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Low Levels of Endovascular Therapy in Black Patients With Ischemic Stroke
Quick Takes
- While there was no evidence of differences in presentation to hospitals or comprehensive stroke centers that performed endovascular treatment procedures, lower rates of endovascular therapy were observed in Black patients.
- Due to the hyperacute and time-sensitive nature of acute ischemic stroke care, patients are often limited to what is offered to them.
- Access to an available and effective endovascular therapy for acute ischemic stroke that can reduce disability needs to be the standard of stroke care.
Study Questions:
Do racial and ethnic group differences exist in access to and use of endovascular therapy for acute ischemic stroke?
Methods:
Data from the 2019 Department of State Health Services (DSHS) of Texas and 2017 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) were used to conduct a retrospective, population-based study on patient- and hospital-level variables for 40,814 state and 523,820 national patient acute ischemic stroke cases. Regression analyses compared stroke care of Black and White patients and Hispanic and White patients hospitalized with acute ischemic stroke.
Results:
In 2019, 40,814 state (Texas) acute ischemic stroke cases included data on 54% White, 17% Black, and 21% Hispanic patients. Compared with White patients, Black and Hispanic patients were younger, more likely to be uninsured, and lived in lower income neighborhoods. The prevalence of hypertension, heart failure, smoking, and substance abuse was greater in Black patients, while atrial fibrillation and diabetes was more prevalent in White and Hispanic patients, respectively. Admissions to comprehensive stroke centers were greater in Black (as opposed to White) patients (45% vs. 39%, p < 0.001), but similar for endovascular therapy-performing hospitals (62% vs. 62%, p = 0.21). While no difference in endovascular therapy rates between White and Hispanic patients were found, lower rates of endovascular therapy were found in Black patients (vs. White patients) (adjusted relative risk, 0.77 [0.61-0.98]; p = 0.032) and those admitted to endovascular therapy-performing hospitals in both noncomprehensive stroke center (3.0% vs. 5.5%, p < 0.001) and comprehensive stroke center hospitals (7.9% vs. 10.4%, p < 0.001). Lower use of endovascular therapy among Black patients (vs. White patients) was confirmed (adjusted relative risk, 0.87 [0.77-0.98]; p = 0.024).
Conclusions:
After adjusting for patient characteristics, endovascular therapy rates were approximately 25% lower in Black patients compared to White and Hispanic patients. There was no evidence to support that Black patients were more likely to present to hospitals without endovascular therapy capability, which was maintained in comprehensive stroke centers and endovascular therapy-performing stroke centers, as well as in the subset of patients treated with intravenous tissue-type plasminogen activator.
Perspective:
Lower rates of endovascular therapy in Black patients compared to White and Hispanic patients did not explain delays in presentation. Narrowing the analysis to patients with large vessel occlusion who presented to a comprehensive stroke center, the disparity between Black and White patients persisted. In this study, neither timely presentation nor access to comprehensive stroke centers was a function of disparities in stroke care.
Clinical Topics: Arrhythmias and Clinical EP, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Acute Heart Failure, Hypertension, Smoking
Keywords: African Americans, Atrial Fibrillation, Brain Ischemia, Diabetes Mellitus, Endovascular Procedures, Ethnic Groups, Health Care Quality, Access, and Evaluation, Heart Failure, Hispanic Americans, Hypertension, Inpatients, Ischemic Stroke, Primary Prevention, Risk, Smoking, Standard of Care, Stroke, Tissue Plasminogen Activator, Vascular Diseases
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