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GIS Analysis of Veterans' Access to Acute Stroke Care

Litt ER, Cowper Ripley DC, Vogel WB, Phipps MS, Wang X, Harnar JA, Graham GD, Jia H. GIS Analysis of Veterans' Access to Acute Stroke Care. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.


Research Objectives Stroke is a major medical diagnosis among Veterans Health Administration (VHA) enrollees, and quality of care is enhanced when patients with acute stroke are admitted within one hour to a facility that has acute stroke treatment capability. However, about 3.3 million VHA enrollees are rural residents and may live far away from a VHA stroke center. In this study, we sought to determine VHA enrollees' and stroke patients' access to VHA and non-VHA acute stroke care by travel time. Study Design In this retrospective, observational study, we included (1) all VHA enrollees aged 65 and older in fiscal year (FY) 2010 and (2) all VHA patients diagnosed with acute ischemic stroke, transient ischemic attack, or intracerebral hemorrhage during FY2006 through FY2010. We used Geographic Information System (GIS) software to map 60-minute ground transportation bands from the enrollees' and stroke patients' residential ZIP codes to the closest VHA and non-VHA stroke care facilities nationally. We calculated the percentage of the enrollees and stroke patients falling within these travel bands, and determined the differences in access when local non-VHA stroke facilities were included. All GIS analyses were conducted using the ARC-GIS software version 10 from ESRI (Redlands, CA). Population Studied All VHA enrollees aged 65 and older and VHA patients diagnosed with acute stroke. Principal Findings We identified 4,694,511 VHA enrollees in FY2010 who were older than 65 years of age and 59,127 unique patients with acute stroke between FY2006 and FY2010. Based on recently mandated VHA stroke center criteria, there are 65 VHA medical centers providing acute stroke care (including 33 full-time primary stroke centers and 32 limited hours stroke facilities) and 1,074 Joint Commission certified non-VHA Primary Stroke Centers across the nation. Our GIS analyses showed that (1) 1,277,099 (27.2%) VHA enrollees over the age of 65 and 28,094 (47.5%) patients with acute stroke lived within 60-minute driving time from a VHA stroke center. With the addition of the non-VHA private stroke centers, the overall 60-minute driving time coverage would increase from 27.2% to 41.7% for VHA enrollees over the age of 65 and from 47.5% to 61.2% for acute stroke patients. Conclusions While up to 47.5% of the VHA enrollees and 61.2% of the VHA stroke patients could potentially receive acute stroke care intramurally or extramurally, creative solutions are required to increase access to acute stroke care for the Veterans residing beyond 60-minute driving time from a VHA and/or non-VHA stroke facility. Implications for Policy, Delivery or Practice Treatment of acute stroke patients in stroke centers increases the odds that patients receive tissue plasminogen activator (tPA) which has been demonstrated to decrease stroke morbidity. The ultimate goal of this study was to make strategic recommendations to VHA policy makers regarding the locations of VHA facilities capable of delivering acute stroke care, and the use of potential alternate strategies such as tele-stroke care or outsourcing to community stroke centers where VHA resources are lacking. Primary Funding Source Department of Veterans Affairs

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