Kefeng Wang

Sex Disparities in Ischemic Stroke Care: FL-PR CReSD Study (Florida–Puerto Rico Collaboration to Reduce Stroke Disparities)

Background and Purpose— Sex-specific disparities in stroke care including thrombolytic therapy and early hospital admission are reported. In a large registry of Florida and Puerto Rico hospitals participating in the Get With The Guidelines—Stroke program, we sought to determine sex-specific differences in ischemic stroke performance metrics and overall thrombolytic treatment. Methods— Around 51 317 (49% women) patients were included from 73 sites from 2010 to 2014. Multivariable logistic regression with generalized estimating equations evaluated sex-specific differences in the prespecified Get With The Guidelines—Stroke metrics for defect-free care in ischemic stroke, adjusting for age, race-ethnicity, insurance status, hospital characteristics, individual risk factors, and the presenting stroke severity. Results— As compared with men, women were older (73±15 versus 69±14 years; P<0.0001), more hypertensive (67% versus 63%, P<0.0001), and had more atrial fibrillation (19% versus 16%; P<0.0001). Defect-free care was slightly lower in women than in men (odds ratio, 0.96; 95% confidence interval, 0.93–1.00). Temporal trends in defect-free care improved substantially and similarly for men and women, with a 29% absolute improvement in women (P<0.0001) and 28% in men (P<0.0001), with P value of 0.13 for time-by-sex interaction. Women were less likely to receive thrombolysis (odds ratio, 0.92; 95% confidence interval, 0.86–0.99; P=0.02) and less likely to have a door-to-needle time <1 hour (odds ratio, 0.83; 95% confidence interval, 0.71–0.97; P=0.02) as compared with men. Conclusions— Women received comparable stroke care to men in this registry as measured by prespecified Get With The Guidelines metrics. However, women less likely received thrombolysis and had door-to-needle time <1 hour, an observation that calls for the implementation of interventions to reduce sex disparity in these measures.

Neighborhood Greenness and Chronic Health Conditions in Medicare Beneficiaries

INTRODUCTION Prior studies suggest that exposure to the natural environment may impact health. The present study examines the association between objective measures of block-level greenness (vegetative presence) and chronic medical conditions, including cardiometabolic conditions, in a large population-based sample of Medicare beneficiaries in Miami-Dade County, Florida. METHODS The sample included 249,405 Medicare beneficiaries aged ≥65 years whose location (ZIP+4) within Miami-Dade County, Florida, did not change, from 2010 to 2011. Data were obtained in 2013 and multilevel analyses conducted in 2014 to examine relationships between greenness, measured by mean Normalized Difference Vegetation Index from satellite imagery at the Census block level, and chronic health conditions in 2011, adjusting for neighborhood median household income, individual age, gender, race, and ethnicity. RESULTS Higher greenness was significantly associated with better health, adjusting for covariates: An increase in mean block-level Normalized Difference Vegetation Index from 1 SD less to 1 SD more than the mean was associated with 49 fewer chronic conditions per 1,000 individuals, which is approximately similar to a reduction in age of the overall study population by 3 years. This same level of increase in mean Normalized Difference Vegetation Index was associated with a reduced risk of diabetes by 14%, hypertension by 13%, and hyperlipidemia by 10%. Planned post-hoc analyses revealed stronger and more consistently positive relationships between greenness and health in lower- than higher-income neighborhoods. CONCLUSIONS Greenness or vegetative presence may be effective in promoting health in older populations, particularly in poor neighborhoods, possibly due to increased time outdoors, physical activity, or stress mitigation.

Walking and Proximity to the Urban Growth Boundary and Central Business District

BACKGROUND Planners have relied on the urban development boundary (UDB)/urban growth boundary (UGB) and central business district (CBD) to encourage contiguous urban development and conserve infrastructure. However, no studies have specifically examined the relationship between proximity to the UDB/UGB and CBD and walking behavior. PURPOSE To examine the relationship between UDB and CBD distance and walking in a sample of recent Cuban immigrants, who report little choice in where they live after arrival to the U.S. METHODS Data were collected in 2008-2010 from 391 healthy, recent Cuban immigrants recruited and assessed within 90 days of arrival to the U.S. who resided throughout Miami-Dade County FL. Analyses in 2012-2013 examined the relationship between UDB and CBD distances for each participants residential address and purposive walking, controlling for key sociodemographics. Follow-up analyses examined whether Walk Score(®), a built-environment walkability metric based on distance to amenities such as stores and parks, mediated the relationship between purposive walking and each of UDB and CBD distance. RESULTS Each one-mile increase in distance from the UDB corresponded to an 11% increase in the number of minutes of purposive walking, whereas each one-mile increase from the CBD corresponded to a 5% decrease in the amount of purposive walking. Moreover, Walk Score mediated the relationship between walking and each of UDB and CBD distance. CONCLUSIONS Given the lack of walking and walkable destinations observed in proximity to the UDB/UGB boundary, a sprawl repair approach could be implemented, which strategically introduces mixed-use zoning to encourage walking throughout the boundarys zone.

Accreditation status and geographic location of outpatient vascular testing facilities among Medicare beneficiaries: The VALUE (Vascular Accreditation, Location & Utilization Evaluation) Study

Objective: There is limited information on the accreditation status and geographic distribution of vascular testing facilities in the US. The Centers for Medicare & Medicaid Services (CMS) provide reimbursement to facilities regardless of accreditation status. The aims were to: (1) identify the proportion of Intersocietal Accreditation Commission (IAC) accredited vascular testing facilities in a 5% random national sample of Medicare beneficiaries receiving outpatient vascular testing services; (2) describe the geographic distribution of these facilities. Methods: The VALUE (Vascular Accreditation, Location & Utilization Evaluation) Study examines the proportion of IAC accredited facilities providing vascular testing procedures nationally, and the geographic distribution and utilization of these facilities. The data set containing all facilities that billed Medicare for outpatient vascular testing services in 2011 (5% CMS Outpatient Limited Data Set (LDS) file) was examined, and locations of outpatient vascular testing facilities were obtained from the 2011 CMS/Medicare Provider of Services (POS) file. Results: Of 13,462 total vascular testing facilities billing Medicare for vascular testing procedures in a 5% random Outpatient LDS for the US in 2011, 13% (n=1730) of facilities were IAC accredited. The percentage of IAC accredited vascular testing facilities in the LDS file varied significantly by US region, p<0.0001: 26%, 12%, 11%, and 7% for the Northeast, South, Midwest, and Western regions, respectively. Conclusions: Findings suggest that the proportion of outpatient vascular testing facilities that are IAC accredited is low and varies by region. Increasing the number of accredited vascular testing facilities to improve test quality is a hypothesis that should be tested in future research.

Health Disparities in the Relationship of Neighborhood Greenness to Mental Health Outcomes in 249,405 U.S. Medicare Beneficiaries

Prior studies suggest that exposure to the natural environment may be important for optimal mental health. The present study examines the association between block-level greenness (vegetative presence) and mental health outcomes, in a population-based sample of 249,405 U.S. Medicare beneficiaries aged ≥65 years living in Miami-Dade County, Florida, USA, whose location did not change from 2010 to 2011. Multilevel analyses examined relationships between greenness, as measured by mean Normalized Difference Vegetation Index from satellite imagery at the Census block level, and each of two mental health outcomes; Alzheimer’s disease and depression, respectively, after statistically adjusting for age, gender, race/ethnicity, and neighborhood income level of the individuals. Higher block-level greenness was linked to better mental health outcomes: There was a reduced risk of Alzheimer’s disease (by 18%) and depression (by 28%) for beneficiaries living in blocks that were 1 SD above the mean for greenness, as compared to blocks that were 1 SD below the mean. Planned post-hoc analyses revealed that higher levels of greenness were associated with even greater mental health benefits in low-income neighborhoods: An increase in greenness from 1 SD below to 1 SD above the mean was associated with 37% lower odds of depression in low-income neighborhoods, compared to 27% and 21% lower odds of depression in medium- and high-income neighborhoods, respectively. Greenness may be effective in promoting mental health in older adults, particularly in low-income neighborhoods, possibly as a result of the increased opportunities for physical activity, social interaction, or stress mitigation.

Racial-Ethnic Disparities in Acute Stroke Care in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study.

Background Racial‐ethnic disparities in acute stroke care can contribute to inequality in stroke outcomes. We examined race‐ethnic disparities in acute stroke performance metrics in a voluntary stroke registry among Florida and Puerto Rico Get With the Guidelines‐Stroke hospitals. Methods and Results Seventy‐five sites in the Florida Puerto Rico Stroke Registry (66 Florida and 9 Puerto Rico) recorded 58 864 ischemic stroke cases (2010–2014). Logistic regression models examined racial‐ethnic differences in acute stroke performance measures and defect‐free care (intravenous tissue plasminogen activator treatment, in‐hospital antithrombotic therapy, deep vein thrombosis prophylaxis, discharge antithrombotic therapy, appropriate anticoagulation therapy, statin use, smoking cessation counseling) and temporal trends. Among ischemic stroke cases, 63% were non‐Hispanic white (NHW), 18% were non‐Hispanic black (NHB), 14% were Hispanic living in Florida, and 6% were Hispanic living in Puerto Rico. NHW patients were the oldest, followed by Hispanics, and NHBs. Defect‐free care was greatest among NHBs (81%), followed by NHWs (79%) and Florida Hispanics (79%), then Puerto Rico Hispanics (57%) (P<0.0001). Puerto Rico Hispanics were less likely than Florida whites to meet any stroke care performance metric other than anticoagulation. Defect‐free care improved for all groups during 2010–2014, but the disparity in Puerto Rico persisted (2010: NHWs=63%, NHBs=65%, Florida Hispanics=59%, Puerto Rico Hispanics=31%; 2014: NHWs=93%, NHBs=94%, Florida Hispanics=94%, Puerto Rico Hispanics=63%). Conclusions Racial‐ethnic/geographic disparities were observed for acute stroke care performance metrics. Adoption of a quality improvement program improved stroke care from 2010 to 2014 in Puerto Rico and all Florida racial‐ethnic groups. However, stroke care quality delivered in Puerto Rico is lower than in Florida. Sustained support of evidence‐based acute stroke quality improvement programs is required to improve stroke care and minimize racial‐ethnic disparities, particularly in resource‐strained Puerto Rico.

Intersocietal Accreditation Commission Accreditation Status of Outpatient Cerebrovascular Testing Facilities Among Medicare Beneficiaries The VALUE Study

Accreditation of cerebrovascular ultrasound laboratories by the Intersocietal Accreditation Commission (IAC) and equivalent organizations is supported by the Joint Commission certification of stroke centers. Limited information exists on the accreditation status and geographic distribution of cerebrovascular testing facilities in the United States. Our study objectives were to identify the proportion of IAC‐accredited outpatient cerebrovascular testing facilities used by Medicare beneficiaries, describe their geographic distribution, and identify variations in cerebrovascular testing procedure types and volumes by accreditation status.

Predictors of Thrombolysis Administration in Mild Stroke: Florida-Puerto Rico Collaboration to Reduce Stroke Disparities

Background and Purpose— Mild stroke is the most common cause for thrombolysis exclusion in patients acutely presenting to the hospital. Thrombolysis administration in this subgroup is highly variable among different clinicians and institutions. We aim to study the predictors of thrombolysis in patients with mild ischemic stroke in the FL-PR CReSD registry (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities). Methods— Among 73 712 prospectively enrolled patients with a final diagnosis of ischemic stroke or TIA from January 2010 to April 2015, we identified 7746 cases with persistent neurological symptoms and National Institutes of Health Stroke Scale ⩽5 who arrived within 4 hours of symptom onset. Multilevel logistic regression analysis with generalized estimating equations was used to identify independent predictors of thrombolytic administration in the subgroup of patients without contraindications to thrombolysis. Results— We included 6826 cases (final diagnosis mild stroke, 74.6% and TIA, 25.4%). Median age was 72 (interquartile range, 21); 52.7% men, 70.3% white, 12.9% black, 16.8% Hispanic; and median National Institutes of Health Stroke Scale, 2 (interquartile range, 3). Patients who received thrombolysis (n=1281, 18.7%) were younger (68 versus 72 years), had less vascular risk factors (hypertension, diabetes mellitus, and dyslipidemia), had lower risk of prior vascular disease (myocardial infarction, peripheral vascular disease, and previous stroke), and had a higher presenting median National Institutes of Health Stroke Scale (4 versus 2). In the multilevel multivariable model, early hospital arrival (arrive by 0–2 hours versus ≥3.5 hours; odds ratio [OR], 8.16; 95% confidence interval [CI], 4.76–13.98), higher National Institutes of Health Stroke Scale (OR, 1.87; 95% CI, 1.77–1.98), aphasia at presentation (OR, 1.35; 95% CI, 1.12–1.62), faster door-to-computed tomography time (OR, 1.81; 95% CI, 1.53–2.15), and presenting to an academic hospital (OR, 2.02; 95% CI, 1.39–2.95) were independent predictors of thrombolysis administration. Conclusions— Mild acutely presenting stroke patients are more likely to receive thrombolysis if they are young, white, or Hispanic and arrive early to the hospital with more severe neurological presentation. Identification of predictors of thrombolysis is important in design of future studies to assess the use of thrombolysis for mild stroke.

Disparities and Trends in Door-to-Needle Time: The FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities).

Background and Purpose— In the United States, about half of acute ischemic stroke patients treated with tPA (tissue-type plasminogen activator) receive treatment within 60 minutes of hospital arrival. We aimed to determine the proportion of patients receiving tPA within 60 minutes (door-to-needle time [DTNT] ⩽60) and 45 minutes (DTNT ⩽45) of hospital arrival by race/ethnicity and sex and to identify temporal trends in DTNT ⩽60 and DTNT ⩽45. Methods— Among 65 654 acute ischemic stroke admissions in the National Institute of Neurological Disorders and Stroke-funded FL-PR CReSD study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) from 2010 to 2015, we included 6181 intravenous tPA-treated cases (9.4%). Generalized estimating equations were used to determine predictors of DTNT ⩽60 and DTNT ⩽45. Results— DTNT ⩽60 was achieved in 42% and DTNT ⩽45 in 18% of cases. After adjustment, women less likely received DTNT ⩽60 (odds ratio, 0.81; 95% confidence interval, 0.72–0.92) and DTNT ⩽45 (odds ratio, 0.73; 95% confidence interval, 0.57–0.93). Compared with Whites, Blacks less likely had DTNT ⩽45 during off hours (odds ratio, 0.68; 95% confidence interval, 0.47–0.98). Achievement of DTNT ⩽60 and DTNT ⩽45 was highest in South Florida (50%, 23%) and lowest in West Central Florida (28%, 11%). Conclusions— In the FL-PR CReSD, achievement of DTNT ⩽60 and DTNT ⩽45 remains low. Compared with Whites, Blacks less likely receive tPA treatment within 45 minutes during off hours. Treatment within 60 and 45 minutes is lower in women compared with men and lowest in West Central Florida compared with other Florida regions and Puerto Rico. Further research is needed to identify reasons for delayed thrombolytic treatment in women and Blacks and factors contributing to regional disparities in DTNT.

Need to Prioritize Education of the Public Regarding Stroke Symptoms and Faster Activation of the 9-1-1 System: Findings from the Florida–Puerto Rico CReSD Stroke Registry

Abstract Objective: Demographic differences (race/ethnicity/sex) in 9-1-1 emergency medical services (EMS) access and utilization have been reported for various time-dependent critical illnesses along with associated outcome disparities. However, data are lacking with respect to measuring the various components of time taken to reach definitive care facilities following the onset of acute stroke symptoms (i.e., stroke onset to 9-1-1 call, EMS response, time on-scene, transport interval) and particularly with respect to any differences across ethnicities and sex. Therefore, the specific aim of this study was to measure the various time intervals elapsing following the first symptom onset (FSO) from an acute stroke until stroke hospital arrival (SHA) and to delineate any race/ethnic/sex-related differences among any of those measurements. Methods: The Florida-Puerto Rico Stroke Registry (FLPRSR) is an on-going, voluntary stroke registry of hospitals participating in the Get with the Guidelines-Stroke initiative. The study population included patients treated at Florida hospitals participating in the FLPRSR between 2010 and 2014 who had called 9-1-1 and were managed and transported by EMS. In total, 10,481 patients (16% black, 8% Hispanic, 74% white) had complete data-sets that included birthdate/year, sex, ethnic background, date/hour/minute of FSO and date/hour/minute of EMS response, scene arrival, and SHA. Results: Median time from FSO to SHA was 339 minutes (interquartile range [IQR] of 284–442), 301 of which constituted the time elapsed from FSO to the 9-1-1 call (IQR =249–392) versus only 10 from 9-1-1 call to EMS arrival (IQR =7–14), 14 on-scene (IQR =11–18) and 12 for transport to SHA (IQR =8–19). The FSO to 9-1-1 call interval, being by far the longest interval, was longest among whites and blacks (302 minutes for both) versus 291 for Hispanics (p = 0.01). However, this 11-minute difference was not deemed clinically-significant. There were neither significant sex-related differences nor any racial/ethnic/sex differences in the relatively short EMS-related intervals. Conclusions: Following acute stroke onset, time elapsed for EMS response and transport is relatively short compared to the lengthy intervals elapsing between symptom onset and 9-1-1 system activation, regardless of demographics. Exploration of innovative strategies to improve public education regarding stroke symptoms and immediate 9-1-1 system activation are strongly recommended.