Is There a 'Stroke Belt' for Ischemic Stroke Hospitalization among Children?

Background: There are regional variations in adult stroke mortality and hospitalization rates in the US, with higher rates in the Southeastern part of the country (the ‘stroke belt’). At least one study found children in stroke belt states also have higher stroke-related mortality; whether they have higher hospitalization rates is unknown. We compared ischemic stroke hospitalization rates for adults and children in stroke belt and non-stroke belt states. Methods: Ischemic stroke discharges (ICD-9-CM 433, 434, 436) were identified for calendar years 2006 and 2009 in the Kids’ Inpatient Database (N=1,434; age 0-20y) and years 2007 and 2009 in the Nationwide Inpatient Sample (N=221,351; age ≥21y). Age-specific population estimates were obtained from US Census data. Hospitalization rates per 100,000 person-years (PY) were calculated in 5-year age increments and by region. Mixed Poisson regression was used to determine the hospitalization rate ratio between stroke belt and non-stroke belt states within age groups; logistic models estimated odds ratios for in-hospital mortality. Results: Hospitalization rates were higher for adults residing in the stroke belt, but were similar for children (1.2 and 1.4 per 100,000 PY; figure). Although adult hospitalization rates were 32%-52% higher in the stroke belt, after adjustment for age, race, and sex, there was no difference in childhood stroke hospitalizations based on stroke belt residence (rate ratio=0.89, 95% CI 0.70-1.12). In-hospital mortality did not differ by region for any age group. Conclusions: Consistent with prior studies, adults in the stroke belt had higher hospitalization rates than those in non-stroke belt states; however, there was no difference for children. Because higher stroke mortality has been reported for adults and children in the stroke belt, the lack of difference in hospitalization rates and in-hospital mortality may suggest a higher late case-fatality rate for children in the stroke belt.