Racial Disparities Still Exist in Advanced Stroke Care, In-Hospital Mortality

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Researchers sought to assess any recent changes in racial inequities trends in stroke treatment and in-hospital mortality, and whether racial inequities differed among patients living in rural areas.

Black patients from rural areas had limited access to advanced stroke care and both Black and White patients from rural areas were at increased risk for in-hospital mortality, according to a retrospective nationwide study published in Stroke.

In the US, there are racial inequalities in stroke outcomes, in which Black individuals have twice the rate of stroke and are 44% more likely to die from stroke compared with White individuals. In order to update the trends of stroke outcomes in the US, researchers from Washington University School of Medicine sourced data from the National Inpatient Sample. Between 2012 and 2017, trends in stroke rates and outcomes were assessed on the basis of ethnicity and residential location.

There were a total of 655,459 patients with sufficient data who had a stroke between 2012 and 2017 in the US. This population was 81% White, 19% Black, and 53% were women.

Among Black and White patients, 65.1% and 46.2% lived in urban areas, 24.7% and 33.4% in towns, and 10.2% and 20.4% in rural areas, respectively. For both Black and White patients, more rural patients lived in the lowest-quartile income neighborhoods compared with urban patients (both P <.001). There were little differences in key medical comorbidities on the basis of residential location.

For patients with acute ischemic stroke (AIS; 69%), intravenous thrombolysis (IVT) and endovascular therapy (EVT) rates generally increased among all patients groups between 2012 and 2017. Black patients from rural areas had the lowest rates of both IVT and EVT in all years.

Compared with White patients from urban areas, White patients from rural areas (adjusted odds ratio [aOR], 0.92; 95% CI, 0.88-0.97), Black patients from urban areas (aOR, 0.81; 95% CI, 0.77-0.85), Black patients from town (aOR, 0.78; 95% CI, 0.73-0.84), and Black patients from rural areas (aOR, 0.69; 95% CI, 0.61-0.78) were less likely to receive IVT.

Fewer patients among all patient groups received EVT compared with White patients from the urban cohort, with rates most greatly reduced among Black patients from rural areas (aOR, 0.61; 95% CI, 0.48-0.77).

All White patients had similar rates of discharge to home and all Black patients were less likely to be discharged to home than White patients (aOR range, 0.79-0.84).

For mortality, compared with White patients from urban areas, White patients who live in town (aOR, 1.15; 95% CI, 1.10-1.19) and rural areas (aOR, 1.37; 95% CI, 1.31-1.43), and Black patients in rural areas (aOR, 1.10; 95% CI, 1.00-1.22) were at increased risk for in-hospital mortality.

No interactions were observed between race and rurality for treatment (P =.43) or outcomes (P =.37).

This study was limited by not having access to data about patient eligibility for IVT and EVT.

Among Americans presenting with AIS, Black patients from rural areas had the lowest access to advanced stroke therapies and were least likely to be discharged to home. All patients from rural areas were at increased risk for in-hospital mortality. “Clinical and policy interventions are needed to improve access and reduce inequities in stroke care and outcomes,” the researchers concluded.

Reference

Hammond G, Waken RJ, Johnson DY, Towfighi A, Maddox KEJ. Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years. Stroke. February 17, 2022. doi:10.1161/STROKEAHA.121.035006