Expanding Acute Stroke Care in Rural America: A Model for Statewide Success

Adcock, Amelia; Choi, Justin; Alvi, Muhammad; Murray, Ann; Seachrist, Eric; Smith, Matthew; Findley, Scott

doi:10.1089/tmj.2019.0087

Cited by 19 publications

(15 citation statements)

References 11 publications

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“…More research is needed to identify the exact health system factors driving barriers to care. In addition, research on healthcare policy would be useful to help curtail rural disparities 6 8 37–40. Currently, our healthcare policies favor large populations due to, among other things: (1) Financial marketing systems that rely on large populations of insured beneficiaries in order to provide services, (2) Prioritization of outcomes on the national level, which shifts resource allocation to large population centers, and (3) No method of compensating for innate efficiencies in remote healthcare settings 6.…”

Section: Discussionmentioning

confidence: 99%

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study

Taylor

Gangnon

Powell

et al. 2023

BMJ Open Diab Res Care

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IntroductionRural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion.Research design and methodsThis 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013–2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black.ResultsOverall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black.ConclusionsA smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.

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Section: Discussionmentioning

confidence: 99%

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study

Taylor

Gangnon

Powell

et al. 2023

BMJ Open Diab Res Care

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“…However, a rural-urban disparity persists with urban stroke patients eligible for thrombolysis at least twice as likely to receive it as compared to their rural counterparts (2). Although, recent rural telestroke networks have demonstrated significant impact in tPA use, the evaluating telestroke physician has traditionally been a neurologist (5,9). In fact, lack of access to a neurologist has been identified as a significant barrier to the use of tPA in ischemic stroke, initially setting the stage for telestroke network creation (10).…”

Section: Discussion/conclusionmentioning

confidence: 99%

A Case for the Non-Neurologist Telestroke Provider

2021

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Introduction: Telestroke networks have effectively increased the number of ischemic stroke patients who have access to acute stroke therapy. However, the availability of a dedicated group of stroke subspecialists is not always feasible. We hypothesize that rates of tPA recommendation, sensitivity of final diagnosis, and post-tPA hemorrhagic complications do not differ significantly between neurologists and an emergency-medicine physician during telestroke consultations.Methods: Retrospective review of all telestroke consults performed at a comprehensive stroke center over 1 year. Statistical analysis: Chi squared test.Results: Three hundred and three consults were performed among 6 spoke sites. 16% (48/303) were completed by the emergency medicine physician; 25% (76/303) were performed by non-stroke-trained neurologists, and 59% (179/303) were completed by a board-certified Vascular Neurologist. Overall rate of tPA recommendation was 40% (104/255), 38% (18/48), 41% (73/179), and 41% (31/76) among the all neurology-trained, emergency medicine-trained, stroke neurology-trained and other neurology- trained provider groups, respectively (p = 0.427). Sensitivity of final stroke diagnosis was 77% (14/18) and 72% (75/104) in the emergency-medicine trained and neurology-trained provider groups (p = 0.777) No symptomatic hemorrhagic complications following the administration of tPA via telestroke consultation occurred in any group over this time period. One asymptomatic intracerebral hemorrhage was observed (0.96% or 1/104) in the neurology-trained provider group.Discussion/Conclusion: Our results did not illustrate any statistically significant difference between care provided by an emergency medicine-trained physician and neurologists during telestroke consultation. While our study is limited by its relatively low numbers, it suggests that identifying a non-neurologist provider who has requisite clinical experience with acute stroke patients can safely and appropriately provide telestroke consultation. The lack of formerly trained neurologists, therefore, may not need to serve as an impediment to building an effective telestroke network. Future efforts should be focused on illuminating all strategies that facilitate sustainable telestroke implementation.

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“…[46][47][48] Telestroke has been a particularly successful model system with widespread implementation and has improved access to stroke specialists and reperfusion therapy. [49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67] In trauma and critical illness, evidence suggests that telehealth can optimize triage, reduce transfers, and better stabilize transferred patients, with decreased mortality and ICU admission rates. [68][69][70][71][72][73][74][75][76][77][78][79][80][81][82][83][84] Among pediatric critical care patients, telehealth has been shown to decrease ICU admissions, transfers, medication errors, and improve provider satisfaction.…”

Section: Access To Specialistsmentioning

confidence: 99%

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

Hayden

Davis

Clark

et al. 2021

Academic Emergency Medicine

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Introduction: Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM. Methods: Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important." Results: Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by | 1453 HAYDEN Et Al.

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Expanding Acute Stroke Care in Rural America: A Model for Statewide Success

Cited by 19 publications

References 11 publications

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study

A Case for the Non-Neurologist Telestroke Provider

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

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