Disparities in Acute Stroke Care: Role of Race and Insurance Status
DOI:
https://doi.org/10.12974/2313-0946.2014.01.02.1Keywords:
Stroke, racial disparities, GWTGAbstract
Background: Minorities constitute groups with higher risk of stroke and stroke severity. Disparities in stroke care may result from greater prevalence of risk factors, barriers to medical care, and lower utilization of preventive therapies. Insurance status may be one limiting factor in access to care and preventive measures.
Purpose: We hypothesize that vascular risk factors differ between racial groups and that insurance status may affect stroke treatment, secondary prevention measures, stroke severity, and outcomes.
Methods: We included 1061 consecutive patients with ischemic stroke (2005-2008) in our local Get-With-The-Guidelines (GWTG) database. Multivariate logistic regression analysis was used to evaluate the relation of race and insurance status to risk factors, intravenous thrombolytic therapy (IV-tPA) use, stroke severity (National Institute of Health Stroke Scale [NIHSS]), hospital complications, and ambulatory status at discharge.
Results: Whites were older than Non-Whites (mean age 65 vs 62 years, p<0.001), and had higher prevalence of atrial fibrillation, coronary artery disease, and carotid stenosis (p<0.01). Non-whites were more likely to have hypertension and diabetes (p<0.01), peripheral arterial disease (p<0.05), and be uninsured (p<0.001). More IV-tPA was used in insured patients (24 vs 2). Blacks and other groups were more likely to be discharged on antihypertensive treatment (OR 1.9, 95% CI 1.0-3.6, and OR 3.8, 95% CI 1.1-13.4 respectively, p=0.04). Blacks were more likely to be discharged on lipid lowering treatment than Whites (OR 3.5, 95% CI 1.4-8.6, p=0.02). There were no significant differences on hospital complications, ambulatory status on discharge or discharge location.
Conclusion: Data at this safety-net hospital suggests racial disparities in stroke risk factors and insurance status, both of which are potential targets for prevention of stroke. Follow up studies are required to clarify the role of universal insurance coverage in reduction of stroke risk and its complications.
References
Sacco RL, Boden-Albala B, Gan R, Chen X, Kargman DE, Shea S, Paik MC, Hauser WA. Stroke incidence among white, black, and hispanic residents of an urban community: The northern manhattan stroke study. Am J Epidemiol. 1998; 147: 259-268. http://dx.doi.org/10.1093/oxfordjournals.aje.a009445
Kissela B, Schneider A, Kleindorfer D, Khoury J, Miller R, Alwell K, Woo D, Szaflarski J, Gebel J, Moomaw C, Pancioli A, Jauch E, Shukla R, Broderick J. Stroke in a biracial population: The excess burden of stroke among blacks. Stroke. 2004; 35: 426-431. http://dx.doi.org/10.1161/01.STR.0000110982.74967.39
Gillum RF. Stroke mortality in blacks. Disturbing trends. Stroke. 1999; 30: 1711-1715. http://dx.doi.org/10.1161/01.STR.30.8.1711
Gutierrez J, Williams OA. A decade of racial and ethnic stroke disparities in the United States. Neurology. 2014; 82(12): 1080-2. http://dx.doi.org/10.1212/WNL.0000000000000237
Jones K, Mansfield CJ. Premature mortality in North Carolina: progress, regress, and disparities by county and race, 2000-2010. N C Med J. 2014; 75(3): 159-69.
Addo J, Ayerbe L, Mohan K, Crichton S, Sheldenkar A, Chen R, Wolfe CD, McKevitt C. Socioeconomic status and stroke: an updated review. Stroke. 2012; 43(4): 1186-91. http://dx.doi.org/10.1161/STROKEAHA.111.639732
Menon SC, Pandey DK, Morgenstern LB. Critical factors determining access to acute stroke care. Neurology. 1998; 51: 427-432. http://dx.doi.org/10.1212/WNL.51.2.427
White H, Boden-Albala B, Wang C, Elkind MS, Rundek T, Wright CB, Sacco RL. Ischemic stroke subtype incidence among whites, blacks, and hispanics: The northern manhattan study. Circulation. 2005; 111: 1327-1331. http://dx.doi.org/10.1161/01.CIR.0000157736.19739.D0
Adams HP, Jr., Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Kwiatkowski T, Lyden PD, Marler JR, Torner J, Feinberg W, Mayberg M, Thies W. Guidelines for thrombolytic therapy for acute stroke: A supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the stroke council, American heart association. Stroke. 1996; 27: 1711-1718.
Johnston SC, Fung LH, Gillum LA, Smith WS, Brass LM, Lichtman JH, Brown AN. Utilization of intravenous tissue-type plasminogen activator for ischemic stroke at academic medical centers: The influence of ethnicity. Stroke. 2001; 32: 1061-1068. http://dx.doi.org/10.1161/01.STR.32.5.1061
Hanchate AD, Schwamm LH, Huang W, Hylek EM. Comparison of ischemic stroke outcomes and patient and hospital characteristics by race/ethnicity and socioeconomic status. Stroke. 2013; 44(2): 469-76. http://dx.doi.org/10.1161/STROKEAHA.112.669341
Hsia AW, Edwards DF, Morgenstern LB, Wing JJ, Brown NC, Coles R, Loftin S, Wein A, Koslosky SS, Fatima S, Sánchez BN, Fokar A, Gibbons MC, Jayam-Trouth A, Kidwell CS. Racial disparities in tpa treatment rate for stroke: a population-based study. Stroke. 2011; 42(8): 2217-2221. http://dx.doi.org/10.1161/STROKEAHA.111.613828
Jones K, Mansfield CJ. Premature mortality in North Carolina: progress, regress, and disparities by county and race, 2000-2010. N C Med J. 2014; 75(3): 159-68.
Gezmu T, Gizzi MS, Kirmani JF, Schneider D, Moussavi M. Disparities in acute stroke severity, outcomes, and care relative to health insurance status. J Stroke Cerebrovasc Dis. 2014; 23(2). http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2013.08.027
Ng DK, Brotman DJ, Lau B, Young JH. Insurance status, not race, is associated with mortality after an acute cardiovascular event in Maryland. J Gen Intern Med. 2012; 27(10): 1368-76. http://dx.doi.org/10.1007/s11606-012-2147-9
LaBresh KA, Reeves MJ, Frankel MR, Albright D, Schwamm LH. Hospital treatment of patients with ischemic stroke or transient ischemic attack using the "Get with the guidelines" Program. Arch Intern Med. 2008; 168: 411-417. http://dx.doi.org/10.1001/archinternmed.2007.101
Office of management and budget. Race and ethnic standards for federal statistics and administrative reporting. 1978; (Directive no 15): 43.
Sacco RL, Boden-Albala B, Abel G, Lin IF, Elkind M, Hauser WA, Paik MC, Shea S. Race-ethnic disparities in the impact of stroke risk factors: The northern manhattan stroke study. Stroke. 2001; 32: 1725-1731. http://dx.doi.org/10.1161/01.STR.32.8.1725
Wolf PA, Benjamin EJ, Belanger AJ, Kannel WB, Levy D, D'Agostino RB. Secular trends in the prevalence of atrial fibrillation: The framingham study. Am Heart J. 1996; 131: 790-795. http://dx.doi.org/10.1016/S0002-8703(96)90288-4
Qureshi AI, Safdar K, Patel M, Janssen RS, Frankel MR. Stroke in young black patients. Risk factors, subtypes, and prognosis. Stroke. 1995; 26: 1995-1998. http://dx.doi.org/10.1161/01.STR.26.11.1995
Tsai CT, Lai LP, Hwang JJ, Lin JL, Chiang FT. Molecular genetics of atrial fibrillation. J Am Coll Cardiol. 2008; 52: 241- 250. http://dx.doi.org/10.1016/j.jacc.2008.02.072
Levine DA, Neidecker MV, Kiefe CI, Karve S, Williams LS, Allison JJ. Racial/ethnic disparities in access to physician care and medications among us stroke survivors. Neurology. 76: 53-61. http://dx.doi.org/10.1212/WNL.0b013e318203e952
Grotta JC, Burgin WS, El-Mitwalli A, Long M, Campbell M, Morgenstern LB, Malkoff M, Alexandrov AV. Intravenous tissue-type plasminogen activator therapy for ischemic stroke: Houston experience 1996 to 2000. Arch Neurol. 2001; 58: 2009-2013. http://dx.doi.org/10.1001/archneur.58.12.2009
Kohrmann M, Nowe T, Huttner HB, Engelhorn T, Struffert T, Kollmar R, Saake M, Doerfler A, Schwab S, Schellinger PD. Safety and outcome after thrombolysis in stroke patients with mild symptoms. Cerebrovasc Dis. 2009; 27: 160-166. http://dx.doi.org/10.1159/000185607
Morgenstern LB, Gonzales NR, Maddox KE, Brown DL, Karim AP, Espinosa N, Moye LA, Pary JK, Grotta JC, Lisabeth LD, Conley KM. A randomized, controlled trial to teach middle school children to recognize stroke and call 911: The kids identifying and defeating stroke project. Stroke. 2007; 38: 2972-2978. http://dx.doi.org/10.1161/STROKEAHA.107.490078
Deitelzweig SB, Lin J, Johnson BH, Schulman KL. Venous thromboembolism in the us: Does race matter? J Thromb Thrombolysis. 31: 133-138. http://dx.doi.org/10.1007/s11239-010-0503-3
Jones LG, Zhang Y, Ahmed MI, Ekundayo OJ, Akhter S, Sawyer P, Aban I, Sims RV, Ahmed A. Understanding the reasons for the underuse of pneumococcal vaccination by community-dwelling older african americans. J Am Geriatr Soc. 58: 2323-2328. http://dx.doi.org/10.1111/j.1532-5415.2010.03181.x
Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for medicare beneficiaries by race and site of care. JAMA. 305: 675-681. http://dx.doi.org/10.1001/jama.2011.123
