Temporal Trends in Racial and Ethnic Disparities in Endovascular Therapy in Acute Ischemic Stroke

Sheriff, Faheem; Xu, Haolin; Maud, Alberto; Gupta, Vikas; Vellipuram, Anantha; Fonarow, Gregg C.; Matsouaka, Roland; Xian, Ying; Reeves, Mathew J.; Smith, Eric E.; Saver, Jeffrey L.; Rodríguez, Gustavo J.; Cruz‐Flores, Salvador; Schwamm, Lee H.

doi:10.1161/jaha.121.023212

Cited by 18 publications

(17 citation statements)

References 38 publications

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“…Racial disparities in stroke care and outcomes are well described and constitute a major public health concern . 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 .…”

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

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“…Reported barriers have included geographical, 55–57 logistical, 58 financial, 59 and sociocultural. 60,61…”

Section: Discussionmentioning

confidence: 99%

Mechanical Thrombectomy Global Access For Stroke (MT-GLASS): A Mission Thrombectomy (MT-2020 Plus) Study

et al. 2023

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Background: Despite the well-established potent benefit of mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke, access to MT has not been studied globally. We conducted a worldwide survey of countries on 6 continents to define MT access (MTA), the disparities in MTA, and its determinants on a global scale. Methods: Our survey was conducted in 75 countries through the Mission Thrombectomy 2020+ global network between November 22, 2020, and February 28, 2021. The primary end points were the current annual MTA, MT operator availability, and MT center availability. MTA was defined as the estimated proportion of patients with LVO receiving MT in a given region annually. The availability metrics were defined as ([current MT operators×50/current annual number of estimated thrombectomy-eligible LVOs]×100 = MT operator availability) and ([current MT centers×150/current annual number of estimated thrombectomy-eligible LVOs]×100= MT center availability). The metrics used optimal MT volume per operator as 50 and an optimal MT volume per center as 150. Multivariable-adjusted generalized linear models were used to evaluate factors associated with MTA. Results: We received 887 responses from 67 countries. The median global MTA was 2.79% (interquartile range, 0.70–11.74). MTA was <1.0% for 18 (27%) countries and 0 for 7 (10%) countries. There was a 460-fold disparity between the highest and lowest nonzero MTA regions and low-income countries had 88% lower MTA compared with high-income countries. The global MT operator availability was 16.5% of optimal and the MT center availability was 20.8% of optimal. On multivariable regression, country income level (low or lower–middle versus high: odds ratio, 0.08 [95% CI, 0.04–0.12]), MT operator availability (odds ratio, 3.35 [95% CI, 2.07–5.42]), MT center availability (odds ratio, 2.86 [95% CI, 1.84–4.48]), and presence of prehospital acute stroke bypass protocol (odds ratio, 4.00 [95% CI, 1.70–9.42]) were significantly associated with increased odds of MTA. Conclusions: Access to MT on a global level is extremely low, with enormous disparities between countries by income level. The significant determinants of MT access are the country’s per capita gross national income, prehospital LVO triage policy, and MT operator and center availability.

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“…Stroke disproportionally affects low income and ethnic and racial minority groups. [37][38][39] Some of these disparities in stroke incidence and outcome may be related to a higher prevalence of traditional and modifiable stroke risk factors among low-income and certain racial-ethnic groups, including smoking, hypertension, obesity, and diabetes. [40][41][42] However, traditional stroke risk factors may not fully account for the increased risk among low-income individuals and racial-ethnic minorities.…”

Section: Sleep and Strokementioning

confidence: 99%

Sleep Health as a Determinant of Disparities in Stroke Risk and Health Outcome

Khot

Taylor

Longstreth

et al. 2023

Stroke

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Sleep is essential to human survival and overall vascular health. Sleep health encompasses the objective and subjective qualities associated with one’s daily pattern of sleep and wakefulness and has become a growing clinical and public health concern. Impaired sleep duration and quality can increase stroke risk and mediate the relationship between the physical aspects of an individual’s environment and disparities in stroke incidence. Here, we review observational studies evaluating the association between sleep health and cerebrovascular disease. We assess the influence on sleep of the physical environment, including the ambient environment with noise levels and the built environment. We also describe the influences on sleep health and stroke risk of social determinants of health, including the chronic stressor of racial discrimination. Finally, we discuss how changes in historical neighborhood characteristics or societal policies can influence the social factors affecting sleep health and stroke risk among socioeconomically disadvantaged groups or ethnic and racial minorities. Given the regional and racial or ethnic differences in stroke risk across the United States, an understanding of novel vascular risk factors, such as the multifaceted role of sleep health, will be critical to develop effective public policies to improve population health.

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Temporal Trends in Racial and Ethnic Disparities in Endovascular Therapy in Acute Ischemic Stroke

Cited by 18 publications

References 38 publications

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

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

Mechanical Thrombectomy Global Access For Stroke (MT-GLASS): A Mission Thrombectomy (MT-2020 Plus) Study

Sleep Health as a Determinant of Disparities in Stroke Risk and Health Outcome

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