Acute Ischemic Stroke Interventions in the United States and Racial, Socioeconomic, and Geographic Disparities

Abstract

Background and ObjectivesIn ischemic stroke (IS) patients, intravenous alteplase (tPA) and endovascular thrombectomy (EVT) reduce long-term disability, but their utilization has not been fully optimized. Prior research has also demonstrated disparities in the use of tPA and EVT specific to sex, race/ethnicity, socioeconomic status, and geographic location. We sought to determine the utilization of tPA and EVT in the United States from 2016-18 and if disparities in utilization persist.MethodsThis is a retrospective, longitudinal analysis of the 2016-18 National Inpatient Sample.We included adult patients who had a primary discharge diagnosis of IS. The primary study outcomes were the proportions who received tPA or EVT. We fit a multivariate logistic regression model to our outcomes in the full cohort and also in the subset of patients who had an available baseline NIH Stroke Scale (NIHSS).ResultsThe full cohort after weighting included 1,439,295 IS patients. The proportion who received tPA increased from 8.8% in 2016 to 10.2% in 2018 (p<0.001); and who had EVT from 2.8% in 2016 to 4.9% in 2018 (p<0.001). Comparing Black to White patients, the odds ratio of receiving tPA was 0.82 (95% CI 0.79-0.86) and for having EVT was 0.75 (95% CI 0.70-0.81). Comparing patients with a median income in their ZIP code of ≤$37,999 to >$64,000, the odds ratio of receiving tPA was 0.81 (95% CI 0.78-0.85) and for having EVT was 0.84 (95% CI 0.77-0.91). Comparing patients living in a rural area to a large metro area, the odds ratio of receiving tPA was 0.48 (95% CI 0.44-0.52) and for having EVT was 0.92 (95% CI 0.81-1.05). These associations were largely maintained after adjustment for NIHSS, although the effect size changed for many of them. Contrary to prior reports with older datasets, sex was not consistently associated with tPA or EVT.ConclusionUtilization of tPA and EVT for IS in the United States increased from 2016 to 2018. Still, there are racial, socioeconomic, and geographic disparities in the accessibility of tPA and EVT for IS patients with important public health implications that require further study.

Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence

“…However, given the changes in eligibility for ET and efforts to improve stroke systems of care, one might expect more dramatic improvement. A more recent retrospective analysis by de Havenon et al of 2016–2018 Nationwide Inpatient Sample data showed an absolute change of 1.4% in the proportion of patients with AIS treated with tPA and 2.1% in the proportion treated with ET 20. Differences between this study and ours may be related to the shorter analysis period.…”

The Neutrophil to Lymphocyte Ratio in Poststroke Infection: A Systematic Review and Meta-Analysis

“…The majority of current studies on this topic were performed in East Asia and Europe. Given that disparities in both stroke rates and stroke outcomes have been shown between different geological locations, such as Asian and North American countries, it is important to note that the results from the studies on this topic to date may not be as applicable to stroke patients located in different geographical regions [ 56 ]. Thus, similar prospective and retrospective studies are warranted in wider geographic locations to characterize any potential differences between these populations.…”

Social Determinants of Health and Stroke Mortality

“…In this issue of Neurology® , de Havenon et al 1 publish a study that examines trends in stroke mortality over a 19-year period (1999–2018), with a focus on potential county-level social determinants of health (SDOH) that may shed light on the rather abrupt change in the previously declining stroke mortality trend that occurred in 2013, particularly among younger individuals. This study contributes to our growing understanding of geographic variation in, and area-level influences on, stroke mortality trends over time.…”