Twenty-Year Disparity Trends in United States Stroke Death Rate by Age, Race/Ethnicity, Geography, and Socioeconomic Status

Abstract

BackgroundIn 2017 the CDC issued an alert that, after decades of consistent decline, the stroke death rate levelled off in 2013, particularly in younger individuals and without clear origin. The objective of this analysis is to understand whether social determinants of health have influenced trends in stroke mortality.MethodsWe performed a longitudinal analysis of county-level ischemic and hemorrhagic stroke death rate per 100,000 adults, from 1999-2018 using a Bayesian spatiotemporally smoothed CDC dataset stratified by age [35-64 (younger) and ≥65 (older)] and then by county-level social determinants of health. We report stroke death rate by county and the percentage change in stroke death rate in 2014-18 compared to 2009-13.ResultsWe included data from 3,082 counties for younger individuals and 3,019 counties for older individuals. The stroke death rate began to increase for younger individuals in 2013 (p<0.001) and the slope of the decrease in stroke death rate tapered for older individuals (p<0.001). During the twenty-year period of our study, counties with a high Social Deprivation Index and ≥10% Black residents consistently had the highest rates of stroke death in both age groups. Comparing 2014-18 to 2009-13, larger increases in younger individuals’ stroke death rate were seen in counties with ≥90% (vs. <90%) non-Hispanic White individuals (3.2% mean death rate change vs. 1.7%, p<0.001), rural (vs. urban) populations (2.6% vs. 2.0%, p=0.019), low (vs. high) proportion of medical insurance coverage (2.9% vs. 1.9%, p=0.002), and high (vs. low) substance abuse and suicide mortality (2.8 vs. 1.9%, p=0.008; 3.3% vs 1.5%, p<0.001). In contrast to the younger individuals, in older individuals the associations with increased death rates were with more traditional social determinants of health such as the Social Deprivation Index, urban location, unemployment rate, and proportion of Black race and Hispanic ethnicity residents.DiscussionImprovements in the United States’ stroke death rate are slowing and even reversing in younger individuals and many US counties. County-level increases in stroke death rate were associated with distinct social determinants of health for younger versus older individuals. These findings may inform targeted public health strategies.

Racial Impact on Inpatient Stroke Quality of Care in Two Community Hospitals

“…Numerous studies have reported the racial disparity in IVT utilization rate [1,10,11,37,38]. We observed the same phenomenon (7% in non-white vs. 13% in white; p = 0.042), which was not surprising given the delay in ED arrival in the case of the non-white group.…”

“…Some patients were missing the race/ethnicity categorization in the GWTG and the medical records and were assumed to be non-white if their country of origin was not the United States or if their primary language was not English. We did not have data on important SODH that have been found to be important predictors of stroke incidence and outcome, such as income, level of education, employment, housing, and insurance status [1,4]. We were unable to follow the recommended disaggregation of races/ethnicities [54] and combined all non-white patients in one group because of the small sample size, which might have obscured important inter-racial differences.…”

“…Racial disparity in stroke outcomes has been well documented [1,2] and highlighted in an important statement by the American Heart Association (AHA) more than a decade ago [3]. While many of the factors contributing to this phenomenon, such as social determinants of health (SODH) [4,5], systemic racism [6], suboptimal risk factor control [7,8], and access to care [9], are not under the control of the stroke center where patients are admitted for their stroke, the acute phase of stroke care is.…”

Frequency, Severity, Risk Factors, and Outcome of Hemorrhagic Transformation in Anterior and Posterior Stroke

“…Lifestyle changes such as decreased physical activity and increased intake of highcaloric food, salt, saturated fats, and trans fatty acids have increased the prevalence of thromboembolic or atherosclerotic events, such as acute ischemic stroke (AIS) and myocardial infarction, in the Western world in recent decades and, more recently, in developing countries [1]. However, due to better preventative measures such as antithrombotic drugs, anticoagulation, statins, antidiabetics, and antihypertensives, stroke incidence and stroke mortality have decreased over the last decades but may be reversing again [2]. Despite these trends, AIS remains one of the five most common causes of death in the US and Europe [3].…”

Advances in the Understanding of Social Determinants of Health in Stroke

“…14,15 A related study demonstrated that socially disadvantaged US counties had significantly higher stroke mortality than counties with low area-level social deprivation. 16 Similarly, historical redlining was associated with modern-day stroke prevalence in New York City independently of contemporary individual measures of socioeconomic status. 17 Data from the Black Women's Health Study suggested that Black women who experienced interpersonal racism had higher stroke incidence than those without prior experiences of racism, 18 thus establishing a direct link between interpersonal racism and stroke incidence later in life.…”