Original Article
Community Socioeconomic and Urban–Rural Disparities in Prehospital Notification of Stroke by Emergency Medical Services in North Carolina
Abstract
Objectives: Notification by emergency medical services (EMS) to the destination hospital of an incoming suspected stroke patient is associated with timelier in-hospital evaluation and treatment. Current data on adherence to this evidence-based best practice are limited, however. We examined the frequency of EMS stroke prenotification in North Carolina by community socioeconomic status (SES) and rurality.Methods: Using a statewide database of EMS patient care reports, we selected 9-1-1 responses in 2019 with an EMS provider impression of stroke or documented stroke care protocol use. Eligible patients were 18 years old and older with a completed prehospital stroke screen. Incident street addresses were geocoded to North Carolina census tracts and linked to American Community Survey socioeconomic data and urban–rural commuting area codes. High, medium, and low SES tracts were defined by SES index tertiles. Tracts were classified as urban, suburban, and rural. We used multivariable logistic regression to estimate independent associations between tract-level SES and rurality with EMS prenotification, adjusting for patient age, sex, and race/ethnicity; duration of symptoms; incident day of week and time of day; 9-1-1 dispatch complaint; EMS provider primary impression; and prehospital stroke screen interpretation.
Results: The cohort of 9527 eligible incidents was mostly at least 65 years old (65%), female (55%), and non-Hispanic White (71%). EMS prenotification occurred in 2783 (29%) patients. Prenotification in low SES tracts (27%) occurred less often than in medium (30%) and high (32%) SES tracts. Rural tracts had the lowest frequency (21%) compared with suburban (28%) and urban (31%) tracts. In adjusted analyses, EMS prenotification was less likely in low SES (vs high SES; odds ratio 0.76, 95% confidence interval 0.67–0.88) and rural (vs urban; odds ratio 0.64, 95% confidence interval 0.52–0.77) tracts.
Conclusions: Across a large, diverse population, EMS prenotification occurred in only one-third of suspected stroke patients. Furthermore, low SES and rural tracts were independently associated with a lower likelihood of prehospital notification. These findings suggest the need for education and quality improvement initiatives to increase EMS stroke prenotification, particularly in underserved communities.
Posted in: Neurology17
This content is limited to qualifying members.
Existing members, please login first
If you have an existing account please login now to access this article or view purchase options.
Purchase only this article ($25)
Create a free account, then purchase this article to download or access it online for 24 hours.
Purchase an SMJ online subscription ($75)
Create a free account, then purchase a subscription to get complete access to all articles for a full year.
Purchase a membership plan (fees vary)
Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.
References
1. Sacco RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:2064–2089.
2. Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics—2021 update: a report from the American Heart Association. Circulation 2021;143: e254–e743.
3. Kumar S, Selim MH, Caplan LR. Medical complications after stroke. Lancet Neurol 2010;9:105–118.
4. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics-2022 update: a report from the American Heart Association. Circulation 2022; 145:e153–e639.
5. Howard G, Howard VJ. Twenty years of progress toward understanding the stroke belt. Stroke 2020;51:742–750.
6. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019;50:e344–e418.
7. Lacy CR, Suh DC, Bueno M, et al. Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.). Stroke 2001;32:63–69.
8. Menon SC, Pandey DK, Morgenstern LB. Critical factors determining access to acute stroke care. Neurology 1998;51:427–432.
9. Morris DL, Rosamond W, Madden K, et al. Prehospital and emergency department delays after acute stroke: the Genentech Stroke Presentation Survey. Stroke 2000;31:2585–2590.
10. Rossnagel K, Jungehülsing GJ, Nolte CH, et al. Out-of-hospital delays in patients with acute stroke. Ann Emerg Med 2004;44:476–483.
11. Schroeder EB, RosamondWD,Morris DL, et al. 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;31:2591–2596.
12. Jauch EC, Saver JL, Adams HP, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870–947.
13. Lin CB, Peterson ED, Smith EE, et al. Emergency medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke. Circ Cardiovasc Qual Outcomes 2012;5:514–522.
14. McKinney JS, Mylavarapu K, Lane J, et al. Hospital prenotification of stroke patients by emergency medical services improves stroke time targets. J Stroke Cerebrovasc Dis 2013;22:113–118.
15. Nielsen VM, DeJoie-Stanton C, Song G, et al. The association between presentation by EMS and EMS Prenotification with receipt of intravenous tissue-type plasminogen activator in a state implementing stroke systems of care. Prehosp Emerg Care 2020;24:319–325.
16. Patel MD, Rose KM, O’brien EC, et al. Prehospital notification by emergency medical services reduces delays in stroke evaluation: findings from the North Carolina Stroke Care Collaborative. Stroke 2011;42:2263–2268.
17. Asaithambi G, Tong X, Lakshminarayan K, et al. Emergency medical services Utilization for acute stroke care: analysis of the Paul Coverdell National Acute Stroke Program, 2014–2019. Prehosp Emerg Care 2022;26:326–332.
18. Patel MD, Brice JH, Evenson KR, et al. Emergency medical services capacity for prehospital stroke care in North Carolina. Prev Chronic Dis 2013;10:E149.
19. Hammond G, Luke AA, Elson L, et al. Urban-rural inequities in acute stroke care and in-hospital mortality. Stroke 2020;51:2131–2138.
20. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff (Millwood) 2002;21:60–76.
21. Caldwell JT, Ford CL, Wallace SP, et al. Intersection of living in a rural versus urban area and race/ethnicity in explaining access to health care in the United States. Am J Public Health 2016;106:1463–1469.
22. Centers for Disease Control and Prevention. About underlying cause of death 1999–2020. https://wonder.cdc.gov/ucd-icd10.html. Published 2021. Accessed October 6, 2022.
23. Rural Health Information Hub. North Carolina. https://www.ruralhealthinfo.org/states/north-carolina. Accessed January 28, 2022.
24. Harris L.R. 2020 Poverty Report: persistent poverty demands a just recovery for North Carolinians. https://www.ncjustice.org/publications/2020-poverty-report-persistent-poverty-demands-a-just-recovery-for-north-carolinians/. Published October 20, 2020. Accessed October 6, 2022.
25. Bonito AJ, Bann C, Eicheldinger C, et al. Creation of New Race-Ethnicity Codes and Socioeconomic Status (SES) Indicators for Medicare Beneficiaries: Final Report. Washington, DC: Agency for Healthcare Research and Quality; 2008.
26. Weeks WB, Kazis LE, Shen Y, et al. Differences in health-related quality of life in rural and urban veterans. Am J Public Health 2004;94:1762–1767.
27. Chari SV, Cui ER, Fehl HE, et al. Community socioeconomic and urban-rural differences in emergency medical services times for suspected stroke in North Carolina. Am J Emerg Med 2023;63:120–126.
28. Gonzales S, Mullen MT, Skolarus L, et al. Progressive rural–urban disparity in acute stroke care. Neurology 2017;88:441–448.
29. Kapral MK, Fang J, Chan C, et al. Neighborhood income and stroke care and outcomes. Neurology 2012;79:1200–1207.
30. Fujiwara S, Kuroda T, Matsuoka Y, et al. Prehospital stroke notification and endovascular therapy for large vessel occlusion: a retrospective cohort study. Sci Rep 2022;12:10107.
31. Hsieh MJ, Tang SC, Chiang WC, et al. Effect of prehospital notification on acute stroke care: a multicenter study. Scand J Trauma Resusc Emerg Med 2016;24:57.
32. Adeoye O, Nyström KV, Yavagal DR, et al. Recommendations for the establishment of stroke systems of care: a 2019 update: a policy statement from the American Stroke Association. Stroke 2019;50:e187–e210.
33. Rudd AG, Bladin C, Carli P, et al. Utstein recommendation for emergency stroke care. Int J Stroke 2020;15:555–564.
34. Gunderson MR, Florin A, Price M, et al. NEMSMA position statement and white paper: process and outcomes data sharing between EMS and receiving hospitals. Prehosp Emerg Care 2021;25:307–313.
