Race-Ethnic Disparities in Rates of Declination of Thrombolysis for Stroke

Abstract

Background:Prior regional or single-center studies have noted that 4-7% of eligible acute ischemic stroke (AIS) patients decline intravenous tissue plasminogen activator (tPA). We sought to determine the prevalence of tPA declination in a nationwide registry of AIS patients and to investigate differences in declination by race-ethnicity.Methods:We used the Get With The Guidelines-Stroke registry to identify AIS patients eligible for tPA and admitted to participating hospitals between January 1, 2016 and March 28, 2019. We compared patient demographics and admitting hospital characteristics between tPA-eligible patients who received and those who declined tPA. Using multivariable logistic regression, we determined patient and hospital factors associated with tPA declination.Results:Among 177,115 tPA-eligible acute ischemic stroke patients at 1,976 sites, 6,545 patients (3.7%) had tPA declination as the sole documented reason for not receiving tPA. Patients declining treatment were slightly older, more likely to be female, arrived more often at “off-hours” and earlier after symptom onset, and were more likely to present to primary stroke centers. Compared with non-Hispanic White, non-Hispanic Black race-ethnicity was independently associated with increased (aOR 1.21, 95% CI 1.11-1.31), Asian race-ethnicity with decreased (aOR 0.72, 95% CI 0.58-0.88), and Hispanic ethnicity (any race) with similar odds of tPA declination (OR 0.98, 95% CI 0.86-1.13) in multivariable analysis.Conclusions:Though the overall prevalence of tPA declination is low, eligible non-Hispanic Black patients are more likely and Asian patients less likely to decline tPA than non-Hispanic White patients. Reducing rates of tPA declinations among non-Hispanic Black patients may be an opportunity to address disparities in stroke care.

Racial- and Gender-Based Disparities in IV-Alteplase Declination

“…The findings of this study 1 have important clinical implications. First, it should be noted that the declination rate of 3.7% is quite low, suggesting that this is not the major contributor for patients not receiving IV tPA.…”

“…Although the study 1 has many strengths, including a large sample size and adjustment for several potential confounders, some important limitations should be considered in the interpretation of the data. First, both the initial documentation of and abstraction of data on why patients do not receive IV tPA may be subject to bias and error, both at the time of treatment and in the data abstraction phase.…”

“…In this issue of Neurology ®, Mendelson et al 1 use data from the Get With The Guidelines Stroke Registry to describe race- and gender-based disparities in IV alteplase (IV tissue plasminogen activator [tPA]), specifically the rates at which there is documentation that patients with acute ischemic stroke (AIS) decline treatment with thrombolytics. Among 177,115 patients (at >1,900 hospital sites) with AIS in whom no contraindications to tPA were documented, 3.7% were reported to have declined tPA.…”

Reader Response: Race-Ethnic Disparities in Rates of Declination of Thrombolysis for Stroke

“…We applaud Mendelson et al 1 for their investigation showing racial differences among those who decline treatment with thrombolytics.…”

Reader Response: Race-Ethnic Disparities in Rates of Declination of Thrombolysis for Stroke

“…Using the Get With the Guidelines-Stroke registry, Mendelson et al 1 showed that 3.7% of patients with acute ischemic stroke decline intravenous tissue plasminogen activator (tPA), despite being eligible. The authors found significant racial differences in the tPA declination rates.…”