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

Abstract

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.

Racial and ethnic disparities in emergency department transfers to public hospitals

“…Emergency medical services may initially transport Black patients to different hospitals than they do White patients, even those living within the same zip code 75–77 ; differences in where patients are initially transported might influence the likelihood that a patient is transferred. In addition, previous literature primarily found that Black patients are less likely to be transferred than White patients 21–23 but that this relationship varies for Hispanic inpatients depending on condition 20,23,24 . This could explain why Hispanic patients with major trauma were more likely to be transferred to a public hospital compared with White patients but less likely to be transferred for all other conditions examined.…”

“…Because Black and Hispanic patients are more likely to have Medicaid or be uninsured, 19 they may be more likely to experience ED transfers. Although descriptive studies suggest no racial/ethnic difference in the likelihood of transfer, 15 Zachrison et al 20 found that Hispanic ED patients with acute ischemic stroke were less likely to be transferred than White patients, even though there was no difference in likelihood of presentation to an initial hospital with capability. Hospitalized patients who are Black are less likely to have been transferred than patients who are White, 21–23 although the probability of inpatient transfer for patients who are Hispanic compared with White patients varies depending on condition 23,24 .…”

A Cross-sectional Survey of Comprehension and Satisfaction of Spanish-Reading Adults Regarding RÁPIDO as a Stroke Awareness Acronym

“…4 Although reperfusion therapies (eg, thrombolytics) are associated with decreased mortality and better outcomes, disparities exist among Hispanic populations. 3,5 Slow hospital arrival time is associated with delayed or missed stroke treatment. 6,7 In a systematic review of 30 studies, 53% of Hispanic stroke patients sought out emergency medical services (EMS) compared with 60% of White and 56% of Black patients.…”

Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach

“…9 Furthermore, there is substantial variability in stroke patient transfer patterns, suggesting a lack of standardization in transfer practices. 10–12…”

“…9 Furthermore, there is substantial variability in stroke patient transfer patterns, suggesting a lack of standardization in transfer practices. [10][11][12] A well-organized system of interhospital transfer is critical to ensure equitable access to disability-reducing reperfusion with endovascular thrombectomy for all patients regardless of initial hospital of presentation. These ongoing transfers of patients between hospitals over time can be understood as forming a hospital transfer network.…”