Stroke Incidence and Outcome Disparity in Rural Regions of Southern West Virginia

Introduction: West Virginia has the highest incidence of obesity, smoking, and diabetes within the United States, placing its population at higher risk of stroke. In addition to these endemic risk factors, Appalachia faces various socioeconomic and health care access challenges that could negatively impact stroke incidence and outcomes. At present, there are limited data regarding geographic variables on stroke outcomes in rural Appalachia. We set out to quantify Appalachian geographic patterns of stroke incidence and outcomes. Methods: This is a retrospective analysis of all patients hospitalized with a diagnosis of stroke in West Virginia's largest tertiary hospital. During the study (2000–2018), 14,488 patients were analyzed, with an emphasis on those who died from stroke (n = 1022). We first used institutional ICD-9/10 data alongside demographics information and chart reviews to evaluate disease patterns while also exploring emerging hot spot pattern changes over time; we then exploited an emerging time series analysis using temporal trends to assess differing instances of stroke occurrence regionally with hot spots defined as higher than expected incidences of stroke and stroke death. Results: Data analysis revealed several hot spots of increasing stroke and mortality rates, many of which achieved statistically significant variance compared to expected norms (P = 0.001). Moreover, this study revealed high-risk zones in rural West Virginia wherein the incidence and mortality rates of stroke are suggestively higher and less resistance to economic change than urban centers. Conclusions: Stroke incidence and mortality were found to be higher than expected in many areas of rural West Virginia. The higher stroke risk populations correlate with area that may be impacted by socioeconomic factors and limited access to primary care. These high-risk areas may therefore benefit from investments in infrastructure, patient education, and unrestricted primary care.

[1]  D. Kazi,et al.  Association of Medicaid Expansion With Cardiovascular Mortality. , 2019, JAMA cardiology.

[2]  R. Mehrotra,et al.  Association of Medicaid Expansion With 1-Year Mortality Among Patients With End-Stage Renal Disease , 2018, JAMA.

[3]  C. Yancy,et al.  Association of State Medicaid Expansion With Rate of Uninsured Hospitalizations for Major Cardiovascular Events, 2009-2014 , 2018, JAMA network open.

[4]  S. Rican,et al.  Geographic Variations of Stroke Hospitalization across France: A Diachronic Cluster Analysis , 2018, Stroke research and treatment.

[5]  K. Simon,et al.  Medicaid Expansion And State Trends In Supplemental Security Income Program Participation. , 2017, Health affairs.

[6]  M. Fornage,et al.  Heart Disease and Stroke Statistics—2017 Update: A Report From the American Heart Association , 2017, Circulation.

[7]  M Giroud,et al.  Telemedicine for the acute management of stroke in Burgundy, France: an evaluation of effectiveness and safety , 2016, European journal of neurology.

[8]  Sudipto Banerjee.  Spatial Data Analysis. , 2016, Annual review of public health.

[9]  V. Fonseca,et al.  Surge in Newly Identified Diabetes Among Medicaid Patients in 2014 Within Medicaid Expansion States Under the Affordable Care Act , 2015, Diabetes Care.

[10]  T. Nakaya,et al.  Impact of neighborhood socioeconomic conditions on the risk of stroke in Japan. , 2015, Journal of epidemiology.

[11]  V. Feigin,et al.  Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010 , 2014, The Lancet.

[12]  A. Odoi,et al.  Neighborhood disparities in stroke and myocardial infarction mortality: a GIS and spatial scan statistics approach , 2011, BMC public health.

[13]  Joshua C. Nyirenda,et al.  Distance from home to hospital and thrombolytic utilization for acute ischemic stroke. , 2011, Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association.

[14]  L. Balluz,et al.  Surveillance of certain health behaviors and conditions among states and selected local areas - Behavioral Risk Factor Surveillance System, United States, 2007. , 2017, Morbidity and mortality weekly report. Surveillance summaries.

[15]  D. Mozaffarian,et al.  Heart disease and stroke statistics--2010 update: a report from the American Heart Association. , 2010, Circulation.

[16]  Eric A Whitsel,et al.  Neighborhood disparities in incident hospitalized myocardial infarction in four U.S. communities: the ARIC surveillance study. , 2009, Annals of epidemiology.

[17]  M. Glymour,et al.  Birth and adult residence in the Stroke Belt independently predict stroke mortality , 2009, Neurology.

[18]  R. D'Agostino,et al.  Advancing the hypothesis that geographic variations in risk factors contribute relatively little to observed geographic variations in heart disease and stroke mortality. , 2009, Preventive Medicine.

[19]  T. Lumley,et al.  Evaluating options for measurement of neighborhood socioeconomic context: evidence from a myocardial infarction case-control study. , 2008, Health & place.

[20]  T. Kurth,et al.  Geographic Patterns in Overall and Specific Cardiovascular Disease Incidence in Apparently Healthy Men in the United States , 2007, Stroke.

[21]  G. Costa,et al.  Socioeconomic inequalities in coronary heart disease in Italy: a multilevel population-based study. , 2006, Social science & medicine.

[22]  Youngihn Kho,et al.  GeoDa: An Introduction to Spatial Data Analysis , 2006 .

[23]  Clinton B Wright,et al.  Ischemic Stroke Subtype Incidence Among Whites, Blacks, and Hispanics: The Northern Manhattan Study , 2005, Circulation.

[24]  M. Casper,et al.  Geographic disparities in heart disease and stroke mortality among black and white populations in the Appalachian region. , 2002, Ethnicity & disease.

[25]  L. Chambless,et al.  Neighborhood of residence and incidence of coronary heart disease. , 2001, The New England journal of medicine.

[26]  C. Hart,et al.  The contribution of risk factors to stroke differentials, by socioeconomic position in adulthood: the Renfrew/Paisley Study. , 2000, American journal of public health.

[27]  J. Sundquist,et al.  Cardiovascular risk factors and the neighbourhood environment: a multilevel analysis. , 1999, International journal of epidemiology.

[28]  L. Pickle,et al.  Geographic variation in stroke mortality in blacks and whites in the United States. , 1997, Stroke.

[29]  R. Gillum,et al.  Relation between residence in the southeast region of the United States and stroke incidence. The NHANES I Epidemiologic Followup Study. , 1996, American journal of epidemiology.