Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.

Objective To compare the sociodemographic, clinical, and hospital related factors associated with discharge of acute ischemic stroke (AIS) survivors to inpatient rehabilitation (IRF) and skilled nursing facility (SNF) rehabilitation services. Design Retrospective descriptive study from the Paul Coverdell National Acute Stroke Program (PCNASP) participating hospitals during 2016 to 2019. Setting 9 Participating states from PCNASP in United States. Participants 130,988 patients with AIS from 569 hospitals (N=337,857). Interventions Not applicable. Main Outcome Measure Discharge to IRF and SNF. Results Patients discharged to a SNF had longer length of hospital stay, more comorbidities, and higher modified Rankin scores compared with patients discharged to an IRF. Nine characteristics were associated with being less likely to be discharged to an IRF than an SNF: older age (85+ years old, adjusted odds ratio [AOR]=0.20 [confidence interval [CI]=0.18-0.21]), identifying as non-Hispanic Black (AOR=0.85 [CI=0.81-0.89]), identifying as Hispanic (AOR=0.80 [CI=0.74-0.87]), having Medicaid or Medicare (AOR=0.73 [CI=0.70-0.77]), being able to ambulate with assistance from another person (AOR=0.93 [CI=0.89-0.97]), being unable to ambulate (AOR=0.73 [CI=0.62-0.87]) and having comorbidities, prior stroke (AOR=0.69 [CI=0.66-0.73]), diabetes (AOR=0.85 [CI=0.82-0.88]), and myocardial infraction or coronary artery disease (AOR=0.94 [CI=0.90-0.97]). Four characteristics were associated with being more likely to be discharged to an IRF than an SNF: being a man (AOR=1.20 [CI=1.16-1.24]), and having a slight disability (Rankin Score 2) (AOR=1.41 [CI=1.29-1.54]), being at larger hospitals (200-399 beds: AOR=1.31 [CI=1.23-1.40]; 400+ beds: AOR=1.29 [CI=1.20-1.38]), and being at a hospital with stroke unit (AOR=1.12 [CI=1.07-1.17]). Conclusion This study found differences in demographic, clinical, and hospital characteristics of AIS patients discharged for rehabilitation to an IRF vs SNF. The characteristics of patients receiving rehabilitation services may be helpful for researchers and hospitals making policies related to stroke discharge and practices that optimize patient outcomes. Populations experiencing inequities in access to rehabilitation services should be identified, and those who qualify for rehabilitation in IRF should receive this care in preference to rehabilitation in SNF.

Objective: Emergency medical service (EMS) transportation after acute stroke is associated with shorter symptom-to-arrival times and more rapid medical attention when compared to patient transportation by private vehicle. Methods: We analyzed data from the Paul Coverdell National Acute Stroke Program from 2014 to 2019 among stroke (ischemic and hemorrhagic) and transient ischemic attack (TIA) patients to examine patterns in EMS utilization. Results: Of 500,829 stroke and TIA patients (mean age 70.9 years, 51.3% women) from 682 participating hospitals during the study period, 60% arrived by EMS. Patients aged 18-64 years vs. >= 65 years (AOR 0.67) were less likely to utilize EMS. Severe stroke patients (AOR 2.29, 95%CI, 2.15-2.44) and hemorrhagic stroke patients vs. ischemic stroke patients (AOR 1.47, 95% CI, 1.43-1.51) were more likely to utilize EMS. Medicare (AOR 1.35, 95% CI, 1.32-1.38) and Medicaid (AOR 1.41, 95% CI, 1.37-1.45) beneficiaries were more likely than privately insured patients to utilize EMS, but no difference was found between no insurance/self-pay patients and privately insured patients on EMS utilization. Overall, there was a decreasing trend in the utilization of EMS (59.6% to 59.3%, p = 0.037). The decreasing trend was identified among ischemic stroke (p < 0.0001) patients but not among TIA (p = 0.89) or hemorrhagic stroke (p = 0.44) patients. There was no observed trend in pre-notification among stroke patients' arrival by EMS across the study period (56.9% to 56.5%, p = 0.99). Conclusions: Strategies to help increase stroke awareness and utilization of EMS among those with symptoms of stroke should be considered in order to help improve stroke outcomes.

Aim: Everyday, nearly 1000 U.S. adults experience out-of-hospital cardiac arrest (OHCA). Survival to hospital discharge varies across many fac-tors, including sociodemographics, location of arrest, and whether bystander intervention was provided. The current study examines recent trends in OHCA survival by location of arrest using a cohort of emergency medical service (EMS) agencies that contributed data to the Cardiac Arrest Registry to Enhance Survival. Methods: The 2015 CARES cohort (N = 122,613) includes EMS agencies contributing data across five consecutive years, 2015-2019. We assessed trends in EMS-attended OHCA survival for the 2015 CARES cohort by location of arrest - public, residential, nursing home. Unadjusted and adjusted percentages were estimated using 3-level hierarchical logistic regression models among cases aged 18-65 years. Results: Overall, survival from EMS-attended OHCA significantly increased from 12.5% in 2015 to 13.8% in 2019 (p = 0.001). Survival from bystan-der witnessed arrests also increased significantly from 17.8% in 2015 to 19.7% in 2019 (p = 0.004). The trend for survival increased overall and for bystander witnessed OHCAs occurring in public places and nursing homes. Conclusion: Increasing trends for EMS-attended OHCA survival were observed in the overall and bystander witnessed groups. No change in the trend for survival was observed among OHCAs in the groups most likely to have a desirable outcome - bystander witnessed, with a shockable rhythm, and receiving bystander intervention. Reporting and monitoring of OHCA may be an important first step in improving outcomes. Additional community interventions focused on bystander CPR and AED use may be warranted.

Objective: Emergency Medical Services can help improve stroke outcomes by recognizing stroke symptoms, establishing response priority for 911 calls, and minimizing prehospital delays. This study examines 911 stroke events and evaluates associations between events dispatched as stroke and critical EMS time intervals. Materials and methods: Data from the National Emergency Medical Services Information System, 2012 to 2016, were analyzed. Activations from 911 calls with a primary or secondary provider impression of stroke were included for adult patients transported to a hospital destination. Three prehospital time intervals were evaluated: (1) response time (RT) <8 min, (2) on-scene time (OST) <15 min, and (3) transport time (TT) <12 min. Associations between stroke dispatch complaint and prehospital time intervals were assessed using multivariate regression to estimate adjusted risk ratios (ARR) and 95% confidence intervals (CIs). Results: Approximately 37% of stroke dispatch complaints were identified by EMS as a suspected stroke. Compared to stroke events without a stroke dispatch complaint, median OST was shorter for events with a stroke dispatch (16 min vs. 14 min, respectively). In adjusted analyses, events dispatched as stroke were more likely to meet the EMS time benchmark for OST <15 min (OST, 1.20 [1.20-1.21]), but not RT or TT (RT, [1.00-1.01]; TT, 0.95 [0.94-0.95]). Conclusions: Our results indicate that dispatcher recognition of stroke symptoms reduces the time spent on-scene by EMS personnel. These findings can inform future EMS stroke education and quality improvement efforts to emphasize dispatcher recognition of stroke signs and symptoms, as EMS dispatchers play a crucial role in optimizing the prehospital response.

Introduction: Although marijuana use has increased since 2012, the perceived risk of adverse outcomes has decreased. This systematic review summarizes articles that examined the association between nonmedical marijuana use (ie, observed smoking, self-report, or urinalysis) and cardiovascular events in observational or experimental studies of adults aged ≥18. Methods: We searched Medline, EMBASE, PsycInfo, CINAHL, Cochrane Library Database, and Global Health from January 1, 1970, through August 31, 2018. Of 3916 citations, 16 articles fit the following criteria: (1) included adults aged ≥18; (2) included marijuana/cannabis use that is self-reported smoked, present in diagnostic coding, or indicated through a positive diagnostic test; (3) compared nonuse of cannabis; (4) examined events related to myocardial infarction, angina, acute coronary syndrome, and/or stroke; (5) published in English; and (6) had observational or experimental designs. Results: Of the 16 studies, 4 were cohort studies, 8 were case-control studies, 1 was a case-crossover study, 2 were randomized controlled trials, and 1 was a descriptive study. Studies ranged from 10 participants to 118 659 619 hospitalizations. Marijuana use was associated with an increased likelihood of myocardial infarction within 24 hours in 2 studies and stroke in 6 studies. Results of studies suggested an increased risk for angina and acute coronary syndrome, especially among people with a history of a cardiovascular event. Conclusion: This review suggests that people who use marijuana may be at increased risk for cardiovascular events. As states expand new laws permitting marijuana use, it will be important to monitor the effect of marijuana use on cardiovascular disease outcomes, perhaps through the inclusion of data on nonmedical marijuana use in diverse national and local surveillance systems.

INTRODUCTION:Studies documented significant reductions in emergency department visits and hospitalizations for acute stroke during the COVID-19 pandemic. A limited number of studies assessed the adherence to stroke performance measures during the pandemic. We examined rates of stroke hospitalization and adherence to stroke quality-of-care measures before and during the early phase of pandemic. METHODS:We identified hospitalizations with a clinical diagnosis of acute stroke or transient ischemic attack among 406 hospitals who contributed data to the Paul Coverdell National Acute Stroke Program. We used 10 performance measures to examine the effect of the pandemic on stroke quality of care. We compared data from 2 periods: pre-COVID-19 (week 11-24 in 2019) and COVID-19 (week 11-24 in 2020). We used χ2 tests for differences in categorical variables and the Wilcoxon-Mann-Whitney rank test or Kruskal-Wallis test for continuous variables. RESULTS:We identified 64,461 hospitalizations. We observed a 20.2% reduction in stroke hospitalizations (from 35,851 to 28,610) from the pre-COVID-19 period to the COVID-19 period. Hospitalizations among patients aged 85 or older, women, and non-Hispanic White patients declined the most. A greater percentage of patients aged 18 to 64 were hospitalized with ischemic stroke during COVID-19 than during pre-COVID-19 (34.4% vs 32.5%, P < .001). Stroke severity was higher during COVID-19 than during pre-COVID-19 for both hemorrhagic stroke and ischemic stroke, and in-hospital death among patients with ischemic stroke increased from 4.3% to 5.0% (P = .003) during the study period. We found no differences in rates of receiving care across stroke type during the study period. CONCLUSION:Despite a significant reduction in stroke hospitalizations, more severe stroke among hospitalized patients, and an increase in in-hospital death during the pandemic period, we found no differences in adherence to quality of stroke care measures.

Introduction: Studies suggest a significant reduction in emergency department visits and hospitalizations for acute ischemic stroke (AIS) during the COVID-19 pandemic in the United States. Few studies have examined AIS hospitalizations, treatments, and outcomes during the pandemic period. The present study compared the demographic and clinical characteristics of patients hospitalized with AIS before and during the COVID-19 pandemic (weeks 11-24 in 2019 vs. 2020). Method: We identified 42,371 admissions with a clinical diagnosis of AIS, from 370 participating hospitals who contributed data during weeks 11-24 in both 2019 and 2020 to the Paul Coverdell National Acute Stroke Program (PCNASP). Results: During weeks 11-24 of the COVID-19 period, AIS hospitalizations declined by 24.5% compared to the same period in 2019 (18,233 in 2020 vs. 24,138 in 2019). In 2020, the percentage of individuals aged <65 years who were hospitalized with AIS was higher compared with the same period in 2019 (34.6% vs. 32.7%, p<0.001); arriving by EMS were higher in 2020 compared with 2019 (47.7% vs. 44.8%, p<0.001). Individuals admitted with AIS in 2020 had a higher mean National Institutes of Health Stroke Scale (NIHSS) score compared with 2019 (6.7 vs. 6.3, p<0.001). In 2020, the in-hospital death rates increased by 16% compared to 2019 (5.0% vs. 4.3%, p<0.001). However, there were no differences in rates of alteplase use, achievement of door to needle in 60 minutes, or complications from reperfusion therapy between the two time periods. Conclusion: A higher percentage of younger (<65 years) individuals and more severe AIS cases were admitted to the participating hospitals during weeks 11 to 24 of the COVID-19 pandemic in 2020 compared to the same period in 2019. The AIS in-hospital death rate increased 16% during the pandemic weeks as compared to the same weeks in 2019. Additional studies are needed to examine the impacts of the COVID-19 pandemic on stroke treatment and outcomes.

Introduction: The nation’s highest rates in stroke deaths are among Blacks. After years of decline, the death rate began to stall around the beginning of this decade. This study will describe differences in stroke characteristics and outcomes by sex within this racial group. Method: The study is limited to patients identified as black and admitted with a clinical diagnosis of intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or ischemic stroke (IS) in the Paul Coverdell National Acute Stroke Program (PCNASP) from 2012-2018. In total, there were 105,676 admissions from 521 participating hospitals. We compared sociodemographic and clinical characteristics by sex within this racial group. Results: Among stroke admissions for black patients, 14,785 (14.0%) were ICH, 4,520 (4.3%) were SAH, and 86,371 (81.7%) were IS. Black women suffered a greater proportion of ICH (5.3% vs 3.2%, p<.0001) and a smaller proportion of SAH (13.0% vs 15.0%, p<.0001) than black men. Black women who suffered an IS were more likely to arrive by EMS than black men (49.7 vs. 47.7%). Black men who suffered an ICH or IS were more likely than black women to be transferred from another hospital (ICH: 34.1% vs 32.4%; IS: 11.9% vs 10.7%). Black men were more likely than black women to be discharged home after IS (50.9% vs 48.1%). Across stoke types, a greater proportion of black men were able to ambulate independently at discharge. Conclusion: In this sample, IS was the most common diagnosis among both men and women (81.8% vs 81.7%) and well-known cardiovascular disease risk factors were identified. Although a number of differences between men and women were found to be statistically significant, the clinical impact is unknown. Clinicians and public health practitioners may need to develop targeted interventions or services for black women to reduce disparities in stroke and risk factors within this racial group.

Background: Gaps exist in understanding the commonality of cardiovascular disease (CVD)-related responses by emergency medical services responders in the United States (US) community setting. Objective: We examined characteristics of CVD-related responses among US adults with 9-1-1 emergency medical services (EMS) responses in a national database. Methods: The 2016 National Emergency Medical Services Information System (NEMSIS) database (Version 2.2.1) from 49 states was used. CVD-related chief complaints were defined by data element E09_12 in the NEMSIS code book. Exclusions were EMS cancellations, persons not found, those with unknown sex, and patients aged <18 years. Rates (per 1,000 EMS responses) were calculated for total population and by patient demographics. Chi-square statistical tests were used to assess associations. Percentages of CVD-related chief complaints were calculated for EMS responses (incident patient disposition, type of destination, and reasons for destination), and clinical characteristics (provider’s primary impression, provider’s secondary impression, primary symptom, and EMS condition code). Results: We identified over 19.8 million EMS responses among adults aged ≥18 years old in 2016, including 1,336,684 (67.4 per 1,000 EMS responses) with CVD-related chief complaints. Rates of CVD-related chief complaints per 1,000 EMS responses for females (68.5), patients aged 65-74 years old (87.7), Hawaiian Pacific Islanders (83.6), whites (73.4), and those living in the South census region (72.8) were significantly higher than their respective counterparts. Among EMS responses, most CVD-related chief complaints were treated and transported by EMS (83.1%), and of those transported by EMS, 83.5% were transported to a hospital. Reasons for hospital destinations among adults with CVD-related chief complaints were patient’s preferred hospital (34%) and closest facility (32.9%). Most CVD-related chief complaints were chest pain or discomfort according to provider’s primary impression (48%) and provider’s secondary impressions (6.1%). Finally, pain (46.2%) was the most frequently reported condition as primary symptom among EMS patient with CVD-related chief complaints. Conclusion: Approximately 1-in-15 EMS (9-1-1) responses among adults involved a CVD-related chief complaint. Future research could focus on trends for CVD-related EMS responses overtime. Keyword: 9-1-1 emergency system, prehospital cardiovascular disease, CVD-related events.

CDC recommends a number of mitigation behaviors to prevent the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Those behaviors include 1) covering the nose and mouth with a mask to protect others from possible infection when in public settings and when around persons who live outside of one's household or around ill household members; 2) maintaining at least 6 feet (2 meters) of distance from persons who live outside one's household, and keeping oneself distant from persons who are ill; and 3) washing hands often with soap and water for at least 20 seconds, or, if soap and water are not available, using hand sanitizer containing at least 60% alcohol (1). Age has been positively associated with mask use (2), although less is known about other recommended mitigation behaviors. Monitoring mitigation behaviors over the course of the pandemic can inform targeted communication and behavior modification strategies to slow the spread of COVID-19. The Data Foundation COVID Impact Survey collected nationally representative data on reported mitigation behaviors during April-June 2020 among adults in the United States aged ≥18 years (3). Reported use of face masks increased from 78% in April, to 83% in May, and reached 89% in June; however, other reported mitigation behaviors (e.g., hand washing, social distancing, and avoiding public or crowded places) declined marginally or remained unchanged. At each time point, the prevalence of reported mitigation behaviors was lowest among younger adults (aged 18-29 years) and highest among older adults (aged ≥60 years). Lower engagement in mitigation behaviors among younger adults might be one reason for the increased incidence of confirmed COVID-19 cases in this group, which have been shown to precede increases among those >60 years (4). These findings underscore the need to prioritize clear, targeted messaging and behavior modification interventions, especially for young adults, to encourage uptake and support maintenance of recommended mitigation behaviors to prevent the spread of COVID-19.

Introduction: Early use of intravenous (IV) alteplase among those with Acute Ischemic Stroke (AIS) has been associated with better outcomes. However, many patients are ineligible for treatment due to late arrival or contraindications. We used PCNASP data to examine the descriptive characteristics and clinical outcomes associated with arrival time. Methods: A total of 233,794 patients were identified with an AIS in PCNASP data from 2016-2018. A total of 131,195 (56%) patients had documented last known well time (LKW). Symptom onset to arrival times (OAT) were categorized into the following using LKW and ED arrival times: 0-2, >2 and ≤3, >3 and ≤4.5, >4.5 hours. We assessed associations between OAT and two outcomes - discharge to home and independent ambulation at discharge using generalized estimating equations (GEE) modeling. Results: Patients with documented LKW time had the following OAT: 39,694 (30.3%) 0-2 hours, 11,573 (8.8%) >2 and ≤3 hours, 13,582 (10.3%) >3 and ≤4.5 hours, and 66,346 (50.6%) >4.5 hours. Overall, 51% were male, 75% were Whites, and 51% of patients arrived by ambulance. Only 17% of patients received IV alteplase. After adjusting for age, sex, race, arrival by ambulance, stroke severity score, and IV alteplase use, compared to those arriving >4.5 hours of symptom onset, patients arriving ≤4.5 hours were more likely to be discharged to home (0-2, 1.85 [1.79, 1.92]; >2 and ≤3, 1.38 [1.32, 1.45]; >3 and ≤4.5, 1.13 [1.08, 1.18]; referent >4.5), and independently ambulate at discharge (0-2, 1.89 [1.82, 1.96]; >2 and ≤3, 1.41 [1.34, 1.48]; >3 and ≤4.5, 1.15 [1.10, 1.21], referent >4.5) (Table). Conclusion: In this study, shorter OAT were associated with better outcomes for AIS patients. Although significant progress has been made in the early management and treatment of stroke, continued efforts are needed to emphasize the significance of early hospital arrival and promote implementation of treatment guidelines to improve clinical outcomes for all stroke patients.

Introduction: Better characterizing patients with recurrent ischemic stroke, whether they are more likely to arrive by ambulance, and their outcomes is important to reinforcing prevention practices and identifying disparities. Method: We identified 226,974 admissions with a clinical diagnosis of ischemic stroke, age≥18 years, from 463 participating hospitals in the PCNASP from 2016-2018, 58,505 or 25.8% of which had a recurrent stroke. We compared descriptive and clinical features of those with a first stroke with those having recurrent stroke. Results: A higher proportion of recurrent stroke admissions was found among black (vs. white) patients: 32.2% vs 24.3%). Recurrent stroke patients were more likely to arrive by ambulance (52.8% vs 45.0%), suffer a more severe stroke (mean NIHSS 6.8 vs 5.9) and less likely to receive alteplase (7.9% vs 10.9%) than those with their first stroke. In addition, those with a recurrent stroke were also more likely to have worse outcomes with fewer recurrent stroke patients being discharged home (42.7% vs 51%). Small differences were seen in the proportion of recurrent stroke patients who were able to ambulate with assistance before their stroke but were then unable to ambulate at discharge (2.2% vs 0.9% for first stroke patients). There were no significant differences seen for in-hospital death. Conclusion: Black patients with ischemic strokes had a higher proportion of recurrent events. Recurrent stroke patients were more likely to arrive by ambulance, and suffer a more severe stroke and have worse outcomes. Understanding disparities among those with recurrent stroke may support public health practitioners and health care professionals intervene to prevent or manage recurrent stroke.

Introduction: Limited studies exist comparing characteristics and outcomes among younger (35-64 years) and older (≥65 years) acute stroke patients. Method: We identified 559,831 admissions with a clinical diagnosis of stroke, ages ≥35 years, from 617 participating hospitals in the Paul Coverdell National Acute Stroke Program (PCNASP) from 2012-2018. We compared demographic and clinical features of those aged 35-64 years with those aged ≥65 years by stroke type. Results: Among stroke admissions identified in PCNASP between 2012 and 2018, 194,063 (34.7%) patients were aged 35-64 years. Among younger adults, there were 26,603 (13.7%) intracerebral hemorrhages (ICH), 14,722 (7.6%) subarachnoid hemorrhages (SAH), and 152,738 (78.7%) ischemic strokes (IS). Among 365,768 patients aged ≥65, the corresponding prevalence was 12.4%, 2.5%, and 85.1% respectively. Compared to those aged ≥65, more men and black patients were identified among those aged 35-64 years in all stroke subtypes (32.1% of ICH patients aged 35-64 were black, compared to 12.7% of those aged ≥65, 20.7% vs. 11.5% of SAH patients, and 28.3% vs. 13.3% of IS patients respectively). Patients aged 35-64 years were less likely to arrive by EMS, and more likely to be admitted as a transfer from another hospital, compared to those aged ≥65 years. The prevalence of current smokers was significantly higher among younger adults compared to those aged ≥65 years across all stroke subtypes. In addition, patients aged 35-64 years had more favorable outcomes in higher percent of ambulation at discharge and discharge to home, and lower in-hospital death rate, compared to older patients. Conclusion: Relative to whites, younger blacks had a higher proportion of strokes than older blacks, regardless of subtype. This information might be helpful in developing prevention strategies, and promoting targeted stroke awareness messaging among younger adults.

Introduction: Out-of-hospital cardiac arrest (OHCA) is a significant public health issue. Hypothesis: This study aims to assess whether patients’ age, sex, race/ethnicity, and urban/non-urban status are associated with the rate of OHCA events among adults who accessed 9-1-1 emergency medical services (EMS) in 2016. Methods: We conducted a cross-sectional analysis using the 2016 National Emergency Medical Services Information System (NEMSIS), a national EMS database. OHCA events among adults aged ≥18 years were extracted by sex, age group, race/ethnicity, urban and non-Urban categories. Those with unknown race/ethnicity (45.8%) or of other race (1.3%) were excluded. Rates of OHCA events were calculated and Chi-square tests were used to assess associations. Results: We identified 205,461 OHCA events with EMS activations among non-Hispanic (NH) whites (68.1%), NH blacks (23.2%), and Hispanics (8.7%) in the 2016 NEMSIS dataset. Of the OHCA events, 59.5% were among males, 81.1% among urban residents, and 15.4% among non-urban residents. The overall OHCA rate was 19.6 per 1,000 EMS activations. OHCA rates per 1,000 EMS activations increased with age for adults until age 74, ranging from 11.2 (18-34 years) to 25.1 (65-74 years), then decreased with age for older adults ≥75 ranging from 22.3 (75-84 years) to 20.8 (≥85 years) ( p <.0001). OHCA rates were higher among males 25.3, Hispanics 20.9, and urban residents 21.7 than females 15.6, other race ethnicities (NH whites 19.8 and NH blacks 18.7), and non-urban residents 17.6 ( p <.0001) respectively. Conlusions: OHCA incidence rates among EMS activations increased with age until age 74. Adult males, Hispanics, and urban patients had statistically significant higher EMS activations for OHCA rates. Findings can be incorporated in community planning for improving EMS services.

Introduction Early recognition of stroke symptoms and recognizing the importance of calling 9-1-1 improves the timeliness of appropriate emergency care, resulting in improved health outcomes. The objective of this study was to assess changes in awareness of stroke symptoms and calling 9-1-1 from 2009 to 2014. Methods We analyzed data among 27,211 adults from 2009 and 35,862 adults from 2014 using the National Health Interview Survey (NHIS). The NHIS included 5 questions in both 2009 and 2014 about stroke signs and symptoms and one about the first action to take when someone is having a stroke. We estimated the prevalence of awareness of each symptom, all 5 symptoms, the importance of calling 9-1-1, and knowledge of all 5 symptoms plus the importance of calling 9-1-1 (indicating recommended stroke knowledge). We assessed changes from 2009 to 2014 in the prevalence of awareness. Data analyses were conducted in 2016. Results In 2014, awareness of stroke symptoms ranged from 76.1% (sudden severe headache) to 93.7% (numbness of face, arm, leg, side); 68.3% of respondents recognized all 5 symptoms, and 66.2% were aware of all recommended stroke knowledge. After adjusting for sex, age, educational attainment, and race/ethnicity, logistic regression results showed a significant absolute increase of 14.7 percentage points in recommended stroke knowledge from 2009 (51.5%) to 2014 (66.2%). Among US adults, recommended stroke knowledge increased from 2009 to 2014. Conclusion Stroke awareness among US adults has improved but remains suboptimal.

Heart disease is the leading cause of death in the United States (1). Heart attacks (also known as myocardial infarctions) occur when a portion of the heart muscle does not receive adequate blood flow, and they are major contributors to heart disease, with an estimated 750,000 occurring annually (2). Early intervention is critical for preventing mortality in the event of a heart attack (3). Identification of heart attack signs and symptoms by victims or bystanders, and taking immediate action by calling emergency services (9-1-1), are crucial to ensure timely receipt of emergency care and thereby improve the chance for survival (4). A recent report using National Health Interview Survey (NHIS) data from 2014 found that 47.2% of U.S. adults could state all five common heart attack symptoms (jaw, neck, or back discomfort; weakness or lightheadedness; chest discomfort; arm or shoulder discomfort; and shortness of breath) and knew to call 9-1-1 if someone had a heart attack (5). To assess changes in awareness and response to an apparent heart attack, CDC analyzed data from NHIS to report awareness of heart attack symptoms and calling 9-1-1 among U.S. adults in 2008, 2014, and 2017. The adjusted percentage of persons who knew all five common heart attack symptoms increased from 39.6% in 2008 to 50.0% in 2014 and to 50.2% in 2017. The adjusted percentage of adults who knew to call 9-1-1 if someone was having a heart attack increased from 91.8% in 2008 to 93.4% in 2014 and to 94.9% in 2017. Persistent disparities in awareness of heart attack symptoms were observed by demographic characteristics and cardiovascular risk group. Public health awareness initiatives and systematic integration of appropriate awareness and action in response to a perceived heart attack should be expanded across the health system continuum of care.

Despite the importance of antihypertensive medication therapy for blood pressure control, no single data system provides estimates of medication nonadherence rates across age groups and health insurance plans types. Using multiple administrative datasets and national survey data, we determined health insurance plan-specific and overall weighted national rates of nonadherence to antihypertensive medications among insured hypertensive US adults in 2015. We used 2015 prescription claims data from Medicare Part D and 3 IBM MarketScan databases (Commercial, Medicaid, Medicare Supplemental) to calculate medication nonadherence rates among hypertensive adults aged ≥18 years with public or private health insurance using the proportion of days covered algorithm. These findings, in combination with National Health Interview Survey findings, were used to project national weighted estimates of nonadherence. We included 23.8 million hypertensive adults who filled 265.8 million prescriptions for antihypertensive medications. Nonadherence differed by health insurance plan type (highest for Medicaid members, 55.4%; lowest for Medicare Part D members, 25.2%). The overall weighted national nonadherence rate was 31.0%, with greater nonadherence among women versus men, younger versus older adults (aged 18-34 years, 58.1%; aged 65-74 years, 24.4%), fixed-dose combination medication nonusers (31.2%) versus users (29.4%), and by pharmacy outlet type (retail only, 30.7%; any mail order, 19.8%). In 2015, almost one-third (≈16.3 million) of insured US adults with diagnosed hypertension were considered nonadherent to their antihypertensive medication regimen, and considerable disparities were evident. Public health and healthcare professionals can use available evidence-based interventions to address nonadherence and improve blood pressure control.

Introduction: Stroke management guidelines have established several recommendations to ensure a proper response by Emergency Medical Services (EMS), including EMS arrival at the scene in ≤8 minutes (response time, RT), and an on-scene time (OST) of ≤15 minutes. Understanding factors associated with achieving these time intervals may help to focus EMS interventions. Hypothesis: We assessed the hypothesis that RT and OST for suspected patients with a dispatch of stroke are more likely to fall within guideline recommendations than those with a dispatch for non-stroke related events. Methods: Using the 2016 National Emergency Medical Services Information System (NEMSIS), a database of patient care reports resulting from 911 calls, we extracted cases with a primary or secondary provider impression of stroke, their EMS arrival to the scene (RT) ≤8 minutes and OST of ≤15 minutes. The sample included persons aged ≥18 years with non-missing sociodemographic data on sex, race/ethnicity, rurality and dispatch calls of events. The percentages of 911 cases, stroke events, and time intervals of interest were calculated. Chi-square tests was used to assess associations. Results: There were 153,730 events (1.4% of all 911 transports) with a primary or secondary provider impression of stroke. Within these events, 69.5% had a RT ≤8 minutes, and 49.2% had an OST ≤15 minutes: differences varied within all sociodemographic groups. A significant difference was found between those dispatched as stroke and those dispatched as other, with a greater proportion of dispatched strokes having both a RT ≤8 minutes (70.2% vs 68.8%) and OST ≤15 minutes (53.0% vs 45.6%). Conclusion: In conclusion, we found a significantly higher proportion of patients dispatched as stroke falling within the critical time intervals of response time and on-scene time. Future EMS stroke education should place more focus on dispatcher knowledge of stroke signs and symptoms, as an integral pre-hospital partner in improving the stroke system of care.