The impact of ethnicity on stroke care access and patient outcomes: a New Zealand nationwide observational study

Thompson, Stephanie; Barber, P Alan; Gommans, John; Cadilhac, Dominique A.; Davis, Alan; Fink, John; Harwood, Matire; Levack, William; McNaughton, Harry; Feigin, Valery; Abernethy, Virginia; Girvan, Jackie; Corbin, Marine; Wilson, Andrew; Douwes, Jeroen; Ranta, Annemarei

doi:10.1016/j.lanwpc.2021.100358

Cited by 24 publications

(28 citation statements)

References 20 publications

(28 reference statements)

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“… 22 , 23 As part of our wider research program, we have recently reported and discussed in much greater detail the issues faced by Māori people with stroke, which include not only significantly worse stroke outcomes but also poorer access to several key stroke interventions. 24 Results of the present study, which focused on geographic inequities, controlled for ethnicity, confirming that ethnicity alone cannot explain the geographic inequities we have identified. However, given that Māori often reside rurally, they will frequently face both ethnic and geographic inequities.…”

Section: Discussionsupporting

confidence: 83%

Geographic Disparities in Stroke Outcomes and Service Access

et al. 2022

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Background and ObjectivesInternational evidence shows that patients treated at nonurban hospitals experience poorer access to key stroke interventions. Evidence for whether this results in poorer outcomes is conflicting and generally based on administrative or voluntary registry data. The aim of this study was to use prospective high-quality comprehensive nationwide patient-level data to investigate the association between hospital geography and outcomes of patients with stroke and access to best-practice stroke care in New Zealand.MethodsThis is a prospective, multicenter, nationally representative observational study involving all 28 New Zealand acute stroke hospitals (18 nonurban) and affiliated rehabilitation and community services. Consecutive adults admitted to the hospital with acute stroke between May 1 and October 31, 2018, were captured. Outcomes included functional outcome (modified Rankin Scale [mRS] score shift analysis), functional independence (mRS score 0–2), quality of life (EuroQol 5-dimension, 3-level health-related quality of life questionnaire), stroke/vascular events, and death at 3, 6, and 12 months and proportion accessing thrombolysis, thrombectomy, stroke units, key investigations, secondary prevention, and inpatient/community rehabilitation. Results were adjusted for age, sex, ethnicity, stroke severity/type, comorbid conditions, baseline function, and differences in baseline characteristics.ResultsOverall, 2,379 patients were eligible (mean [SD] age 75 [13.7] years; 51.2% male; 1,430 urban, 949 nonurban). Patients treated at nonurban hospitals were more likely to score in a higher mRS score category (greater disability) at 3 (adjusted odds ratio [aOR] 1.28, 95% CI 1.07–1.53), 6 (aOR 1.33, 95% CI 1.07–1.65), and 12 (aOR 1.31, 95% CI 1.06–1.62) months and were more likely to have died (aOR 1.57, 95% CI 1.17–2.12) or experienced recurrent stroke and vascular events at 12 months (aOR 1.94, 95% CI 1.14–3.29 and aOR 1.65, 95% CI 1.09–2.52). Fewer nonurban patients received recommended stroke interventions, including endovascular thrombectomy (aOR 0.25, 95% CI 0.13–0.49), acute stroke unit care (aOR 0.60, 95% CI 0.49–0.73), antiplatelet prescriptions (aOR 0.72, 95% CI 0.58–0.88), ≥60 minutes of daily physical therapy (aOR 0.55, 95% CI 0.40–0.77), and community rehabilitation (aOR 0.69, 95% CI 0.56–0.84).DiscussionPatients managed at nonurban hospitals experience poorer stroke outcomes and reduced access to key stroke interventions across the entire care continuum. Efforts to improve access to high quality stroke care in nonurban hospitals should be a priority.

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Section: Discussionsupporting

confidence: 83%

Geographic Disparities in Stroke Outcomes and Service Access

et al. 2022

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“…These findings may be explained by the fact that employment before stroke was more common in the urban cohort than the nonurban cohort, and that the patients with employment are likely to have better quality of life as observed in previous research. 22,23 Overall, we found that the cost for an additional QALY in the urban group was greater than $60 000 compared with those in the nonurban group but cost-effective in the majority of iterations.…”

Section: Discussionmentioning

confidence: 76%

Comparison of Stroke Care Costs in Urban and Nonurban Hospitals and Its Association With Outcomes in New Zealand: A Nationwide Economic Evaluation

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Cadilhac

Thompson

et al. 2023

Stroke

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Background: Although geographical differences in treatment and outcomes after stroke have been described, we lack evidence on differences in the costs of treatment between urban and nonurban regions. Additionally, it is unclear whether greater costs in one setting are justified given the outcomes achieved. We aimed to compare costs and quality-adjusted life years in people with stroke admitted to urban and nonurban hospitals in New Zealand. Methods: Observational study of patients with stroke admitted to the 28 New Zealand acute stroke hospitals (10 in urban areas) recruited between May and October 2018. Data were collected up to 12 months poststroke including treatments in hospital, inpatient rehabilitation, other health service utilization, aged residential care, productivity, and health-related quality of life. Costs in New Zealand dollars were estimated from a societal perspective and assigned to the initial hospital that patients presented to. Unit prices for 2018 were obtained from government and hospital sources. Multivariable regression analyses were conducted when assessing differences between groups. Results: Of 1510 patients (median age 78 years, 48% female), 607 presented to nonurban and 903 to urban hospitals. Mean hospital costs were greater in urban than nonurban hospitals ($13 191 versus $11 635, P =0.002), as were total costs to 12 months ($22 381 versus $17 217, P <0.001) and quality-adjusted life years to 12 months (0.54 versus 0.46, P <0.001). Differences in costs and quality-adjusted life years remained between groups after adjustment. Depending on the covariates included, costs per additional quality-adjusted life year in the urban hospitals compared to the nonurban hospitals ranged from $65 038 (unadjusted) to $136 125 (covariates: age, sex, prestroke disability, stroke type, severity, and ethnicity). Conclusions: Better outcomes following initial presentation to urban hospitals were associated with greater costs compared to nonurban hospitals. These findings may inform greater targeted expenditure in some nonurban hospitals to improve access to treatment and optimize outcomes.

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“…Thompson and colleagues did find that Non-Europeans have poorer access to a few other key measures including acute-stroke unit and anticoagulant and they are less likely to achieve favorable outcomes. This study also found that cultural support services for minority ethnic groups were inconsistently implemented, and among those offered, accessed only by a minority of patients 4 . Similarly, in the United States, minorities were found less likely to receive anticoagulant for atrial fibrillation, and when treated, the quality of anticoagulant use was lower in black and Hispanic individuals.…”

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confidence: 66%

“…2,3 In The Lancet Regional Health − Western Pacific, Thompson and colleagues described racial disparities in stroke care and outcomes in a nationwide observational study in New Zealand. 4 To begin with, this study showed that the majority of stroke interventions, especially acute reperfusion and revascularization therapies, were similar between different ethnic groups in New Zealand. This reflects the efficacious acute and postacute stroke care, as well as the public stroke awareness FAST (Face, Arm, Speech, Time) campaigns in New Zealand.…”

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confidence: 92%