{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T15:02:56Z","timestamp":1785250976479,"version":"3.55.0"},"reference-count":32,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"9","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["JAHA"],"published-print":{"date-parts":[[2026,5,5]]},"abstract":"<jats:sec xml:lang=\"en\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p xml:lang=\"en\">Stroke hospitalization represents underlying stroke incidence and hospital utilization. We sought to identify factors associated with county\u2010level hospitalization rates (HRs) and counties with HRs above or below expectation using publicly available data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec xml:lang=\"en\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p xml:lang=\"en\">\n                      This cross\u2010sectional study is based on the analysis of county\u2010level 3\u2010year average stroke HRs (principal\n                      <jats:italic toggle=\"no\">International Classification of Diseases, Tenth Revision [ICD\u201010]<\/jats:italic>\n                      , codes I60.X\u2013I69.X) among Medicare fee\u2010for\u2010service beneficiaries from 2018 to 2020. Linear mixed models were fitted to investigate 6 sets of factors associated with HRs in a serial additive stepwise fashion (ie, demographics, overall population vascular risk factors, risk factor treatment, health delivery and access, environmental features, and socioeconomic status). We reported on marginal\n                      <jats:italic toggle=\"no\">R<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      , the most impactful factors, and characterized proportional difference between crude and predicted HRs.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec xml:lang=\"en\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p xml:lang=\"en\">\n                      The cohort of 3198 (98.6%) counties and county\u2010equivalents had a mean stroke HR of 11.2 per 100\u2009000 (SD=2.6). The mean characteristics of the included counties were as follows: 19.4% age \u226565\u2009years, 73% White race, 7.6% coronary heart disease prevalence, 38% hyperlipidemia prevalence, and 5.7 primary care physicians per 10\u2009000. In the fully adjusted model, between\u2010county unexplained variation remained moderately high (\n                      <jats:italic toggle=\"no\">R<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      =0.57). The most impactful factors associated with stroke HRs were prevalence of coronary heart disease, hypertension, smoking, nonadherence to antihypertensive medication, and elevation above sea level. Counties in the northwest United States generally had lower\u2010than\u2010expected HRs.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec xml:lang=\"en\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p xml:lang=\"en\">Considerable unexplained county\u2010level variance in stroke HRs exists after accounting for a wide variety of known and potential predictors. Future work to clarify the mechanism of known predictors and explain variance may inform interventions to improve systems of care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/jaha.125.048231","type":"journal-article","created":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T09:53:12Z","timestamp":1777369992000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["County\u2010Level Contributors to Geographic Variation in Medicare Fee\u2010for\u2010Service Stroke Hospitalization Rates: A Cross\u2010Sectional Study"],"prefix":"10.1161","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4006-217X","authenticated-orcid":false,"given":"Raed","family":"Hailat","sequence":"first","affiliation":[{"name":"The Ohio State University Wexner Medical Center","place":["Columbus, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0814-0222","authenticated-orcid":false,"given":"Mohamed","family":"Ridha","sequence":"additional","affiliation":[{"name":"The Ohio State University Wexner Medical Center","place":["Columbus, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8055-1942","authenticated-orcid":false,"given":"Matthew","family":"Gusler","sequence":"additional","affiliation":[{"name":"The Ohio State University Wexner Medical Center","place":["Columbus, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4470-2648","authenticated-orcid":false,"given":"Chun Chieh","family":"Lin","sequence":"additional","affiliation":[{"name":"The Ohio State University Wexner Medical Center","place":["Columbus, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin","family":"Kerber","sequence":"additional","affiliation":[{"name":"The Ohio State University Wexner Medical Center","place":["Columbus, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6999-6019","authenticated-orcid":false,"given":"Jeffrey","family":"Wing","sequence":"additional","affiliation":[{"name":"The Ohio State University","place":["Columbus, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2296-1588","authenticated-orcid":false,"given":"James F.","family":"Burke","sequence":"additional","affiliation":[{"name":"The Ohio State University Wexner Medical Center","place":["Columbus, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_2_2_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000001123"},{"key":"e_1_3_2_3_2","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.122.039098"},{"key":"e_1_3_2_4_2","doi-asserted-by":"publisher","DOI":"10.1002\/ana.22385"},{"key":"e_1_3_2_5_2","doi-asserted-by":"publisher","DOI":"10.5888\/pcd21.230339"},{"key":"e_1_3_2_6_2","doi-asserted-by":"publisher","DOI":"10.1159\/000449102"},{"key":"e_1_3_2_7_2","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.119.024155"},{"key":"e_1_3_2_8_2","doi-asserted-by":"publisher","DOI":"10.1161\/JAHA.116.003233"},{"key":"e_1_3_2_9_2","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.112.669705"},{"key":"e_1_3_2_10_2","unstructured":"Centers for Disease Control and Prevention . 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