Sex and Race‐Ethnic Disparities in Door‐to‐CT Time in Acute Ischemic Stroke: The Florida Stroke Registry

Polineni, Sai; Perez, Enmanuel J.; Wang, Kefeng; Gutierrez, Carolina M; Walker, Jeffrey T.; Foster, Dianne; Dong, Chuanhui; Asdaghi, Negar; Romano, Jose G.; Sacco, Ralph L.; Rundek, Tatjana

doi:10.1161/jaha.120.017543

Cited by 13 publications

(8 citation statements)

References 40 publications

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“…Additionally, female sex was significantly associated with prolonged door-in-door-out time. Prior literature has shown that female patients are less likely to receive certain stroke care benchmarks, such as door-to-CT time of 25 minutes or less . Controlling for insurance status partially mitigated these disparities, but further study is warranted to ascertain the underlying causes and to ultimately implement system redesigns to achieve health equity.…”

Section: Discussionmentioning

confidence: 99%

“…Patient demographics, including fixed categories for race and ethnicity were extracted from the medical record for inclusion in the registry. These variables were included as racial and sex disparities in other aspects of stroke identification and care have been well described in the literature . Patient risk factors included history of hypertension, diabetes, dyslipidemia, atrial fibrillation, prior stroke, prior TIA, prosthetic heart valve, coronary artery disease or myocardial infarction, carotid artery stenosis, peripheral vascular disease, heart failure, and smoking.…”

Section: Methodsmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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

Stamm

Royan

Giurcanu

et al. 2023

JAMA

View full text Add to dashboard Cite

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“…This contrasts with previous studies demonstrating differences in treatment time associated with race and ethnicity. 12,21,22 However, our study demonstrates that systemic disparities still exist with pre-hospital factors at the hospital level. Patients presenting to CHs first had less likelihood of stroke activation and longer DTN time (though they had shorter DTC time).…”

Section: Discussionmentioning

confidence: 66%

“…This contrasts with previous studies demonstrating differences in treatment time associated with race and ethnicity. 12,21,22…”

Section: Discussionmentioning

confidence: 99%

Patient and Hospital Characteristics Associated with Disparities in Acute Stroke Treatment in Community and Academic Hospitals

Shen,

Corlin,

Coté

et al. 2023

Preprint

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ImportanceSystemic biases and barriers may affect identification, emergency transportation, and care coordination for people with stroke. We assessed patient- and hospital-level factors for associations with pre-hospital and emergency department care processes. We compared trends for patients first presenting to an academic medical center versus community hospitals.ObjectiveAssess whether patient and hospital characteristics were associated with differences in emergency medical services utilization, stroke code activation, and time to treatment for patients first hospitalized with stroke at academic medical center versus community hospitals. We hypothesized that disparities exist by patient characteristics (e.g., race and ethnicity, primary language) within each clinical setting, and that differences exist across the clinical settings.DesignRetrospective cohort study using data from the electronic health record at an academic medical center (Tufts Medical Center).SettingTertiary care referral center.Participants542 patients aged ≥18 years hospitalized with stroke (96% with acute ischemic stroke) between 1/1/2018-12/31/2020, including patients who presented directly to the academic medical center and patients transferred from community hospitals.Main OutcomesEmergency medical services use, stroke code activation, door-to-computed tomography time, and door-to-needle time.ResultsAcademic medical center non-Hispanic Asians (odds ratio (OR)=0.25; 95% confidence interval (CI)=0.13-0.47) and Hispanics (OR=0.19; 95% CI=0.05-0.72) and community hospital non-Hispanic Black/African-Americans (OR=0.17; 95% CI=0.05-0.62) were less likely to use emergency medical services compared to non-Hispanic whites. Patients with non-English primary language were less likely to use emergency medical services (OR=0.38; 95% CI=0.23-0.63) compared to English-speaking patients overall, in academic medical centers (OR=0.46; 95% CI=0.25-0.83) and community hospitals (OR=0.18; 95% CI=0.06-0.51). Community hospital Hispanics were less likely to have stroke code activation (OR=0.24; 95% CI=0.05-0.86) compared to non-Hispanic whites. Patients first presenting to a community hospital versus an academic medical center were less likely to have stroke code activation (OR=0.12; 95% CI=0.07-0.19), had shorter door-to-computed tomography time (31% shorter; 95% CI=15-43% shorter), and had longer door-to-needle time (29% longer; 95% CI=5-58% longer).ConclusionsPatient-level factors and hospital setting were associated with differences in acute care suggesting opportunities for community outreach on emergency medical service use, interventions to alleviate language barriers, and approaches to address systemic racism affecting stroke care.Key PointsQuestionAre there differences in acute stroke care between patients first hospitalized at academic medical centers versus community hospitals?FindingsIn this retrospective cohort study (n=542), academic medical center patients identifying as non-Hispanic Asian or Hispanic, community hospital patients identifying as non-Hispanic Black/African-American, and patients with a non-English primary language were less likely to use emergency medical services. Community hospital patients identifying as Hispanic were less likely to have stroke code activation. Community hospital patients were less likely to have stroke code activation, had shorter door-to-computed tomography time, and had longer door-to-needle time.MeaningTargeted intervention and outreach are needed.

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“…In the hospital setting, socioeconomic disparities exist for patients with stroke in terms of access to treatment [11,15,16]. Additionally, variability in stroke imaging utilization on the basis of age, sex, race, and insurance type has been reported [12,[22][23][24][25]. Furthermore, disadvantaged socioeconomic groups have historically been the last to benefit from newer medical technologies [26].…”

Section: Introductionmentioning

confidence: 99%