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Geographic Disparities Associated with Stroke and Myocardial Infarction in East Tennessee

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Geographic Disparities Associated with Stroke and Myocardial Infarction in East Tennessee University of Tennessee, Knoxville TRACE: Tennessee Research and Creative Exchange Doctoral Dissertations Graduate School 12-2011 Geographic Disparities Associated with Stroke and Myocardial Infarction in East Tennessee Ashley Pedigo Golden [email protected] Follow this and additional works at: https://trace.tennessee.edu/utk_graddiss Part of the Biostatistics Commons, Cardiovascular Diseases Commons, Epidemiology Commons, Health Services Research Commons, Multivariate Analysis Commons, and the Vital and Health Statistics Commons Recommended Citation Golden, Ashley Pedigo, "Geographic Disparities Associated with Stroke and Myocardial Infarction in East Tennessee. " PhD diss., University of Tennessee, 2011. https://trace.tennessee.edu/utk_graddiss/1182 This Dissertation is brought to you for free and open access by the Graduate School at TRACE: Tennessee Research and Creative Exchange. It has been accepted for inclusion in Doctoral Dissertations by an authorized administrator of TRACE: Tennessee Research and Creative Exchange. For more information, please contact [email protected]. To the Graduate Council: I am submitting herewith a dissertation written by Ashley Pedigo Golden entitled "Geographic Disparities Associated with Stroke and Myocardial Infarction in East Tennessee." I have examined the final electronic copy of this dissertation for form and content and recommend that it be accepted in partial fulfillment of the equirr ements for the degree of Doctor of Philosophy, with a major in Comparative and Experimental Medicine. Agricola Odoi, Major Professor We have read this dissertation and recommend its acceptance: Tim E. Aldrich, Karla J. Matteson, Bruce A. Ralston, William L. Seaver Accepted for the Council: Carolyn R. Hodges Vice Provost and Dean of the Graduate School (Original signatures are on file with official studentecor r ds.) Geographic Disparities Associated with Stroke and Myocardial Infarction in East Tennessee A Dissertation Presented for the Doctor of Philosophy Degree The University of Tennessee, Knoxville Ashley Pedigo Golden December 2011 Dedication This dissertation is dedicated to my parents, Ronnie and JoAnn Pedigo, for their many sacrifices, constant love, and support that have enabled me to accomplish my educational goals. ii Acknowledgements This dissertation could not have been completed without the help from many individuals, whom I wish to acknowledge and give thanks. I am sincerely grateful for the opportunity to learn and work under the supervision of Dr. Agricola Odoi. His expertise, guidance, and dedication to excellence have been integral to my educational and professional growth. Thank you, Dr. Odoi, for your patience and wisdom in this journey. I would like to extend my appreciation to the members of my committee: Dr. Tim Aldrich, Dr. Karla Matteson, Dr. Bruce Ralston, and Dr. William Seaver. Each of you has provided both academic and professional support for which I am very thankful. Special thanks are due to Lisa Escalante for her assistance in all things EMS. I am grateful to my colleagues, Jenny and Doreen, for their friendship and support. To my friends and family, thank you for your encouragement and faith in me. I owe my deepest gratitude to my husband, David, whose constant love and understanding provided me strength. Finally, I thank God for his mercy and blessings on me. iii Abstract Stroke and myocardial infarction (MI) are serious conditions whose burdens vary by socio-demographic and geographic factors. Although several studies have investigated and identified disparities in burdens of these conditions at the county and state levels, little is known regarding their geographic epidemiology at the neighborhood level. Both conditions require emergency treatments and therefore timely geographic accessibility to appropriate care is critical. Investigation of disparities in geographic accessibility to stroke and MI care and the role of Emergency Medical Services (EMS) in reducing treatment delays are vital in improving health outcomes. Therefore, the objectives of this work were to: (i) classify neighborhoods based on socio-demographic and geographic characteristics; (ii) investigate spatial patterns of neighborhood level mortality; (iii) identify disparities in geographic accessibility to stroke and MI care; and (iv) identify disparities in EMS transport times for stroke and MI patients in East Tennessee. Fuzzy cluster analysis was used to classify neighborhoods into peer neighborhoods (PNs) based on their socio-demographic and geographic factors. Neighborhood level spatial patterns of stroke and MI mortality risks were investigated using Spatial Empirical Bayesian smoothing techniques and neighborhoods with high mortality risks identified using spatial scan statistics. Travel times to stroke and cardiac care facilities were computed using network analysis to investigate geographic accessibility. Records of over 3,900 suspected stroke and MI patients, from two EMS providers, were used to investigate disparities in EMS transport delays. iv Four distinct PNs were identified. The highest stroke/MI mortality risks were observed in less affluent, urban PNs, and lowest risks in more affluent, suburban PNs. Several significant (p<0.0001) stroke and MI high mortality risk spatial clusters were identified. Approximately 8% and 15% of the population did not have timely accessibility to appropriate stroke and MI care, respectively. The disparity was greatest for populations in rural areas. Important disparities in EMS transport delays were identified, with the travel time to a hospital contributing the longest delay. The identified disparities in neighborhood characteristics, mortality risks, geographic accessibility, and EMS transport delays are invaluable in guiding resource allocation, service provision, and policy decisions to support evidence-based population health planning and policy. v Table of Contents CHAPTER 1 1.0 Introduction ............................................................................................................. 1 1.1 Literature Review .................................................................................................... 4 1.1.1 Stroke and Myocardial Infarction (MI) ................................................................. 4 1.1.1.1 Disease biology, etiology, and symptoms ..................................................... 4 1.1.1.1.1 Stroke ..................................................................................................... 4 1.1.1.1.2 Myocardial Infarction .............................................................................. 5 1.1.1.2 Diagnoses and treatments ............................................................................ 7 1.1.1.2.1 Stroke ..................................................................................................... 7 1.1.1.2.2 Myocardial Infarction ............................................................................ 10 1.1.1.3 Disease Burden .......................................................................................... 11 1.1.1.3.1 Stroke ................................................................................................... 12 1.1.1.3.2 Coronary Heart Disease and Myocardial Infarction .............................. 13 1.1.1.4 Temporal trends .......................................................................................... 14 1.1.1.4.1 Stroke ................................................................................................... 14 1.1.1.4.2 Coronary Heart Disease and Myocardial Infarction .............................. 15 1.1.1.5 Vital Statistics ............................................................................................. 17 1.1.2 Socio-demographic determinants of stroke and myocardial infarction .............. 18 1.1.2.1 Demographic factors ................................................................................... 18 1.1.2.2 Socioeconomic factors ................................................................................ 19 1.1.2.3 Geographic clustering of socioeconomic and demographic factors ............ 21 1.1.3 Geographic patterns of stroke and myocardial infarction .................................. 23 1.1.3.1 Geographic disparities in burdens .............................................................. 23 1.1.3.2 Neighborhood level spatial analyses .......................................................... 24 1.1.4 Geographic accessibility to stroke and MI care ................................................. 26 1.1.4.1 Disparities in access to healthcare ............................................................. 26 1.1.4.2 Measuring geographic accessibility to healthcare ....................................... 28 1.1.4.3 Improving geographic accessibility ............................................................. 30 vi 1.1.5 Role of Emergency Medical Services (EMS) in timely access to stroke and MI care ................................................................................................. 32 1.1.5.1 Delays in receiving emergency care for stroke and MI ............................... 32 1.1.5.2 Components of pre-hospital delays ............................................................ 36 1.1.5.2.1 Decision Delays .................................................................................... 37 1.1.5.2.2 Transport Delays .................................................................................. 39 1.1.5.3 Improving pre-hospital delays ....................................................................
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