. doi: 10.1089/tmj.2009.0018. [DOI] [PubMed] [Google Scholar]
  32. Mullen MT, Judd S, Howard VJ, Kasner SE, Branas CC, Albright KC, Carr BG. Disparities in evaluation at certified primary stroke centers: reasons for geographic and racial differences in stroke. Stroke. 2013;44(7):1930–1935. doi: 10.1161/STROKEAHA.111.000162. doi: 10.1161/STROKEAHA.111.000162. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Mullen MT, Kasner SE, Kallan MJ, Kleindorfer DO, Albright KC, Carr BG. Joint commission primary stroke centers utilize more rt-PA in the nationwide inpatient sample. J Am Heart Assoc. 2013;2(2):e000071. doi: 10.1161/JAHA.112.000071. doi: 10.1161/JAHA.112.000071 2/2/e000071 [pii] [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Ornato JP. Gender delay in emergency medical services: does it really exist? Circ Cardiovasc Qual Outcomes. 2009;2(1):4–5. doi: 10.1161/CIRCOUTCOMES.108.841916. doi: 10.1161/circoutcomes.108.841916. [DOI] [PubMed] [Google Scholar]
  35. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19(2):127–140. doi: 10.1097/00005650-198102000-00001. [DOI] [PubMed] [Google Scholar]
  36. Perednia DA, Allen A. Telemedicine technology and clinical applications. JAMA. 1995;273(6):483–488. [PubMed] [Google Scholar]
  37. Prabhakaran S, McNulty M, O'Neill K, Ouyang B. Intravenous thrombolysis for stroke increases over time at primary stroke centers. Stroke. 2012;43(3):875–877. doi: 10.1161/STROKEAHA.111.640060. doi: 10.1161/STROKEAHA.111.640060. [DOI] [PubMed] [Google Scholar]
  38. Qureshi AI, Chaudhry SA, Rodriguez GJ, Suri MF, Lakshminarayan K, Ezzeddine MA. Outcome of the ‘Drip-and-Ship’ Paradigm among Patients with Acute Ischemic Stroke: Results of a Statewide Study. Cerebrovasc Dis Extra. 2012;2(1):1–8. doi: 10.1159/000335097. doi: 10.1159/000335097. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Ramanujam P, Castillo E, Patel E, Vilke G, Wilson MP, Dunford JV. Prehospital transport time intervals for acute stroke patients. J Emerg Med. 2009;37(1):40–45. doi: 10.1016/j.jemermed.2007.11.092. doi: 10.1016/j.jemermed.2007.11.092. [DOI] [PubMed] [Google Scholar]
  40. Reeves M, Bhatt A, Jajou P, Brown M, Lisabeth L. Sex differences in the use of intravenous rt-PA thrombolysis treatment for acute ischemic stroke: a meta-analysis. Stroke. 2009;40(5):1743–1749. doi: 10.1161/STROKEAHA.108.543181. doi: 10.1161/STROKEAHA.108.543181 STROKEAHA.108.543181 [pii] [DOI] [PubMed] [Google Scholar]
  41. Reeves MJ, Arora S, Broderick JP, Frankel M, Heinrich JP, Hickenbottom S, Paul Coverdell Prototype Registries Writing, G. Acute stroke care in the US: results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry. Stroke. 2005;36(6):1232–1240. doi: 10.1161/01.STR.0000165902.18021.5b. doi: 10.1161/01.STR.0000165902.18021.5b. [DOI] [PubMed] [Google Scholar]
  42. Reeves MJ, Fonarow GC, Zhao X, Smith EE, Schwamm LH. Quality of care in women with ischemic stroke in the GWTG program. Stroke. 2009;40(4):1127–1133. doi: 10.1161/STROKEAHA.108.543157. doi: 10.1161/STROKEAHA.108.543157 STROKEAHA.108.543157 [pii] [DOI] [PubMed] [Google Scholar]
  43. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, Stroke Statistics, S. Heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2–e220. doi: 10.1161/CIR.0b013e31823ac046. doi: 10.1161/CIR.0b013e31823ac046. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Roth DL, Haley WE, Clay OJ, Perkins M, Grant JS, Rhodes JD, Howard G. Race and gender differences in 1-year outcomes for community-dwelling stroke survivors with family caregivers. Stroke. 2011;42(3):626–631. doi: 10.1161/STROKEAHA.110.595322. doi: 10.1161/STROKEAHA.110.595322. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Saler M, Switzer JA, Hess DC. Use of telemedicine and helicopter transport to improve stroke care in remote locations. Curr Treat Options Cardiovasc Med. 2011;13(3):215–224. doi: 10.1007/s11936-011-0124-y. doi: 10.1007/s11936-011-0124-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Schwamm LH, Ali SF, Reeves MJ, Smith EE, Saver JL, Messe S, Fonarow GC. Temporal Trends in Patient Characteristics and Treatment With Intravenous Thrombolysis Among Acute Ischemic Stroke Patients at Get With the Guidelines-Stroke Hospitals. Circ Cardiovasc Qual Outcomes. 2013 doi: 10.1161/CIRCOUTCOMES.111.000303. doi: CIRCOUTCOMES.111.000095 [pii] 10.1161/CIRCOUTCOMES.111.000095. [DOI] [PubMed] [Google Scholar]
  47. Schwamm LH, Audebert HJ, Amarenco P, Chumbler NR, Frankel MR, George MG, Intervention Recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. Stroke. 2009;40(7):2635–2660. doi: 10.1161/STROKEAHA.109.192361. doi: 10.1161/STROKEAHA.109.192361. [DOI] [PubMed] [Google Scholar]
  48. Services, T. D. o. S. H. [9/13/2013];Requirements for Stroke Facility Designation. 2009 from http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=25&pt=1&ch=157&rl=133.
  49. Services, T. D. o. S. H. Texas Stroke Facilities. 2013 9/25/2013 from http://www.dshs.state.tx.us/emstraumasystems/etrastroke.shtm. [Google Scholar]
  50. Sibley LM, Weiner JP. An evaluation of access to health care services along the rural-urban continuum in Canada. BMC Health Serv Res. 2011;11:20. doi: 10.1186/1472-6963-11-20. doi: 10.1186/1472-6963-11-20. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Stewart SF, Switzer JA. Perspectives on telemedicine to improve stroke treatment. Drugs Today (Barc) 2011;47(2):157–167. doi: 10.1358/dot.2011.47.2.1576694. doi: 10.1358/dot.2011.47.2.1576694. [DOI] [PubMed] [Google Scholar]
  52. Switzer JA, Demaerschalk BM, Xie J, Fan L, Villa KF, Wu EQ. Cost-effectiveness of hub-and-spoke telestroke networks for the management of acute ischemic stroke from the hospitals' perspectives. Circ Cardiovasc Qual Outcomes. 2013;6(1):18–26. doi: 10.1161/CIRCOUTCOMES.112.967125. doi: 10.1161/CIRCOUTCOMES.112.967125. [DOI] [PubMed] [Google Scholar]
  53. Switzer JA, Hall C, Gross H, Waller J, Nichols FT, Wang S, Hess DC. A web-based telestroke system facilitates rapid treatment of acute ischemic stroke patients in rural emergency departments. J Emerg Med. 2009;36(1):12–18. doi: 10.1016/j.jemermed.2007.06.041. doi: 10.1016/j.jemermed.2007.06.041. [DOI] [PubMed] [Google Scholar]
  54. Switzer JA, Hess DC. Development of regional programs to speed treatment of stroke. Curr Neurol Neurosci Rep. 2008;8(1):35–42. doi: 10.1007/s11910-008-0007-0. [DOI] [PubMed] [Google Scholar]
  55. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333(24):1581–1587. doi: 10.1056/NEJM199512143332401. doi: 10.1056/NEJM199512143332401. [DOI] [PubMed] [Google Scholar]
  56. TJC. The Joint Commission: Advanced Certification for Primary Stroke Centers. 2013 2013, from http://www.jointcommission.org/certification/primary_stroke_centers.aspx.
  57. Towfighi A, Saver JL. Stroke declines from third to fourth leading cause of death in the United States: historical perspective and challenges ahead. Stroke. 2011;42(8):2351–2355. doi: 10.1161/STROKEAHA.111.621904. doi: 10.1161/STROKEAHA.111.621904. [DOI] [PubMed] [Google Scholar]
  58. USCensusBureau US Census Bureau: State and Country Quickfacts. 2010 Thursday; 14-Mar-2013 11:17:50 EDT Retrieved November 26, 2011, from http://quickfacts.census.gov/qfd/states/48000.html.
  59. Veritas DN. DNV Stroke Center Certifications. 2013 from http://dnvaccreditation.com/pr/dnv/primary-stroke-center-certification.aspx.
  60. Wojner-Alexandrov AW, Alexandrov AV, Rodriguez D, Persse D, Grotta JC. Houston paramedic and emergency stroke treatment and outcomes study (HoPSTO). Stroke. 2005;36(7):1512–1518. doi: 10.1161/01.STR.0000170700.45340.39. doi: 10.1161/01.STR.0000170700.45340.39. [DOI] [PubMed] [Google Scholar]
  61. Wu TC, Lyerly MJ, Albright KC, Ward E, Hassler A, Messier J, Carr BG. Impact of Telemedicine on Access to Acute Stroke Care in the State of Texas. Ann Clin Transl Neurol. 2014;1(1):27–33. doi: 10.1002/acn3.20. doi: 10.1002/acn3.20. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702–706. doi: 10.1093/aje/kwh090. [DOI] [PubMed] [Google Scholar]

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