Determinants of Use of Emergency Medical Services in a Population With Stroke

Symptoms: The Second Delay in Accessing Stroke Healthcare (DASH II) Study
Emily B. Schroeder, Wayne D. Rosamond, Dexter L. Morris, Kelly R. Evenson and Albert R.
Hinn

Stroke. 2000;31:2591-2596
doi: 10.1161/01.STR.31.11.2591
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2000 American Heart Association, Inc. All rights reserved.
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 Determinants of Use of Emergency Medical Services in a
Population With Stroke Symptoms
The Second Delay in Accessing Stroke Healthcare (DASH II) Study
Emily B. Schroeder, MSPH; Wayne D. Rosamond, PhD; Dexter L. Morris, PhD, MD;
Kelly R. Evenson, PhD; Albert R. Hinn, MD

Background and Purpose—With the advent of time-dependent thrombolytic therapy for ischemic stroke, it has become
increasingly important for stroke patients to arrive at the hospital quickly. This study investigates the association
between the use of emergency medical services (EMS) and delay time among individuals with stroke symptoms and
examines the predictors of EMS use.
Methods—The Second Delay in Accessing Stroke Healthcare Study (DASH II) was a prospective study of 617 individuals
arriving at emergency departments in Denver, Colo, Chapel Hill, NC, and Greenville, SC, with stroke symptoms.
Results—EMS use was associated with decreased prehospital and in-hospital delay. Those who used EMS had a median
prehospital delay time of 2.85 hours compared with 4.03 hours for those who did not use EMS (P⫽0.002). Older
individuals were more likely to use EMS (odds ratio [OR] 1.21 for each 5-year increase, 95% CI 1.14 to 1.29), as were
individuals who expressed a high sense of urgency about their symptoms (OR 1.69, 95% CI 1.09 to 2.62). Knowledge
of stroke symptoms was not associated with increased EMS use (OR 0.63, 95% CI 0.40 to 0.98). Patients were more
likely to use EMS if someone other than the patient first identified that there was a problem (OR 2.35, 95% CI 1.61 to
3.44).
Conclusions—Interventions aimed at increasing EMS use among stroke patients need to stress the urgency of stroke
symptoms and the importance of calling 911 and need to be broad-based, encompassing not only those at high risk for
stroke but also their friends and family. (Stroke. 2000;31:2591-2596.)
Key Words: cerebrovascular disorders 䡲 emergency medical services 䡲 stroke onset 䡲 stroke, acute

S troke is a major cause of disability and death in the

United States, with ⬇600 000 strokes and 160 000 deaths
occurring annually.1 Event rates and case fatality have been
declining. New evidence, however, suggests that the rate of
improvement has decreased in recent years.2 Until recently,
treatment of acute strokes has been mainly supportive.
Although the National Institute of Neurological Disorders
and Stroke rt-PA trial provided evidence that thrombolytic
therapy for acute stroke can improve neurological outcome,
such therapy is time dependent.3 Current guidelines from the
American Heart Association recommend thrombolytic ther-
apy treatment within 3 hours of the onset of symptoms and
caution that the benefit of such therapy for ischemic stroke
beyond 3 hours from the onset of symptoms has not been
established.4 Additionally, recommendations for the estab-
lishment of primary stroke centers to improve acute stroke
care have recently been published, stressing the importance of
rapid and efficient treatment of stroke patients.5
Consequently, timely medical attention for patients with
acute stroke is increasingly critical. An association between
early arrival and the use of emergency medical services
(EMS) has been found in some studies6 –10 but not in all.11,12
Other studies have found an association between referral
pattern and early arrival.13–17 Patients whose first medical
contact was with 911 or EMS arrived at the hospital faster
than did patients whose first medical contact was with a
personal physician or a study hospital.13–17 Use of 911/EMS
transport has also been associated with decreased in-hospital
delay, including time to physician evaluation8,11,18 and time to
CT scan.18 Two of these studies examined predictors of EMS
use and found that patients who arrived by ambulance had
more severe strokes,10 were older, more likely to be black,
and more likely to have blood discernible on the initial CT.13
The present study examines EMS use in a prospective
study of individuals arriving at emergency departments (EDs)
with symptoms of stroke. Prehospital and in-hospital delay
among those who did and did not use EMS was compared.
Potential predictors of EMS use were examined by both
univariate and multivariate analyses. It was hypothesized that

Received June 5, 2000; final revision received August 4, 2000; accepted August 22, 2000.
From the Department of Epidemiology (E.B.S., W.D.R., K.R.E.), School of Public Health, and the Departments of Emergency Medicine (D.L.M.) and
Neurology (A.H.), School of Medicine, University of North Carolina, Chapel Hill.
Reprint requests to Emily B. Schroeder, Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, 137 East
Franklin St, Suite 306, CB #8050, Chapel Hill, NC 27599-8050. E-mail eschroed@email.unc.edu
© 2000 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org

2591
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2592 Stroke November 2000
patients expressing a greater sense of urgency about their
symptoms, patients who had another person first identify that
there was a problem, and older patients would be more likely
to use EMS, whereas patients expressing more concerns
about seeking health care and patients living alone would be
less likely to use EMS. It was also hypothesized that there
would be little association between knowledge of stroke
symptoms and EMS use.
Subjects and Methods
Study Design
A prospective registry of patients presenting to the ED with signs or
symptoms suggestive of stroke was established in 3 study centers.
The institutional review board on human participants in research at
each center approved the study protocol. Participants or next of kin
gave informed consent to be interviewed and to have their medical
records abstracted.
Study Setting and Population
The present study was conducted in 7 hospitals in 3 cities: Denver
General Hospital, St Josephs Exempla Hospital, and University of
Colorado Health Sciences Center in Denver, Colo; Allen Bennett
Hospital, Greenville Memorial Hospital, and Hillcrest Hospital in
Greenville, SC; and the University of North Carolina Hospital,
Chapel Hill.
The University of North Carolina Hospital is a university-based
tertiary care facility that also serves as the primary care facility for
the surrounding area. The ED volume is ⬇38 000 adult patients per
year, with ⬇230 patients with a discharge diagnosis of stroke
admitted through the ED each year. Greenville Memorial Hospital is
a tertiary care facility with an ED volume of 65 000 per year, with
⬎600 patients with acute stroke admitted each year. Allen Bennett
and Hillcrest Hospital are 2 suburban hospitals with ED volumes
⬍20 000 per year. University Hospital in Denver, Colo, is a
university-based hospital with a total ED volume of 34 000 per year,
with ⬇140 patients with acute strokes admitted through the ED each
year. Denver General Hospital and St Josephs Exempla Hospital are
affiliated private institutions in the Denver area.
Between October 1997 and December 1998, trained ED staff
nurses enrolled 617 patients presenting with any of the following
symptoms suggestive of stroke: sudden unilateral weakness or
numbness of face, arm, or leg; sudden dimness or loss of vision; loss
of speech; sudden severe headache; or unexplained dizziness. These
broad criteria, based on symptoms at presentation and not on the
hospital discharge diagnosis, resulted in the enrollment of many
patients who ultimately were not diagnosed as having stroke. These
sensitive criteria, however, allowed for the characterization of
care-seeking behavior among a full spectrum of patients responding
to strokelike symptoms. It is estimated that the enrolled patients
represent 33% of all eligible patients with strokelike symptoms.
Measurement
During case enrollment, a trained nurse conducted with the patient or
proxy a 20-minute interview consisting of information on demo-
graphics, time of onset of symptoms, nature of initial response, time
to contacting healthcare system, symptom recognition, knowledge
and attitude about stroke, and barriers to seeking care. Study
personnel tracked the course of the patient in the ED, noting the time
to being seen by a physician, time to CT scan, time to being seen by
a neurologist, and treatments received.
After each patient was discharged from the hospital, the medical
records were obtained and abstracted for information on healthcare
utilization while the patient was in the hospital as well as the final
hospital discharge diagnosis. Medical records were obtained for 609
of the 617 patients enrolled. Clinical diagnoses (transient ischemic
attack [TIA], ischemic stroke, intracerebral hemorrhage, subarach-
noid hemorrhage, and nonstroke) were determined through review of
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the discharge survey from the medical records and other pertinent
information by a single neurologist (A.H.).
Race and prior history of stroke were obtained from the medical
records. Patients were determined to have knowledge of stroke
symptoms if they correctly named at least one stroke symptom
(dizziness, loss of speech, numbness in arms or legs or face,
weakness, headache, visual disturbance, paralysis, motor deficit,
facial palsy, confusion, or disorientation) in response to an open-
ended question.19 Patients were asked whether they had previously
been told that they were at high stroke risk and whether they had
previously received information about stroke symptoms. Potential
barriers to timely access to medical care were established by asking
the patient whether any of the following applied to him/her: (1)
“didn’t think symptoms were serious,” (2) “didn’t want to bother my
physician,” (3) “concern for cost,” (4) “bad prior experience with
hospitals/physicians,” and (5) “did not believe there was anything to
help me.” Patients were also asked the following: “On a 1 to 10 scale,
how urgent did you believe it was that you seek medical care for
these symptoms?” Patients giving a response of 10 were considered
to express a high sense of urgency and were compared with patients
giving a response of 1 through 9. Questions regarding age, living
alone, the identity of the person who first noticed symptoms (patient
or bystander), time of day of the onset of symptoms, educational
level, and location of the patient at the time of symptom onset (eg,
at home or work) could be answered by either the patient or a proxy.
Symptom onset was obtained during the interview of the patient or
proxy in the ED. If symptoms occurred during sleep, the onset time
was the last time known to be symptom free. Time to seeing an ED
physician (EP) was defined as the time from arrival in the ED (first
time recorded in ED, usually triage or registration) until first being
seen by an EP. Time to CT scan was defined as the time from ED
arrival to completion of the CT scan. Time to seeing a neurologist
was defined as the time from ED arrival until first contact with a
neurologist.
Data Analysis
Seven patients with missing information on EMS use were excluded.
Fifty-one patients with prehospital delay periods ⬎48 hours were
also excluded, leaving 559 patients for these analyses. For statistical
tests, an ␣ level of 0.05 was considered statistically significant.
Univariate associations of categorical variables with EMS use were
evaluated by ␹2 tests. Because of the skewed distribution of the delay
times, the Wilcoxon rank sum test was used for comparisons of time
differences. For multiple pairwise comparisons, the Scheffé method
was used, with the corresponding probability value adjusted for
multiple comparisons. Associations of factors with EMS use were
obtained from multiple logistic regression, adjusted for age and study
center. Factors examined were age, sex, race, prior history of stroke,
living alone, identity of the person who first noticed symptoms
(patient or bystander), stroke type, knowledge of stroke symptoms,
having been told that s/he was at high stroke risk, having previously
received information about stroke symptoms, 5 potential barriers to
seeking care, and sense of urgency. There was insufficient data to
determine severity and its association with EMS use. All analyses
were performed by use of SAS Version 6.12 (SAS Institute).
Results
Of the 559 patients included in the analysis, 212 (39%) had a
diagnosis of ischemic stroke; 21 (4%), intracerebral hemor-
rhage; 2 (0.4%), subarachnoid hemorrhage; 122 (22%), TIA;
and 194 (35%), diagnoses other than stroke. Eight were
missing medical records and thus were not given clinical
diagnoses. Twenty-five percent of interviews were completed
by a proxy. Those participants discharged with a diagnosis
other than stroke or TIA had a variety of diagnoses, including
migraine, drug toxicity, syncope, seizure, other neurological
disorders, and ill-defined conditions. The mean⫾SD age of
the participants was 68⫾15 years, 56% were female, and
 Schroeder et al EMS Use in a Population With Stroke Symptoms 2593

TABLE 1. Patient Characteristics Patients who used EMS had significantly shorter times
% (n) EMS Use, % P
from symptom onset to arrival, time to seeing an EP, time to
CT scan, and time to being seen by a neurologist (Table 3).
Stroke type
Patients who used EMS were also significantly more likely to
Ischemic stroke 38.6 (213) 59.6 0.001 arrive within 2 hours (P⫽0.012) and 3 hours (P⫽0.035) than
Intracerebral hemorrhage 3.8 (21) 71.4 were patients who did not use EMS.
Subarachnoid hemorrhage 0.4 (2) 0.0 EMS use was highest among those with intracerebral
TIA 22.1 (122) 39.3 hemorrhage (71%), followed by those with ischemic stroke
Nonstroke 25.7 (142) 43.0 (60%), those with nonstroke diagnoses (43%), and those with
Uncertain 9.4 (52) 28.9
TIA (39%). By use of the Scheffé method to adjust for
multiple comparisons, EMS use was statistically different
Total 559 47.9
only between those with TIA and those with ischemic stroke
Age
(P⫽0.005) and between those with nonstroke diagnoses and
⬍50 y 13.1 (73) 31.5 0.001 those with ischemic stroke (P⫽0.021).
50–⬍60 y 17.2 (96) 35.4 After adjusting for study center, age was predictive of EMS
60–⬍70 y 20.1 (112) 42.9 use, with older patients more likely to use EMS than younger
70–⬍80 y 28.0 (156) 50.0 patients (OR for each 5-year increase 1.21, 95% CI 1.14 to
ⱖ80 y 21.7 (121) 69.4 1.29). The remaining models were adjusted only for age and
Sex
study center. Sex (OR 1.20, 95% CI 0.84 to 1.72) and race
(OR 1.52, 95% CI 1.00 to 2.31) did not predict EMS use.
Male 44.5 (249) 50.6 0.260
Patients with better knowledge and access to information
Female 55.5 (310) 45.8
regarding stroke symptoms were not more likely to use EMS.
Center Surprisingly, those with knowledge of stroke symptoms (OR
Denver, Colo 28.6 (160) 65.0 NA 0.63, 95% CI 0.40 to 0.98) and those who reported having
Chapel Hill, NC 50.1 (280) 40.0 previously received information about stroke symptoms (OR
Greenville, SC 21.3 (119) 43.7 0.59, 95% CI 0.38 to 0.91) were less likely to use EMS.
Race Similarly, those who reported a bad prior experience with
Nonwhite 29.5 (150) 48.7 0.539
physicians or hospitals were less likely to use EMS (OR 0.37,
95% CI 0.15 to 0.89). Those who lived alone were also less
White 70.5 (359) 45.7
likely to use EMS (OR 0.63, 95% CI 0.41 to 0.96).
Live alone
A heightened sense of urgency about the symptoms was
Yes 23.1 (129) 44.2 0.331 associated with greater EMS use (OR 1.69, 95% CI 1.09 to
No 76.9 (430) 49.1 2.62), whereas concern for cost was not (OR 0.85, 95% CI
Who first identified a 0.43 to 1.71). Another strong predictor of EMS use was
problem having someone other than the patient first identify that there
Patient 60.0 (332) 38.3 0.001 was a problem (OR 2.35, 95% CI 1.61 to 3.44). There was no
Other 40.0 (221) 61.5 association between EMS use and history of stroke, educa-
NA indicates not applicable. tional level, time of day of symptom onset, day of the week
of symptom onset (weekend or weekday), or location of
71% were white (Table 1). Forty-eight percent of all partic- symptom onset (eg, at home or at work).
ipants were transported by EMS. When the analyses were restricted to those with confirmed
Twenty-seven percent of participants had a history of strokes or TIA (n⫽358), the ORs remained essentially
unchanged. The associations between knowledge of stroke
stroke (Table 2). Sixty-nine percent of the participants cor-
symptoms and EMS use (OR 0.73, 95% CI 0.41 to 1.31),
rectly identified at least one stroke symptom in response to an
between sense of urgency and EMS use (OR 1.44, 95% CI
open-ended question. Only 38% of participants reported that
0.84 to 2.47), and between living alone and EMS use (OR
they had previously been told that they were at high risk for
0.66, 95% CI 0.38 to 1.13) were slightly attenuated.
stroke. Thirty-eight percent of participants reported that they
had previously been given information about stroke symp- Discussion
toms. When prompted about concerns that might have con- The use of EMS by patients with stroke symptoms markedly
tributed to their decision to delay seeking care for their decreased both prehospital and in-hospital delay. Older peo-
symptoms, the most common was that they did not think that ple were more likely to use EMS, as were individuals with
their symptoms were serious (37%). Few patients agreed that diagnoses of ischemic stroke and intracerebral hemorrhage.
worries about the cost of their treatment (12%) or concerns After adjusting for age and study center, an important
about bothering their physician (13%) were associated with predictor of EMS use was having someone other than the
their decision to delay seeking care for their symptoms. patient first identify that there was a problem. The individu-
However, 45% of those who did not think their symptoms al’s sense of urgency was also an important predictor in the
were serious were diagnosed with stroke, and another 25% entire study population, although its importance was dimin-
were diagnosed with TIA. ished when restricted to confirmed strokes/TIAs. Reporting a

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2594 Stroke November 2000

TABLE 2. Patients’ Knowledge, Awareness, History, and Attitudes Concerning Stroke

EMS Use
Among
Responses, %

Total, n Yes Answers, % Yes No P*

History of stroke 552 27.2 50.0 47.5 0.603
Correctly identified a stroke symptom 443 69.3 38.1 50.0 0.019
Told at high risk for stroke 456 38.4 39.4 44.5 0.289
Reported to have previously been given information about 442 38.0 36.9 46.0 0.061
stroke symptoms
Expressed high sense of urgency 445 33.7 45.3 39.3 0.224
Reasons for delay
Didn’t believe there was anything to help me 393 7.4 44.8 39.0 0.538
Bad prior experience with hospitals/physicians 394 9.1 22.2 40.8 0.030
Didn’t think symptoms were serious 414 37.4 37.4 40.5 0.530
Didn’t want to bother my physician 394 12.9 39.2 39.4 0.984
Concern for cost 395 12.4 30.6 40.5 0.187
*␹ test comparing EMS use among yes responses and no responses.
2

bad prior experience with physicians and/or hospitals was
associated with statistically significantly decreased EMS use.
Knowledge and awareness of stroke symptoms was not
associated with increased EMS use. Factors related to timely
access to medical care for stroke symptoms are important
because they may represent opportunities to reduce delays by
guiding intervention strategy or identifying groups that are in
particular need of intervention.
Prehospital Delay
Shorter transport time is probably not the primary determi-
nant of the association of EMS use with reduced prehospital
delay time. Previous studies have shown that travel time to
the hospital is actually a small proportion of the total
prehospital delay period. Because transport time is not the
major component of prehospital delay,7 the majority of the
reduction in prehospital delay due to EMS use must be
attributed to other factors. People who perceive their symp-
toms (or the symptoms of someone around them) as serious
and urgent are likely both to take quick action and to call 911.
In contrast, those who do not think their symptoms represent
an emergency are more likely to wait before taking any action
and are less likely to call 911. Accordingly, we found that
those who expressed the greatest sense of urgency were more
likely to use EMS than those who expressed less urgency.
In-Hospital Delay
There are several possible explanations for the shorter in-
hospital delay for those who use EMS compared with those
who do not use EMS. The first may be that patients arriving
by EMS are most often placed directly in a bed and are
available to be seen by an EP immediately, whereas patients
arriving via the front door must first be triaged before they
can physically be brought to a bed. Registration delays or lack
of recognition of the urgency of the problem at triage could
further add to the delay.18 In addition, it is possible that the
mere fact of arriving by EMS raises the level of concern for
the patient by the physicians and ED staff.
Alternatively, patients arriving by EMS may be more
severely ill and thus naturally would be seen by an EP
sooner.10 Although the present study attempted to measure
severity by use of both the Barthel Index20 and the Orpington
Prognostic Scale,21 the large number of missing values made
it impossible to adequately test this hypothesis. However,
type of stroke was strongly associated with EMS use. Patients
with hemorrhagic stroke were more likely to use EMS than

TABLE 3. Median (Interquartile Range) Delay Times by EMS Use

EMS

Time Lapse Total Yes No P*

Symptoms to arrival, h 3.50 (1.40–9.10) 2.85 (1.15–7.42) 4.08 (1.70–10.97) 0.002
ⱕ2 h, % 36.1 41.7 31.2 0.012†
ⱕ3 h, % 47.3 52.2 43.0 0.035†
Arrival to EP, h 0.31 (0.08–0.63) 0.17 (0.03–0.40) 0.50 (0.23–0.83) 0.001
Arrival to CT scan, h 1.46 (1.00–2.18) 1.27 (0.83–2.00) 1.62 (1.18–2.33) 0.001
Arrival to neurologist, h 2.43 (1.35–3.57) 2.13 (1.17–3.27) 2.73 (1.83–3.70) 0.027
Values are median (interquartile range) or as indicated.
*Wilcoxon rank sum test, except where noted.
†␹2 test.

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 Schroeder et al
were patients with ischemic stroke, and patients with either
hemorrhagic or ischemic stroke were more likely to use EMS
than were those with TIA. This supports the theory that
patients who use EMS have more severe symptoms than
patients not using EMS. Other studies suggest that severity
does have a role in rapid response within the ED. Kothari et
al22 found that patients arriving by Basic Cardiac Life
Support transport had longer times to seeing EPs than did
those arriving by Advanced Cardiac Life Support transport,
indicating that the severity of the patient’s illness cannot be
dismissed as a factor influencing delay.
The present study supports our previous work indicating
that time from the onset of symptoms may also play a role in
the perception of severity by the ED staff.18 Regardless of
their beliefs about the usefulness of tissue plasminogen
activator for ischemic stroke, the ED staff may regard
someone whose symptoms have been present for only 1 hour
as being different from someone whose symptoms have been
present for ⬎1 day. The data reported suggest that the time to
being seen by an EP is decreased for those presenting within
3 hours of the onset of symptoms. However, as seen in our
previous work,18 arrival by EMS still resulted in decreased
times to seeing an EP and to time to CT, regardless of the
length of out-of-hospital delay.
Associations With EMS Use
The direct association of age with EMS use replicates the
findings of Barsan et al,13 as did the lack of an association
with the sex of the patient. In contrast to their findings,
however, no association with race was found.13 A strong
predictor of EMS use was having somebody other than the
patient first identify that there was a problem. The key role of
witnesses has been reported by others.9,23
Patients with greater knowledge and awareness of stroke
and its symptoms were not more likely to use EMS. In fact,
those with knowledge of stroke symptoms and who reported
having previously received information about stroke symp-
toms were less likely to use EMS. This is in agreement with
findings by others that knowledge of stroke symptoms does
not decrease delay time.7,10,12,24 It is possible that the lack of
an association between knowledge of stroke symptoms and
delay time is due to inadequate measurement of knowledge.
In addition, having a history of stroke did not have an effect
on EMS use. Other studies have found that a history of stroke
does not decrease delay time.7,10,24 When patients are given
information about stroke, more emphasis needs to be placed
on the “call to action” and the emergency nature of stroke
symptoms.
Limitations and Strengths
Prospective ED registries of specific patient complaints are
subject to advantages and limitations of data collection in a
critical care environment. One limitation was that many of the
patients were incapable of completing an interview and that
responses from proxies were used. This could influence the
validity of some of the data collected. However, every effort
was made by the nurses in the ED to interview the informant
most familiar with the circumstances surrounding the onset of
symptoms. More important, many of the questions (eg, about
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EMS Use in a Population With Stroke Symptoms 2595
sense of urgency and concerns that might lead to delay) could
be answered only by the patient. Therefore, these questions
are subject to a large number of missing values, and the
distribution of missing values is biased, with the most
severely disabled patients being much more likely to have
missing values. For example, 10% of patients with a diagno-
sis of TIA were missing responses to the sense-of-urgency
question, whereas 24% and 30% of patients with ischemic
stroke and hemorrhagic stroke, respectively, had missing
responses. It is unclear how the bias may affect the results of
the present study.
Nevertheless, a significant strength of the present study
stems from its use of a standardized prospective interview
questionnaire, instead of relying solely on medical record
review. Such a review is often inadequate to obtain detailed
data on the timing of symptom onset.6 The hospitals included
in the present study represent a mix of urban and rural
hospitals and of research and community hospitals in 3
geographic locations. The study population included roughly
equal numbers of men and women and a substantial propor-
tion of nonwhite participants. Consequently, these findings
probably have broader generalizability.
Conclusions
EMS was underused in this population with stroke symptoms,
with less than half of the participants using EMS. Only sixty
percent of those with ischemic stroke used EMS. If the factors
that influence EMS use can be better understood, interven-
tions could be developed to increase EMS use among this
population. The results from the present study confirm
findings that knowledge of stroke symptoms is not sufficient
to prompt people to take action. The patient’s own sense of
urgency about his or her symptoms and having a bystander
first identify that there was a problem were much more
important factors. Consequently, interventions aimed at in-
creasing EMS use among stroke patients need to stress the
urgency of stroke symptoms and the importance of calling
911 and need to be broad-based, encompassing not only those
at high risk for stroke but also their friends and family
members.
Acknowledgments
This study was funded by a grant from Glaxo Wellcome Inc and by
a National Research Service Award, Cardiovascular Epidemiology
Training Grant to E.B. Schroeder from the National Institutes of
Health/National Heart, Lung, and Blood Institute
(grant 5-T32-HL-07055).
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