Race, Ethnicity, and State-by-State Geographic Variation in Hemorrhagic Stroke in Dialysis Patients

Abstract

Background and objectives Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. A similar pattern of geographic variation in ischemic strokes has also recently been reported in patients undergoing long-term dialysis, but whether this is also the case for hemorrhagic stroke is unknown.Design, setting, participants, & measurements Medicare claims from 2000 to 2005 were used to ascertain hemorrhagic stroke events in a large cohort of incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios (ARRs) for stroke.Results A total of 265,685 Medicare-eligible incident dialysis patients were studied. During a median follow-up of 15.5 months, 2397 (0.9%) patients sustained a hemorrhagic stroke. African Americans (ARR, 1.43; 95% confidence interval [CI], 1.30 to 1.57), Hispanics (ARR, 1.78; 95% CI, 1.57 to 2.03), and individuals of other races (ARR, 1.51; 95% CI, 1.26 to 1.80) had a significantly higher risk for hemorrhagic stroke compared with whites. In models adjusted for age and sex, four states had O/E ARRs for hemorrhagic stroke that were significantly greater than 1.0 (California, 1.15; Maryland, 1.25; North Carolina, 1.25; Texas, 1.19), while only 1 had an ARR less than 1.0 (Wisconsin, 0.79). However, after adjustment for race and ethnicity, no states had ARRs that varied significantly from 1.0.Conclusion Race and ethnicity, or other factors that covary with these, appear to explain a substantial portion of state-by-state geographic variation in hemorrhagic stroke. This finding suggests that the factors underlying the high rate of hemorrhagic strokes in dialysis patients are likely to be system-wide and that further investigations into regional variations in clinical practices are unlikely to identify large opportunities for preventive interventions for this disorder.

Circadian Variation in the Incidence of Stroke-Induced Aphasia Types in Ahvaz, South-West of Iran

“…The time and climatic features in the incidence of stroke and aphasia are among these factors, which were vastly studied in some countries (13)(14)(15)(16)(17)(18)(19). According to the statistical information in Italy, the incidence of stroke is lower during the summer and is higher in the fall than in the winter (20).…”

Temporal Trends in the Outcomes of Dialysis Patients Admitted With Acute Ischemic Stroke

“…Patients with end‐stage renal disease receiving maintenance dialysis have higher incidences of both ischemic and hemorrhagic strokes compared with the general population 2, 3, 4, 5. In addition, distinctive risk profiles, mechanisms of stroke, and racial disparities have been suggested in several population studies of ischemic stroke in the dialysis population 2, 3, 4, 5, 6, 7, 8, 9. Dialysis status has also been shown to be an independent predictor of in‐hospital mortality following acute stroke 2, 5, 10, 11, 12.…”

Geovariation in Fracture Risk among Patients Receiving Hemodialysis

“…These data provide some evidence that geographic location may affect a patient's risk of fracture, independent of other established risk factors. Because geographic variation in the risk of several other outcomes in patients on dialysis is recognized (24)(25)(26)(27)(28)(29)(30), the geographic variation in fracture risk is not surprising. New in this study is the finding that latitude is also predictive and independent of geographic location.…”

“…For example, no study has evaluated whether geographic factors, demographic factors (such as race/ethnicity), or local treatment practices, all of which may influence access to care and have been studied in relationship to other aspects of dialysis outcomes (24)(25)(26)(27)(28)(29)(30), are associated with fracture risk in the United States dialysis population. Whether rates of fracture and tendon rupture in the dialysis population vary by geographic region has not been specifically studied.…”