Racial Disparities in Endovascular Thrombectomy: It’s More Than Just Access

Zachrison, Kori S.; Cross, Danielle

doi:10.1161/strokeaha.121.037921

Cited by 3 publications

(4 citation statements)

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“…28 Strategies from network science may prove valuable. 29,30 Our findings also reinforce prior literature, as we found that stroke patients from racial or ethnic minority groups in California had lower odds than White patients of receiving reperfusion interventions. [31][32][33][34] This was true for both receipt of alteplase and EVT.…”

Section: Discussionsupporting

confidence: 88%

“…As spatial justice is increasingly recognized as a critical component of building equitable systems of care, it will be important to examine the role of transfer patterns and the structure of the hospital network created by interhospital transfers in reinforcing or perpetuating disparities in patient access to high‐quality acute stroke care 28 . Strategies from network science may prove valuable 29,30 …”

Section: Discussionmentioning

confidence: 99%

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The relationship between stroke system organization and disparities in access to stroke center care in California

Zachrison

Samuels‐Kalow

et al. 2022

JACEP Open

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Background There are significant racial and ethnic disparities in receipt of reperfusion interventions for acute ischemic stroke. Our objective was to determine whether there are disparities in access to stroke center care by race or ethnicity that help explain differences in reperfusion therapy and to understand whether interhospital patient transfer plays a role in improving access. Methods Using statewide administrating data including all emergency department and hospital discharges in California from 2010 to 2017, we identified all acute ischemic stroke patients. Primary outcomes of interest included presentation to primary or comprehensive stroke center (PSC or CSC), interhospital transfer, discharge from PSC or CSC, and discharge from CSC alone. We used hierarchical logistic regression modeling to identify the relationship between patient‐ and hospital‐level characteristics and outcomes of interest. Results Of 336,247 ischemic stroke patients, 55.4% were non‐Hispanic White, 19.6% Hispanic, 10.6% non‐Hispanic Asian/Pacific Islander, and 10.3% non‐Hispanic Black. There was no difference in initial presentation to stroke center hospitals between groups. However, adjusted odds of reperfusion intervention, interhospital transfer and discharge from CSC did vary by race and ethnicity. Adjusted odds of interhospital transfer were lower among Hispanic (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98) and non‐Hispanic Asian/Pacific Islander patients (OR 0.84, 95% CI 0.79 to 0.90) and odds of discharge from a CSC were lower for Hispanic (OR 0.91, 95% CI 0.85 to 0.97) and non‐Hispanic Black patients (OR 0.74, 95% CI 0.67 to 0.81). Conclusions There are racial and ethnic disparities in reperfusion intervention receipt among stroke patients in California. Stroke system of care design, hospital resources, and transfer patterns may contribute to this disparity.

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 99%

The relationship between stroke system organization and disparities in access to stroke center care in California

Zachrison

Samuels‐Kalow

et al. 2022

JACEP Open

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“…More specifically, Black patients and patients with low-income may be less likely to receive endovascular therapy; however, this has been improving over time . Although limited access to advanced care may be one explanation, it may also be a multifactorial problem with contributions from structural racism and other factors at the hospital and systems levels as well . Additionally, female sex was significantly associated with prolonged door-in-door-out time.…”

Section: Discussionmentioning

confidence: 99%

Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Stamm

Royan

Giurcanu

et al. 2023

JAMA

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ImportanceTreatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED).ObjectiveTo evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times.Design, Setting, and ParticipantsUS registry–based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals.ExposurePatient- and hospital-level characteristics.Main Outcomes and MeasuresThe primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, &gt;120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy.ResultsAmong 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (−20.1 minutes; 95% CI, −22.1 to −18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (−66.7 minutes; 95% CI, −68.7 to −64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (−16.8 minutes; 95% CI, −21.0 to −12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times.Conclusions and RelevanceIn this US registry–based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.

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“…Finally, while this article focuses on geographic disparities in access to MT, we cannot ignore that racial disparities are also present, despite similar rates of admission to thrombectomy-capable centers within the eligible time window. 5a,6a Solutions that address geographic disparities may not rectify racial inequity, which is far too often rooted in both inherent individual and system-level bias.…”

Section: Commentmentioning

confidence: 99%

Access to Mechanical Thrombectomy for Stroke: Center Qualifications, Prehospital Management, and Geographic Disparities

et al. 2022

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Mechanical thrombectomy (MT) became the "gold-standard" treatment for most patients with acute ischemic stroke due to anterior circulation large vessel occlusion. With such a remarkable paradigm shift, it is important that this modality of treatment becomes widely and homogeneously available throughout the United States and other countries. Although the time window for MT is large (24 hours in selected patients), time is still a major determinant of outcome. Several variables are involved in achieving timely access of MT for the majority of the population: prehospital management systems, transportation models, in-hospital workflow organization, accreditation and infrastructure of centers, training of neurointervention professionals, and geographic distribution of centers. The current situation in the United States regarding MT access is marked by geographic and socioeconomic disparities. We provide an overview of current challenges and solutions in achieving more universal access to MT for the population.

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Racial Disparities in Endovascular Thrombectomy: It’s More Than Just Access

Cited by 3 publications

References 20 publications

The relationship between stroke system organization and disparities in access to stroke center care in California

The relationship between stroke system organization and disparities in access to stroke center care in California

Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Access to Mechanical Thrombectomy for Stroke: Center Qualifications, Prehospital Management, and Geographic Disparities

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