Demographic Disparities in Proximity to Certified Stroke Care in the United States

Background and Purpose: Demographic disparities in proximity to stroke care influence time to treatment and clinical outcome but remain understudied at the national level. This study quantifies the relationship between distance to the nearest certified stroke hospital and census-derived demographics. Methods: This cross-sectional study included population data by census tract from the United States Census Bureau's 2014-2018 American Community Survey, stroke hospitals certified by a state or national body and providing intravenous thrombolysis, and geographic data from a public mapping service. Data were retrieved from March to November 2020. Quantile regression analysis was used to compare relationships between road distance to the nearest stroke center for each census tract and tract-level demographics of age, race, ethnicity, medical insurance status, median annual income, and population density. Results: Two thousand three hundred eighty-eight stroke centers and 71 929 census tracts including 316 995 649 individuals were included. Forty-nine thousand nine hundred eighteen (69%) tracts were urban. Demographic disparities in proximity to certified stroke care were greater in nonurban areas than urban areas. Higher representation of individuals with age ≥65 years was associated with increased median distance to a certified stroke center in nonurban areas (0.51 km per 1% increase [99.9% CI, 0.42-0.59]) but not in urban areas (0.00 km [-0.01 to 0.01]). In urban and nonurban tracts, median distance was greater with higher representation of American Indian (urban: 0.10 km per 1% increase [0.06-0.14]; nonurban: 1.06 km [0.98-1.13]) or uninsured populations (0.02 km [0.00-0.03]; 0.27 km [0.15-0.38]). Each $10 000 increase in median income was associated with a decrease in median distance of 5.04 km [4.31-5.78] in nonurban tracts, and an increase of 0.17 km [0.10-0.23] in urban tracts. Conclusions: Disparities were greater in nonurban areas than in urban areas. Nonurban census tracts with greater representation of elderly, American Indian, or uninsured people, or low median income were substantially more distant from certified stroke care.