Utilization of intravenous tissue-type plasminogen activator for ischemic stroke at academic medical centers: the influence of ethnicity

Disparities in Access to Reperfusion Therapy for Acute Ischemic Stroke (DARTS): A Comprehensive Meta-Analysis of Ethnicity, Socioeconomic Status, and Geographical Factors

BACKGROUND

Reperfusion therapies, such as intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT), are crucial for improving outcomes in patients with acute ischemic stroke (AIS). However, access to these treatments can vary significantly due to ethnicity, socioeconomic status (SES), and geographical location, impacting patient outcomes.

OBJECTIVES

The Disparities in Access to Reperfusion Therapy for Acute Ischemic Stroke (DARTS) study aims to systematically assess disparities in access to IVT and EVT on the basis of ethnicity, SES, and geographical location.

METHODS

A comprehensive meta-analysis was conducted, incorporating data from 38 studies involving 5,256,531 patients with AIS. The analysis evaluated IVT and EVT utilization rates across ethnic groups, SES levels, and geographical locations.

RESULTS

The findings reveal substantial disparities in access to reperfusion therapies. IVT and EVT utilization rates varied significantly by ethnicity (9% ethnic, 11% non-ethnic for IVT; 7% ethnic, 6% non-ethnic for EVT), SES (13% low SES, 16% high SES for IVT; 7% low SES, 10% high SES for EVT), and geography (9% rural, 12% urban for IVT; 1% rural, 4% urban for EVT). Black patients had significantly lower odds of receiving IVT (OR 0.69, p = 0.001) and EVT (OR 0.87, p = 0.005) compared with white patients. Similarly, patients with low SES and those from rural areas faced reduced odds of receiving IVT (OR 0.74, p < 0.001; OR 0.72, p = 0.002) and EVT (OR 0.74, p < 0.001; OR 0.39, p < 0.001). Rural patients also had significantly lower odds of timely hospital arrival (p < 0.001), posing a barrier to accessing reperfusion therapies.

CONCLUSIONS

The DARTS study (and this meta-analysis) reveals significant access disparities in AIS treatment related to ethnicity, geography, and SES, particularly affecting Black communities, low SES individuals, and rural populations. Despite advances in reperfusion therapies, suboptimal implementation rates persist. To address these issues, we recommend the EQUITY framework: Educate, Ensure Quality, provide Universal Access, Implement Inclusive Policy Reforms, Enhance Timely Data Collection, and Yield Culturally Sensitive Care Practices. Adopting these recommendations will improve access, reduce disparities, and enhance stroke management and outcomes globally. Equitable access is essential for all eligible patients to fully benefit from reperfusion treatments.

Socioeconomic influences on stroke outcomes: A comprehensive zip code-based hospital analysis

BACKGROUND AND OBJECTIVES

Stroke remains a leading cause of morbidity and mortality worldwide. Socioeconomic disparities significantly affect the treatment and outcomes of cardiovascular and cerebrovascular diseases, including acute ischemic stroke. This study examines patients treated at Thomas Jefferson University Hospital, with ZIP code-based socioeconomic data predominantly representing areas in Pennsylvania and New Jersey, as the majority of patients originate from these regions.

METHODS

This study is a retrospective analysis based on a prospectively maintained database of 697 patients who underwent mechanical thrombectomy between 2016 and 2023. ZIP codes were retrospectively added to the database to determine socioeconomic status (SES). SES was assessed by matching patient ZIP codes to median household income data from the Census for the years 2016-2022. Baseline characteristics, stroke characteristics, procedural details, and outcomes were collected. Patients were stratified into income quintiles (Q1: $14,658-$52,635; Q2: $52,905-$64,046; Q3: $64,140-$77,737; Q4: $78,449-$95,128; Q5: $95,231-$217,674). Multivariate regression was conducted to identify predictors of good functional outcomes (mRS 0-2).

RESULTS

The study included 697 patients representing 270 zip codes distributed across income quintiles as follows: Q1 (n = 140), Q2 (n = 142), Q3 (n = 138), Q4 (n = 138), and Q5 (n = 139). Significant racial differences were observed between income quintiles, with a higher proportion of African-American patients in Q1 (40.7 %) compared to Q5 (19.9 %; p < 0.001), and more white patients in Q5 (82.7 %) compared to Q1 (47.1 %; p < 0.001). The Onset to arterial puncture time was longer in Q1 (369 min) compared to Q5 (258 min; p = 0.004). There were no significant differences in stroke outcomes such as successful recanalization (TICI 2b-3), hemorrhagic transformation, median NIHSS score on discharge, 30-day readmission, disposition to home, or length of stay between Q1 and Q5. SES was not a significant predictor of good functional outcomes (mRS 0-2).

CONCLUSION

This study found no significant differences in stroke outcomes between low SES and high SES patients undergoing mechanical thrombectomy for acute ischemic stroke. Patients from higher SES had a shorter duration from stroke onset to arterial puncture, and there was a tendency though not significant for higher SES patients to have a higher rate of 30-day readmission, and higher rate of discharge to home. Further research is needed to confirm.

Racial differences in triage assessment at rural vs urban Maine emergency departments

Data continue to accumulate demonstrating that those belonging to racialized groups face implicit bias in the emergency care delivery system across many indices, including triage assessment. The Emergency Severity Index (ESI) was developed and widely implemented across the US to improve the objectivity of triage assessment and prioritization of care delivery; however, research continues to support the presence of subjective bias in triage assessment. We sought to assess the relationship between perceived race and/or need for translator and assigned ESI score and whether this was impacted by hospital geography. We performed retrospective EMR-based review of patients presenting to urban and rural emergency departments of a health system in Maine with one of the top ten most common chief complaints (CC) across a 5-year period, excluding psychiatric CCs. We used multivariable regression to analyze the relationships between perceived race, need for translator, and gender with ESI score, wait time, and hallway bed assignments. We found that patients perceived as non-white were more likely to receive lower acuity ESI scores and have longer wait times as compared to patients perceived as white. Patients perceived as female were more likely to receive lower acuity scores and wait longer to be seen than patients perceived as male. The need for an interpreter was associated with increased wait times but not significantly associated with ESI score. After stratification by hospital geography, evidence of subjective bias was limited to urban emergency departments and was not evident in rural emergency departments. Further investigation of subjective bias in emergency departments in Maine, particularly in urban settings, is warranted.

Unveiling the evolving landscape of stroke care costs: A time-driven analysis

INTRODUCTION

Stroke is a common cause of mortality in the United States. However, the economic burden of stroke on the healthcare system is not well known. In this study, we aim to calculate the annual cumulative and per-patient cost of stroke.

METHODS

We conducted a retrospective analysis of Nationwide Emergency Department Sample (NEDS). We calculate annual trends in cost for stroke patients from 2006 to 2019. A multivariate linear regression with patient characteristics (e.g. age, sex, Charlson Comorbidity Index) as covariates was used to identify factors for higher costs.

RESULTS

In this study time-period, 2,998,237 stroke patients presented to the ED and 2,481,171 (83 %) were admitted. From 2006 to 2019, the cumulative ED cost increased by a factor of 7.0 from 0.49 ± 0.03 to 3.91 ± 0.16 billion dollars (p < 0.001). The cumulative inpatient (IP) cost increased by a factor of 2.7 from 14.42 ± 0.78 to 37.06 ± 2.26 billion dollars (p < 0.001. Per-patient ED charges increased by a factor of 3.0 from 1950 ± 64 to 7818 ± 260 dollars (p < 0.001). Per-patient IP charges increased by 89 % from 40.22 +/- 1.12 to 76.06 ± 3.18 thousand dollars (p < 0.001).

CONCLUSION

Strokes place an increasing financial burden on the US healthcare system. Certain patient demographics including age, male gender, more comorbidities, and insurance type were significantly associated with increased cost of care.

Health Care Disparities in Stroke Rehabilitation

Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age, race/ethnicity, and sex, but other areas make up a gap in the literature. This article conducted a literature review of original research articles published between 2008 and 2022. The article also expands on research that highlights stroke disparities in risk factors, rehabilitative stroke care, language barriers, outcomes for stroke survivors, and interventions focused on rehabilitative stroke disparities.

Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021

Importance

Understanding is needed of racial and ethnic-specific trends in care quality and outcomes associated with the US nationwide quality initiative Target: Stroke (TS) in targeting thrombolysis treatment for acute ischemic stroke.

Objective

To examine whether the TS quality initiative was associated with improvement in thrombolysis metrics and outcomes across racial and ethnic groups.

Design, Setting, and Participants

This retrospective cohort study included patients who presented within 4.5 hours of ischemic stroke onset at hospitals participating in the Get With The Guidelines-Stroke initiative from January 1, 2003, to December 31, 2021. The data analysis was performed between December 15, 2022, and November 27, 2023.

Exposures

TS phases I (2010-2013), II (2014-2018), and III (2019-2021).

Main Outcomes and Measures

The primary outcomes were thrombolysis rates and time metrics. Patient function and mortality were secondary outcomes.

Results

Analyses included 1 189 234 patients, of whom 1 053 539 arrived to the hospital within 4.5 hours. The cohort included 50.4% female and 49.6% male patients and 2.8% Asian [median (IQR) age, 72 (61-82) years], 15.2% Black [median (IQR) age, 64 (54-75) years], 7.3% Hispanic [median (IQR) age, 68 (56-79) years], and 74.1% White [median (IQR) age, 75 (63-84) years] patients). Unadjusted thrombolysis rates increased in both the pre-TS (2003-2009) and TS periods in all racial and ethnic groups from 10% to 15% in 2003 to 43% to 46% in 2021, but disparities were observed in adjusted analyses and persisted in TS phase III, with Asian, Black, and Hispanic patients having significantly lower odds of receiving thrombolysis than White patients (adjusted odds ratio, 0.85 [95% CI, 0.81-0.90], 0.76 [95% CI, 0.74-0.78], and 0.86 [95% CI, 0.83-0.89], respectively). Door-to-needle (DTN) times improved in all racial and ethnic groups during TS, with DTN times of 60 minutes or less increasing from 26% to 28% in 2009 to 66% to 72% in 2021. However, in adjusted analyses, racial and ethnic disparities emerged. During TS phase III, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis with a DTN time of 60 minutes or less compared with White patients (risk-adjusted odds ratios, 0.91 [95% CI, 0.84-0.98], 0.78 [95% CI, 0.75-0.81], and 0.87 [95% CI, 0.83-0.92], respectively). During TS, clinical outcomes improved for all racial and ethnic groups from pre-TS, with TS phase III showing higher odds of ambulation at discharge among Asian, Black, Hispanic, and White patients. Asian, Black, and Hispanic patients were less likely to present within 4.5 hours.

Conclusions and Relevance

In this cohort study of patients with ischemic stroke, the TS quality initiative was associated with improvement in thrombolysis frequency, timeliness, and outcomes for all racial and ethnic groups. However, disparities persisted, indicating a need for further interventions.

A new multi-parameter imaging platform for in vivo drug efficacy evaluation of ischemic stroke

Ischemic stroke with high incidence and disability rate severely endangers human health. Current clinical treatment strategies are quite limited, new drugs for ischemic stroke are urgently needed. However, most existing methods for the efficacy evaluation of new drugs possess deficiencies of divorcing from the true biological context, single detection indicator and complex operations, leading to evaluation biases and delaying drug development process. In this work, leveraging the advantages of fluorescence imaging with non-invasive, real-time, in-situ, high selectivity and high sensitivity, a new multi-parameter simultaneous fluorescence imaging platform (MPSFL-Platform) based on two fluorescence materials was constructed to evaluate the efficacy of new drug for ischemic stroke. Through simultaneous fluorescence observing three key indicators of ischemic stroke, malondialdehyde (MDA), formaldehyde (FA), and monoamine oxidase A (MAO-A), the efficacy evaluations of three drugs for ischemic stroke were real-time and in-situ performed. Compared with edaravone and butylphthalide, edaravone dexborneol exhibited better therapeutic effect by using MPSFL-Platform. The successful establishment of MPSFL-Platform is serviceable to accelerate the conduction of preclinical trial and the exploration of pathophysiology mechanism for drugs related to ischemic stroke and other brain diseases, which is perspective to promote the efficiency of new drug development.

Racial Disparities in Utilization of Emergency Medical Services and Related Impact on Poststroke Disability

BACKGROUND

Prompt seeking of emergency medical services (EMS) assistance at stroke onset is critical to minimize poststroke disability.

OBJECTIVE

The aim was to study how racial differences in EMS decision-relevant factors and EMS use impact stroke care and disability outcomes.

DESIGN

A prospective observational study.

PARTICIPANTS

A total of 1168 acute ischemic stroke patients discharged from April 2016 to October 2017 at a safety net hospital were included; 108 patients were surveyed before discharge.

MEASURES

(1) Prehospital delay: EMS use, timely hospital arrival; (2) Stroke care: alteplase receipt and inpatient rehab; (3) Outcomes: Functional improvement at discharge (admission minus discharge scores on National Institutes of Health Stroke Scale), 90-day modified Rankin Scale; (4) EMS decision-relevant factors: Stroke symptom knowledge, source of knowledge, unfavorable past EMS/care experiences, and financial barriers to EMS use.

RESULTS

Despite more Black patients using EMS than Whites/Asians (56% vs. 48%, P =0.003), their timely hospital arrival was 30% less likely. Adjusted for stroke severity, receipt of alteplase, and inpatient rehab were similar, but Black patients fared worse on functional improvement at discharge (among severe strokes, 2.4 National Institutes of Health Stroke Scale points less improvement, P <0.01), and on functional normalcy at 90 days (modified Rankin Scale score 0-1 being 60% less likely across severity categories) ( P <0.01). Fewer Black patients knew any stroke symptoms before the stroke (72% vs. 87%, P =0.03), and fewer learned about stroke from providers ( P =0.01). Financial barriers and provider mistrust were similar.

CONCLUSIONS

Black patients had less knowledge of stroke symptoms, more care-seeking delay, and poorer outcomes. Including stroke education as a standard of chronic disease care may mitigate stroke outcome disparities.

Racial and Ethnic Disparities in Stroke Reperfusion Therapy in the USA

Racial and ethnic inequities in stroke care are ubiquitous. Acute reperfusion therapies, i.e., IV thrombolysis (IVT) and mechanical thrombectomy (MT), are central to acute stroke care and are highly efficacious at preventing death and disability after stroke. Disparities in the use of IVT and MT in the USA are pervasive and contribute to worse outcomes among racial and ethnic minority individuals with ischemic stroke. A meticulous understanding of disparities and underlying root causes is necessary in order to develop targeted mitigation strategies with lasting effects. This review details racial and ethnic disparities in the use of IVT and MT after stroke and highlights inequities in the underlying process measures as well as the contributing root causes. Furthermore, this review spotlights the systemic and structural inequities that contribute to race-based differences in the use of IVT and MT, including geographic and regional differences and differences based on neighborhood, zip code, and hospital type. In addition, recent promising trends suggesting improvements in racial and ethnic IVT and MT disparities and potential approaches for future solutions to achieve equity in stroke care are briefly discussed.

Current and Emerging Therapies for Atherosclerotic Cardiovascular Disease Risk Reduction in Hypertriglyceridemia

Hypertriglyceridemia (HTG) is a prevalent medical condition in patients with cardiometabolic risk factors and is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD), if left undiagnosed and undertreated. Current guidelines identify HTG as a risk-enhancing factor and, as a result, recommend clinical evaluation and lifestyle-based interventions to address potential secondary causes of elevated triglyceride (TG) levels. For individuals with mild to moderate HTG at risk of ASCVD, statin therapy alone or in combination with other lipid-lowering medications known to decrease ASCVD risk are guideline-endorsed. In addition to lifestyle modifications, patients with severe HTG at risk of acute pancreatitis may benefit from fibrates, mixed formulation omega-3 fatty acids, and niacin; however, evidence does not support their use for ASCVD risk reduction in the contemporary statin era. Novel therapeutics including those that target apoC-III and ANGPTL3 have shown to be safe, well-tolerated, and effective for lowering TG levels. Given the growing burden of cardiometabolic disease and risk factors, public health and health policy strategies are urgently needed to enhance access to effective pharmacotherapies, affordable and nutritious food options, and timely health care services.

Using qualitative data to inform the adaptation of a stroke preparedness health intervention

Qualitative research methods are often used to develop health interventions, but few researchers report how their qualitative data informed intervention development. Improved completeness of reporting may facilitate the development of effective behavior change interventions. Our objective was to describe how we used qualitative data to develop our stroke education intervention consisting of a pamphlet and video. First, we created a questionnaire grounded in the theory of planned behavior to determine reasons people delay in activating emergency medical services and presenting to the hospital after stroke symptom onset. From our questionnaire data, we identified theoretical constructs that affect behavior which informed the active components of our intervention. We then conducted cognitive interviews to determine emergency department patients’ understanding of the intervention pamphlet and video. Our cognitive interview data provided insight into how our intervention might produce behavior change. Our hope is that other researchers will similarly reflect upon and report on how they used their qualitative data to develop health interventions.

Utilizing Implementation Science to Bridge Cerebrovascular Health Disparities: a Local to Global Perspective

PURPOSE OF REVIEW

Stroke is a prime example of a medical disorder whose incidence, prevalence, and outcomes are strongly characterized by health disparities across the globe. This scoping literature review seeks to depict how implementation science could be utilized to advance health equity in the prevention, acute treatment, and post-acute management of stroke in the underserved regions of high-income countries as well as in all low-income countries.

RECENT FINDINGS

A major reason for the persisting and widening cerebrovascular disease disparities is that evidence-based stroke prevention and treatment interventions have been differentially translated (if at all) to various populations and settings. The field of implementation science is endowed with frameworks, theories, methodological approaches, and outcome measures, including equity indices, which could be harnessed to facilitate the translation of evidence-based interventions into clinical practice for underserved and vulnerable communities. Encouragingly, there are several novel frameworks, which eminently merge implementation science constructs with health equity determinants, thereby opening up key opportunities to bridge burgeoning worldwide gaps in cerebrovascular health equity.

Moving Towards Equity With Digital Health Innovations for Stroke Care

Digital health has long been championed as a means to expanding access to health care. Now that the COVID-19 pandemic accelerated many health systems' integration of digital tools for care, digital health may provide a path towards more accessible stroke prevention and treatment, particularly for historically disadvantaged patient populations. Stroke management is composed of multiple time points where digital health innovations have the potential to augment health access and treatment: from primary prevention, to the time-sensitive detection of ischemic stroke, administration of thrombolytic agents and consideration for endovascular interventions, to appropriate post-acute care, rehabilitation, and lifelong secondary stroke prevention-stroke care relies on a multidisciplinary and standardized approach. However, as we discuss pointedly in this Focused Update, underrepresented individuals face multilevel digital health disparities that potentially diminish the benefits of these digital advances. As such, these multilevel needs must be discussed and accounted for as health systems seek to integrate innovative and equitable digital health solutions towards stroke care.

Health Equity and Actionable Disparities in Stroke: 2021 Update

There are stark inequities in stroke incidence, prevalence, acute care, rehabilitation, risk factor control, and outcomes. To address these inequities, it is critical to engage communities in identifying priorities and designing, implementing, and disseminating interventions. This issue of Stroke features health equity themed lectures delivered during the International Stroke Conference and Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving meetings in 2021 as well as articles covering issues of disparities and diversity in stroke. Bruce Ovbiagele, MD, MSc, MAS, MBA, MLS, received the 2021 William Feinberg Award Lecture for his lifetime achievements in seeking global and local solutions to cerebrovascular health inequities. The second annual Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving symposium, which took place the day before the International Stroke Conference in February 2021, focused on community-engaged research for reducing inequities in stroke. Phil Gorelick, MD was awarded the Edgar J. Kenton III Award for his lifetime achievements in using community engagement strategies to recruit and retain Black participants in observational studies and clinical trials. Walter Koroshetz, MD, Director of the National Institute of Neurological Disorders and Stroke delivered the keynote lecture on stroke inequities and Richard Benson, MD, PhD, Director of the Office of Global Health and Health Disparities at National Institute of Neurological Disorders and Stroke, gave a lecture focused on National Institute of Neurological Disorders and Stroke efforts to address inequities. Nichols et al highlighted approaches of community-based participatory research to address stroke inequities. Verma et al showcased digital health innovations to reduce inequities in stroke. Das et al showed that the proportion of underrepresented in medicine vascular neurology fellows has lowered over the past decade and authors provided a road map for enhancing the diversity in vascular neurology. Clearly, to overcome inequities, multipronged strategies are required, from broadening representation among vascular neurology faculty to partnering with communities to conduct research with meaningful impact.

Race-Ethnic Disparities in Rates of Declination of Thrombolysis for Stroke

BACKGROUND

Prior regional or single-center studies have noted that 4-7% of eligible acute ischemic stroke (AIS) patients decline intravenous tissue plasminogen activator (tPA). We sought to determine the prevalence of tPA declination in a nationwide registry of AIS patients and to investigate differences in declination by race-ethnicity.

METHODS

We used the Get With The Guidelines-Stroke registry to identify AIS patients eligible for tPA and admitted to participating hospitals between January 1, 2016 and March 28, 2019. We compared patient demographics and admitting hospital characteristics between tPA-eligible patients who received and those who declined tPA. Using multivariable logistic regression, we determined patient and hospital factors associated with tPA declination.

RESULTS

Among 177,115 tPA-eligible acute ischemic stroke patients at 1,976 sites, 6,545 patients (3.7%) had tPA declination as the sole documented reason for not receiving tPA. Patients declining treatment were slightly older, more likely to be female, arrived more often at "off-hours" and earlier after symptom onset, and were more likely to present to primary stroke centers. Compared with non-Hispanic White, non-Hispanic Black race-ethnicity was independently associated with increased (aOR 1.21, 95% CI 1.11-1.31), Asian race-ethnicity with decreased (aOR 0.72, 95% CI 0.58-0.88), and Hispanic ethnicity (any race) with similar odds of tPA declination (OR 0.98, 95% CI 0.86-1.13) in multivariable analysis.

CONCLUSIONS

Though the overall prevalence of tPA declination is low, eligible non-Hispanic Black patients are more likely and Asian patients less likely to decline tPA than non-Hispanic White patients. Reducing rates of tPA declinations among non-Hispanic Black patients may be an opportunity to address disparities in stroke care.

Evidence-Based Disparities in Stroke Care Metrics and Outcomes in the United States: A Systematic Review

Stroke disproportionately affects racial minorities, and the level to which stroke treatment practices differ across races is understudied. Here, we performed a systematic review of disparities in stroke treatment between racial minorities and White patients. A systematic literature search was performed on PubMed to identify studies published from January 1, 2010, to April 5, 2021 that investigated disparities in access to stroke treatment between racial minorities and White patients. A total of 30 studies were included in the systematic review. White patients were estimated to use emergency medical services at a greater rate (59.8%) than African American (55.6%), Asian (54.7%), and Hispanic patients (53.2%). A greater proportion of White patients (37.4%) were estimated to arrive within 3 hours from onset of stroke symptoms than African American (26.0%) and Hispanic (28.9%) patients. A greater proportion of White patients (2.8%) were estimated to receive tPA (tissue-type plasminogen activator) as compared with African American (2.3%), Hispanic (2.6%), and Asian (2.3%) patients. Rates of utilization of mechanical thrombectomy were also lower in minorities than in the White population. As shown in this review, racial disparities exist at key points along the continuum of stroke care from onset of stroke symptoms to treatment. Beyond patient level factors, these disparities may be attributed to other provider and system level factors within the health care ecosystem.

Bringing CT Scanners to the Skies: Design of a CT Scanner for an Air Mobile Stroke Unit

Stroke is the second most common cause of death and remains a persistent health challenge globally. Due to its highly time-sensitive nature, earlier stroke treatments should be enforced for improved patient outcome. The mobile stroke unit (MSU) was conceptualized and implemented to deliver the diagnosis and treatment to a stroke patient in the ultra-early time window (<1 h) in the pre-hospital setting and has shown to be clinically effective. However, due to geographical challenges, most rural communities are still unable to receive timely stroke intervention, as access to specialized stroke facilities for optimal stroke treatment poses a challenge. Therefore, the aircraft counterpart (Air-MSU) of the conventional road MSU offers a plausible solution to this shortcoming by expanding the catchment area for regional locations in Australia. The implementation of Air-MSU is currently hindered by several technical limitations, where current commercially available CT scanners are still oversized and too heavy to be integrated into a conventional helicopter emergency medical service (HEMS). In collaboration with the Australian Stroke Alliance and Melbourne Brain Centre, this article aims to explore the possibilities and methodologies in reducing the weight and, effectively, the size of an existing CT scanner, such that it can be retrofitted into the proposed search and rescue helicopter—Agusta Westland AW189. The result will be Australia’s first-ever customized CT scanner structure designed to fit in a search-and-rescue helicopter used for Air-MSU.

Social Determinants of Health in Neurology

Neurologic health disparities are created and perpetuated by structural and social determinants of health. These factors include, but are not limited to, interpersonal bias, institutional factors that lead to disparate access to care, and neighborhood-level factors, such as socioeconomic status, segregation, and access to healthy food. Effects of these determinants of health can be seen throughout neurology, including in stroke, epilepsy, headache, amyotrophic lateral sclerosis, multiple sclerosis, and dementia. Interventions to improve neurologic health equity require multilayered approaches to address these interdependent factors that create and perpetuate disparate neurologic health access and outcomes.

Impact of Intravenous Alteplase Door-to-Needle Times on 2-Year Mortality in Patients With Acute Ischemic Stroke

Objective: We sought to determine whether administration of Intravenous Thrombolysis (IVT) to patients with Acute Ischemic Stroke (AIS) within 60 min from hospital arrival is associated with lower 2-year mortality.

Methods: This retrospective study was conducted among patients receiving IVT in hospitals participating in the Georgia Coverdell Acute Stroke Registry (GCASR) from January 1, 2008 through June 30, 2018. Two-year mortality data was obtained by linking the 2008–2018 Georgia Discharge Data System data and the 2008–2020 Georgia death records. We analyzed the study population in two groups based on the time from hospital arrival to initiation of IVT expressed as Door to Needle time (DTN) in a dichotomized (DTN ≤ 60 vs. > 60 min) fashion.

Results: The median age of patients was 68 years, 49.4% were females, and the median NIHSS was 9. DTN ≤60 min was associated with lower 30-day [odds ratio (OR), 0.62; 95% CI, 0.52–0.73; P < 0.0001], 1-year (OR, 0.71; 95% CI, 0.61–0.83; P < 0.0001) and 2-year (OR, 0.76; 95% CI, 0.65–0.88; P = 0.001) mortality as well as lower rates of sICH at 36 h (OR, 0.57; 95% CI, 0.43–0.75; P = 0.0001), higher rates of ambulation at discharge (OR, 1.38; 95% CI, 1.25–1.53; P < 0.0001) and discharge to home (OR, 1.36; 95% CI, 1.23–1.52; P < 0.0001).

Conclusion: Faster DTN in patients with AIS was associated with lower 2-year mortality across all age, gender and race subgroups. These findings reinforce the need for intensifying quality improvement measures to reduce DTN in AIS patients.

Established evidence-based treatment guidelines help mitigate disparities in quality of emergency care

BACKGROUND

Evidence-based guidelines are often cited as a means of ensuring high-quality care for all patients. Our objective was to assess whether emergency department (ED) adherence to core evidence-based guidelines differed by patient sex and race/ethnicity and to assess the effect of ED guideline adherence on patient outcomes by sex and race/ethnicity.

METHODS

We conducted a preplanned secondary analysis of data from a multicenter retrospective observational study evaluating variation in ED adherence to five core evidence-based treatment guidelines including aspirin for acute coronary syndrome, door-to-balloon time for acute ST-elevation myocardial infarction, systemic thrombolysis for acute ischemic stroke, antibiotic selection for inpatient pneumonia, and early management of severe sepsis/septic shock. This study was performed at six hospitals in Colorado with heterogeneous and diverse practice environments. Hierarchical generalized linear modeling was used to estimate adjusted associations between ED adherence and patient sex and race/ethnicity while controlling for other patient, physician, and environmental factors that could confound this association.

RESULTS

A total of 1,880 patients were included in the study with a median (IQR) age of 62 (51-74) years. Males and non-Hispanic whites comprised 59% and 71% of the cohort, respectively. While unadjusted differences were identified, our adjusted analyses found no significant association between ED guideline adherence and sex or race/ethnicity. Patients who did not receive guideline adherent care in the ED were significantly more likely to die while in the hospital (odds ratio = 2.0, 95% confidence interval = 1.3 to 3.2).

CONCLUSIONS

Longstanding, nationally reported evidence-based guidelines can help eliminate sex and race/ethnicity disparities in quality of care. When providers know their care is being monitored and reported, their implicit biases may be less likely to impact care.

Racial and Socioeconomic Disparities in the Use and Outcomes of Endovascular Thrombectomy for Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Racial and socioeconomic disparities in the incidence, treatment, and outcomes of acute ischemic stroke exist and have been described. We aimed to characterize disparities in the use of endovascular thrombectomy in a nationally representative analysis.

MATERIALS AND METHODS

Discharge data from the Nationwide Inpatient Sample between 2006 and 2016 were queried using validated International Classification of Disease codes. Patients admitted to US hospitals with acute ischemic stroke were included and stratified on the basis of race, income, and primary payer. Trends in endovascular thrombectomy use, good outcome (discharge to home/acute rehabilitation), and poor outcome (discharge to skilled nursing facility, hospice, in-hospital mortality) were studied using univariate and multivariable analyses.

RESULTS

In this analysis of 1,322,162 patients, endovascular thrombectomy use increased from 53/111,829 (0.05%) to 3054/146,650 (2.08%) between 2006 and 2016, respectively. Less increase was observed in black patients from 4/12,733 (0.03%) to 401/23,836 (1.68%) and those in the lowest income quartile from 10/819 (0.03%) to 819/44,984 (1.49%). Greater increase was observed in the highest income quartile from 18/22,138 (0.08%) to 669/27,991 (2.39%). Black race predicted less endovascular thrombectomy use (OR = 0.79; 95% CI, 0.72-0.86). The highest income group predicted endovascular thrombectomy use (OR = 1.24; 95% CI, 1.13-1.36) as did private insurance (OR = 1.30; 95% CI, 1.23-1.38). High income predicted good outcome (OR = 1.10; 95% CI. 1.06-1.14), as did private insurance (OR = 1.36; 95% CI, 1.31-1.39). Black race predicted poor outcome (OR = 1.33; 95% CI, 1.30-1.36). All results were statistically significant (P < .01).

CONCLUSIONS

Despite a widespread increase in endovascular thrombectomy use, black and low-income patients may be less likely to receive endovascular thrombectomy. Future effort should attempt to better understand the causes of these disparities and develop strategies to ensure equitable access to potentially life-saving treatment.

Are there socio-economic inequities in access to reperfusion therapy: The stroke 69 cohort

BACKGROUND AND PURPOSE

Low socio-economic status of individuals has been reported to be associated with a higher incidence of stroke and influence the diagnosis after revascularization. However, whether it is associated with poorer acute stroke management is less clear. To determine whether social deprivation was associated with a poorer access to reperfusion therapy, either intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT) in a population-based cohort.

METHODS

Over a 14-month period, all consecutive adult patients admitted to any emergency department or a comprehensive or primary stroke center (CSC/PSC) of the Rhône county with a confirmed ischemic stroke were included. The socioeconomic status of each patient was measured using the European Deprivation Index (EDI). The association between EDI and access to reperfusion therapy was assessed in univariate and multivariate logistic regression analyses.

RESULTS

Among the 1226 consecutive IS patients, 316 (25%) were admitted directly in a PSC or CSC, 241 (19.7%) received a reperfusion therapy; 155 IVT alone, 20 EVT alone, and 66 both therapies. Median age was 79 years, 1030 patients had an EDI level of 1 to 4, and 196 an EDI of 5 (the most deprived group). The most deprived patients (EDI level 5) did not have a poorer access to reperfusion therapy compared to all other patients in univariate (OR 1.22, 95%CI [0.85; 1.77]) nor in multivariate analyses (adjOR 0.97, 95%CI [0.57; 1.66]).

CONCLUSIONS

We did not find any significant association between socioeconomic deprivation and access to reperfusion therapy. This suggests that the implementation of EVT was not associated with increased access inequities.

Lack of Racial, Ethnic, and Sex Disparities in Ischemic Stroke Care Metrics within a Tele-Stroke Network

INTRODUCTION

Differences in access to stroke care and compliance with standard of care stroke management among patients of varying racial and ethnic backgrounds and sex are well-characterized. However, little is known on the impact of telestroke in addressing disparities in acute ischemic stroke care.

METHODS

We conducted a retrospective review of acute ischemic stroke patients evaluated over our 17-hospital telestroke network in Texas from 2015-2018. Patients were described as Non-Hispanic White (NHW) male or female, Non-Hispanic Black (NHB) male or female, or Hispanic (HIS) male or female. We compared frequency of tPA and mechanical thrombectomy (MT) utilization, door-to-consultation times, door-to-tPA times, and time-to-transfer for patients who went on to MT evaluation at the hub after having been screened for suspected large vessel occlusion at the spoke.

RESULTS

Among 3873 patients (including 1146 NHW male (30%) and 1134 NHW female (29%), 405 NHB male (10%) and 491 NHB female (13%), and 358 HIS male (9%) and 339 HIS female (9%) patients), we did not find any differences in door-to consultation time, door-to-tPA time, time-to-transfer, frequency of tPA administration, or incidence of MT utilization.

CONCLUSION

We did not find racial, ethnic, and sex disparities in ischemic stroke care metrics within our telestroke network. In order to fully understand how telestroke alleviates disparities in stroke care, collaboration among networks is needed to formulate a multicenter telestroke database similar to the Get-With-The Guidelines.

Development, Adaptation and Scale-up of a Community-wide, Health Behavior Theory-based Stroke Preparedness Intervention

Objective: Acute stroke treatments reduce the likelihood of post-stroke disability, but are vastly underutilized. In this paper, we describe the development, adaptation, and scale-up of the Stroke Ready program - a health behavior theory-based stroke preparedness intervention that addresses underlying behavioral factors that contribute to acute stroke treatment underutilization. Methods: Through a community-based participatory research (CBPR) approach, we conducted needs and determinant assessments, which informed creation and pilot testing of Stroke Ready. Based on these results, we then scaled Stroke Ready to the entire community by greatly expanding the delivery system. Results: The scaled Stroke Ready program is a community-wide stroke preparedness education program consisting of peer-led workshops, print materials, and digital, social, and broadcast media campaigns. Whereas the Stroke Ready pilot workshop was delivered to 101 participants, 5945 participants have received the scaled Stroke Ready peer-led workshop to date. Additionally, we have sent mailers to over 44,000 households and reached approximately 35,000 people through our social media campaign. Conclusion: Strategies including an expanded community advisory board, adaptation of the intervention and community-engaged recruitment facilitated the scale-up of Stroke Ready, which may serve as a model to increase acute stroke treatment rates, particularly in majority African-American communities.

Wake-Promoting Effect of Bloodletting Puncture at Hand Twelve Jing-Well Points in Acute Stroke Patients: A Multi-center Randomized Controlled Trial

OBJECTIVE

To assess the effect and safety of bloodletting puncture at hand twelve Jing-Well points (HTWPs) in acute stroke patients with conscious disturbance.

METHODS

In this multi-center and randomized controlled trial, 360 patients suffered from ischemic or hemorrhagic stroke with conscious disturbance within 48 h from the onset of symptom were divided into bloodletting (180 cases) and control (180 cases) groups using a block randomization. Patients in both groups received routine Western medicine, and patients in the bloodletting group received additional bloodletting puncture at HTWPs on admission immediately before conventional treatment. The primary outcome measure was Glasgow Coma Scale (GCS) score and the secondary outcomes included blood pressure, respiratory rate and pulse rate. All variables were evaluated at baseline (before bloodletting), 0 (after bloodletting immediately), 15, 30, 50 and 80 min post bloodletting.

RESULTS

At 80 min post bloodletting, the proportion of patients with improved consciousness in the bloodletting group was greater than the control group (P<0.05). In the separate analysis of moderate consciousness disturbance subgroup, bloodletting therapy benefited ischemic patients, and improved the eye and language response of GCS score at 15, 30, 50, 80 min post bloodletting (P<0.05 or P<0.01). No significant differences were observed regarding the secondary outcomes between two groups (P>0.05).

CONCLUSION

The bloodletting puncture at HTWPs was safe and could improve conscious levels of ischemic stroke patients, highlighting a first-aid intervention for acute stroke. (Registration No. ChiCTR-INR-16009530).

Trends of Racial/Ethnic Differences in Emergency Department Care Outcomes Among Adults in the United States From 2005 to 2016

Importance: While the literature documenting health disparities has advanced in recent decades, less is known about the pattern of racial/ethnic disparities in emergency care in the United States. Objective: To describe the trends and differences of health outcomes and resource utilization among racial/ethnic groups in US emergency care for adult patients over a 12-year period. Design, Setting, and Participants: This cross-sectional study of emergency department (ED) data from the nationally representative National Hospital Ambulatory Medical Survey (NHAMCS) examined multiple dimensions of ED care and treatment from 2005 to 2016 among adults in the US. Main Outcomes and Measures: The main outcomes include ED care outcomes (hospital admission, ICU admission, and death in the ED/hospital), resource utilization outcomes (medical imaging use, blood test, and procedure use), and patients' waiting time in the ED. The main exposure variable is race/ethnicity including white patients (non-Hispanic), black patients (non-Hispanic), Hispanic patients, Asian patients, and Other. Results: During the 12-year study period, NHAMCS collected data on 247,989 adult (> 18 years old) ED encounters, providing a weighted sample of 1,065,936,835 ED visits for analysis. Asian patients were 1.21 times more likely than white patients to be admitted to the hospital following an ED visit (aOR 1.21, 95% CI 1.12-1.31). Hispanic patients presented no significant difference in hospital admission following an ED visit (aOR 1.01, 95% CI 0.97-1.06) with white patients. Black patients were 7% less likely to receive an urgent ESI score than white patients less likely to receive immediate or emergent scores, as opposed to semi- or non-urgent scores. Black patients were also 10% less likely than white patients to be admitted to the hospital and were 1.26 times more likely than white patients to die in the ED or hospital. Conclusions and Relevance: Race is associated with significant differences in ED treatment and admission rates, which may represent disparities in emergency care. Hispanic and Asian Americans were equal or more likely to be admitted to the hospital compared to white patients. Black patients received lower triage scores and higher mortality rates. Further research is needed to understand the underlying causes and long-term health consequences of these disparities.

Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke

IMPORTANCE

Earlier administration of intravenous tissue plasminogen activator (tPA) in acute ischemic stroke is associated with reduced mortality by the time of hospital discharge and better functional outcomes at 3 months. However, it remains unclear whether shorter door-to-needle times translate into better long-term outcomes.

OBJECTIVE

To examine whether shorter door-to-needle times with intravenous tPA for acute ischemic stroke are associated with improved long-term outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included Medicare beneficiaries aged 65 years or older who were treated for acute ischemic stroke with intravenous tPA within 4.5 hours from the time they were last known to be well at Get With The Guidelines-Stroke participating hospitals between January 1, 2006, and December 31, 2016, with 1-year follow-up through December 31, 2017.

EXPOSURES

Door-to-needle times for intravenous tPA.

MAIN OUTCOMES AND MEASURES

The primary outcomes were 1-year all-cause mortality, all-cause readmission, and the composite of all-cause mortality or readmission.

RESULTS

Among the 61 426 patients treated with tPA within 4.5 hours, the median age was 80 years and 43.5% were male. The median door-to-needle time was 65 minutes (interquartile range, 49-88 minutes). The 48 666 patients (79.2%) who were treated with tPA and had door-to-needle times of longer than 45 minutes, compared with those treated within 45 minutes, had significantly higher all-cause mortality (35.0% vs 30.8%, respectively; adjusted HR, 1.13 [95% CI, 1.09-1.18]), higher all-cause readmission (40.8% vs 38.4%; adjusted HR, 1.08 [95% CI, 1.05-1.12]), and higher all-cause mortality or readmission (56.0% vs 52.1%; adjusted HR, 1.09 [95% CI, 1.06-1.12]). The 34 367 patients (55.9%) who were treated with tPA and had door-to-needle times of longer than 60 minutes, compared with those treated within 60 minutes, had significantly higher all-cause mortality (35.8% vs 32.1%, respectively; adjusted hazard ratio [HR], 1.11 [95% CI, 1.07-1.14]), higher all-cause readmission (41.3% vs 39.1%; adjusted HR, 1.07 [95% CI, 1.04-1.10]), and higher all-cause mortality or readmission (56.8% vs 53.1%; adjusted HR, 1.08 [95% CI, 1.05-1.10]). Every 15-minute increase in door-to-needle times was significantly associated with higher all-cause mortality (adjusted HR, 1.04 [95% CI, 1.02-1.05]) within 90 minutes after hospital arrival, but not after 90 minutes (adjusted HR, 1.01 [95% CI, 0.99-1.03]), higher all-cause readmission (adjusted HR, 1.02; 95% CI, 1.01-1.03), and higher all-cause mortality or readmission (adjusted HR, 1.02 [95% CI, 1.01-1.03]).

CONCLUSIONS AND RELEVANCE

Among patients aged 65 years or older with acute ischemic stroke who were treated with tissue plasminogen activator, shorter door-to-needle times were associated with lower all-cause mortality and lower all-cause readmission at 1 year. These findings support efforts to shorten time to thrombolytic therapy.

Racial Disparities in Stroke Recovery Persistence in the Post-Acute Stroke Recovery Phase: Evidence from the Health and Retirement Study

Background and Purpose

Blacks have a higher burden of post-stroke disability. Factors associated with racial differences in long-term post-stroke disability are not well-understood. Our aim was to assess the long-term racial differences in risk factors associated with stroke recovery.

Methods

We examined Health and Retirement Study (HRS) longitudinal interview data collected from adults living with stroke who were aged >50 years during 2000-2014. Analysis of 1,002 first-time, non-Hispanic, Black (210) or White (792) stroke survivors with data on activities of daily living (ADL), fine motor skills (FMS) and gross motor skills (GMS) was conducted. Ordinal regression analysis was used to assess the impact of sex, race, household residents, household income, comorbidities, and the time since having a stroke on functional outcomes.

Results

Black stroke survivors were younger compared with Whites (69 ± 10.4 vs 75 ± 11.9). The majority (~65%) of Black stroke survivors were female compared with about 54% White female stroke survivors (P=.007). Black stroke survivors had more household residents (P<.001) and comorbidities (P<.001). Aging, being female, being Black and a longer time since stroke were associated with a higher odds of having increased difficulty in ADL, FMS and/or GMS. Comorbidities were associated with increased difficulty with GMS. Black race increased the impact of comorbidities on ADL and FMS in comparison with Whites.

Conclusion

Our data suggest that the effects of aging, sex and unique factors associated with race should be taken into consideration for future studies of post-stroke recovery and therapy.

Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature

BACKGROUND/AIMS

This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery.

METHODS

A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy.

RESULTS

One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model.

CONCLUSION

Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.

Providing Stroke and Hypertension Education in Amharic for Ethiopian Persons Living in Dallas, Texas, United States

BACKGROUND

The purpose of this study was to compare knowledge of a stroke education module provided to bilingual members of the Ethiopian immigrant population in Dallas, Texas, presented in the Amharic language as compared to in English.

METHODS

A convenience sample of 84 participants were recruited using a snowball technique and randomly assigned to receive education in English or Amharic. The participants completed a pre- and posttest of their knowledge about strokes, a demographic survey, and a satisfaction survey. Data was analyzed using a general linear model and chi-square analysis.

RESULTS

There were no statistically significant differences between satisfaction scores comparing those educated in Amharic versus English (χ2 = 6.5108, p = .0107). Although mean pretest (10.8) and posttest (16.4) stroke knowledge scores were higher across all groups (p < .001), the mean posttest scores were lower for subjects who watched the Amharic versus the English video (14.9 vs. 18.1, p = .003).

CONCLUSION

This study did not show a statistically significant increase in knowledge about stroke when presented learning materials in subjects' native language compared to in English. The use of video to present stroke and stroke-risk educational content can be used in future research and global health initiatives to increase stroke knowledge in the Amharic-speaking community.

Racial/Ethnic Disparities in Acute Ischemic Stroke Treatment Within a Telestroke Network

Background: The growth of telestroke services expanded the reach of acute stroke treatment. However, ethnic disparities in receiving such treatment have not been fully assessed. Materials and Methods: We reviewed prospectively maintained data on patients evaluated through the Medical University of South Carolina telestroke program between January 2016 and November 2018. Outcomes included odds of receiving intravenous recombinant tissue plasminogen activator (tPA), receiving mechanical thrombectomy (MT), and achieving door-to-needle (DTN) time ≤60 and ≤45 min among patients receiving tPA. We used logistic regression to analyze the contribution of race/ethnicity. Results: We included 2,977 patients, of whom 1,093 (36.7%) identified as nonwhite; of these, 1,048 patients (95.9%) identified as black or African American. Significantly more nonwhite patients were seen at a primary stroke center (PSC) (68.4% vs. 52.3% in whites, p < 0.001). However, white patients had significantly higher odds of receiving tPA (odds ratio [OR] 1.47, confidence interval [95% CI] 1.17-1.84). There was no significant difference in receiving MT between races. Among patients receiving tPA, whites had higher odds of DTN ≤45 min (OR 1.76, 1.20-2.57) and ≤60 min (OR 1.87, 95% CI 1.31-2.66). Conclusions: White patients had better odds achieving DTN ≤45 min and DTN ≤60 min if receiving tPA within a telestroke setting, as well as higher odds of receiving tPA, even after adjustment for comorbidities. This was noted despite white patients having less access to PSCs. However, larger scale studies are needed to further study the impact of ethnic disparities.

Neurology practice and stroke services across East China: a multi-site, county-level hospital-based survey

Background

Neurological disorders are an economic and public health burden which requires efficient and adequate medical resources. Currently, little is known about the status of the quality of neurological care services available in China. As neurological primary care is mostly provided at the county hospital level, investigation of this geographical level is required. The aim of this study is to evaluate currently available neurology care services in Yangtze River Delta Urban Agglomerations in east China.

Methods

A multi-site, county-level hospital-based observational survey was conducted in east China from January 2017 to December 2017. A questionnaire was made to assess hospital and the departmental patient care capabilities, human resources and technical capacity in neurology departments.

Results

Of 228 hospitals across the Yangtze River Delta Urban Agglomerations, 217 documents were returned. Of these, 22 were excluded due to invalid hospital information or duplicate submission. Overall, most hospitals have neurology departments (162, 83.1%) while less than half of the hospitals have a stroke center (80, 41.0%) and neurology emergency department (46, 23.6%). Among 162 hospitals with neurology department, 5 were excluded due to inadequate sharing, leaving 157 hospitals for analysis. About 84.1% of these neurology departments can administer intravenous thrombolysis while about one third of them has the ability to perform arterial thrombectomy (36.9%). In addition, 46.2% of hospitals can carry out computed tomography angiography (CTA) in emergency room. Tertiary care hospitals are much more equipped with modern medical resources compared to the secondary hospitals. In four administrative regions, the neurology services are better in more economically advanced regions.

Conclusions

Neurological care services need to be enhanced at the county-level hospitals to improve health care delivery.

Stroke Warning Information and Faster Treatment (SWIFT): Cost-Effectiveness of a Stroke Preparedness Intervention

BACKGROUND

Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window.

OBJECTIVE

We evaluated the cost-effectiveness of a stroke preparedness behavioral intervention study (Stroke Warning Information and Faster Treatment [SWIFT]), a stroke intervention demonstrating capacity to decrease race-ethnic disparities in ED arrival times.

METHODS

Using the literature and SWIFT outcomes for 2 interventions, enhanced educational (EE) materials, and interactive intervention (II), we assess the cost-effectiveness of SWIFT in 2 ways: (1) Markov model, and (2) cost-to-outcome ratio. The Markov model primary outcome was the cost per quality-adjusted life-year (QALY) gained using the cost-effectiveness threshold of $100 000/QALY. The primary cost-to-outcome endpoint was cost per additional patient with ED arrival <3 hours, stroke knowledge, and preparedness capacity. We assessed the ICER of II and EE versus standard care (SC) from a health sector and societal perspective using 2015 USD, a time horizon of 5 years, and a discount rate of 3%.

RESULTS

The cost-effectiveness of the II and EE programs was, respectively, $227.35 and $74.63 per additional arrival <3 hours, $440.72 and $334.09 per additional person with stroke knowledge proficiency, and $655.70 and $811.77 per additional person with preparedness capacity. Using a societal perspective, the ICER for EE versus SC was $84 643 per QALY gained and the ICER for II versus EE was $59 058 per QALY gained. Incorporating fixed costs, EE and II would need to administered to 507 and 1693 or more patients, respectively, to achieve an ICER of $100 000/QALY.

CONCLUSION

II was a cost-effective strategy compared with both EE and SC. Nevertheless, high initial fixed costs associated with II may limit its cost-effectiveness in settings with smaller patient populations.

A Decade of Improvement in Door-to-Needle Time Among Acute Ischemic Stroke Patients, 2008 to 2017

BACKGROUND

The clinical benefit of intravenous (IV) alteplase in acute ischemic stroke is time dependent. We assessed the overall temporal changes in door-to-needle (DTN) time and examine the factors associated with DTN time ≤60 and ≤45 minutes.

METHODS AND RESULTS

A total of 496 336 acute ischemic stroke admissions were identified in the Paul Coverdell National Acute Stroke Program from 2008 to 2017. We used generalized estimating equations models to examine the factors associated with DTN time ≤60 and ≤45 minutes, and calculated adjusted odds ratios and 95% CI. Between 2008 and 2017, the percentage of acute ischemic stroke patients who received IV alteplase including those transferred, increased from 6.4% to 15.3%. After excluding those who received IV alteplase at an outside hospital, a total of 39 737 (8%) acute ischemic stroke patients received IV alteplase within 4.5 hours of the time the patient last known to be well. Significant increases were seen in DTN time ≤60 minutes (26.4% in 2008 to 66.2% in 2017, P<0.001), as well as DTN time ≤45 minutes (10.7% in 2008 to 40.5% in 2017, P<0.001). Patients aged 55 to 84 years were more likely to receive IV alteplase within 60 minutes, while those aged 55 to 74 years were more likely to receive IV alteplase within 45 minutes, as compared with those aged 18 to 54 years. Arrival by emergency medical service, and patients with severe stroke were more likely to receive IV alteplase within 60 and 45 minutes. Conversely, women, black patients as compared with white, and patients with a medical history of diseases associated with stroke were less likely to receive DTN time ≤60 or 45 minutes.

CONCLUSIONS

Rapid improvements in DTN time were observed in the Paul Coverdell National Acute Stroke Program; however, opportunities to reduce disparities remain.

Functional Neurologic Symptom Disorder in Children: Clinical Features, Diagnostic Investigations, and Outcomes at a Tertiary Care Children's Hospital

OBJECTIVE

To describe the presenting symptoms and short-term outcomes of children diagnosed with functional neurologic symptom disorder and to compare the demographic and clinical characteristics of children who received neurodiagnostic testing to those who did not.

STUDY DESIGN

Single center, retrospective review of 222 children who presented to the emergency department of a children's hospital, and diagnosed with functional neurologic symptom disorder, between 2010 and 2015.

RESULTS

Out of 222 visits (females = 156, African Americans = 130, mean age = 13.9 years), neurodiagnostic tests were performed in 102/222 (46%) visits. The most commonly performed investigations were magnetic resonance imaging (MRI) of brain (n = 37) and electroencephalogram (EEG) (n = 56) and were noted to be unremarkable in all instances. Neurodiagnostic tests were more likely to be performed in patients who (1) were non-African American (54% vs 40%; P = .03), (2) presented with new-onset symptoms (55% vs 31%; P < .01), (3) underwent hospitalization (61% vs 17%; P < .01), and (4) were evaluated by a neurologist (59% vs 9%; P < .01) or a psychiatrist (58% vs 28%; P < .01). Common clinical presentations included seizurelike or strokelike symptoms. Short-term follow-up was possible in 20%, with an alternate diagnosis of syncope, noted in only 1 child.

CONCLUSIONS

Most children who presented with a functional neurologic symptom disorder in our study were noted to have seizurelike or strokelike presentations and were adolescent females. Caucasians were more likely to undergo neurodiagnostic investigations. Radiologic and neurophysiological tests were more commonly performed when neurology and psychiatry consultations were sought. Such investigations had low diagnostic utility.

Factors affecting post-stroke motor recovery: Implications on neurotherapy after brain injury

Neurological disorders are a major cause of chronic disability globally among which stroke is a leading cause of chronic disability. The advances in the medical management of stroke patients over the past decade have significantly reduced mortality, but at the same time increased numbers of disabled survivors. Unfortunately, this reduction in mortality was not paralleled by satisfactory therapeutics and rehabilitation strategies that can improve functional recovery of patients. Motor recovery after brain injury is a complex, dynamic, and multifactorial process in which an interplay among genetic, pathophysiologic, sociodemographic and therapeutic factors determines the overall recovery trajectory. Although stroke recovery is the most well-studied form of post-injury neuronal recovery, a thorough understanding of the pathophysiology and determinants affecting stroke recovery is still lacking. Understanding the different variables affecting brain recovery after stroke will not only provide an opportunity to develop therapeutic interventions but also allow for developing personalized platforms for patient stratification and prognosis. We aim to provide a narrative review of major determinants for post-stroke recovery and their implications in other forms of brain injury.

Racial disparities in refusal of stroke thrombolysis in Chicago

OBJECTIVE

To evaluate race differences in tissue plasminogen activator (tPA) refusal among eligible patients with acute ischemic stroke (AIS) in Chicago.

METHODS

Using the Get With The Guidelines-Stroke registry data from 15 primary stroke centers between January 2013 and June 2015, we performed a retrospective analysis of patients with AIS presenting to the emergency department within 4.5 hours from symptom onset. Patient or proxy refusal was captured as a reason for nonadministration of tPA to eligible patients in the registry. We assessed whether tPA refusal differed by race using logistic regression.

RESULTS

Among 704 tPA-eligible patients with AIS, tPA was administered to 86.2% (black race, 82.5% vs nonblack race, 89.5%; p < 0.001). Fifty-three (7.5%) tPA refusals were documented. Refusal was more common in black vs nonblack patients (10.6% vs 4.8%; p = 0.004). In multivariable analysis, the following were associated with tPA refusal: black race (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] 1.3-4.6), self-pay status (adjusted OR 3.23, 95% CI 1.2-8.71), prior stroke (adjusted OR 2.11, 95% CI 1.14-3.90), age (adjusted OR 1.04, 95% CI 1.02-1.07), and NIH Stroke Scale score (adjusted OR 0.94, 95% CI 0.90-0.99).

CONCLUSIONS

Among tPA-eligible patients with AIS in Chicago, over 7% refused tPA. Refusal was more common in black patients and accounted for the apparent lower rates of tPA use in black vs nonblack patients. Further research is needed to understand barriers to consent and overcome race-ethnic disparities in tPA treatment for AIS.

Race and prescribing

Treatment of mental illness in Black and minority ethnic groups differs from that in the White majority. Large differences in admission, detention and seclusion rates have been recorded. These disparities extend into the physical healthcare setting, particularly in the USA but also within the UK National Health Service. There are many influences on prescribing of psychotropic medication, not least the metabolising capacity of the individual. Ethnic differences do occur, particularly for East Asian peoples. However, these differences are broadly similar across ethnic groups, particularly for the cytochrome P450 enzymes responsible for metabolising psychotropic medicines. Psychotropic medication prescribing also differs by ethnicity. Specifically, antipsychotic dose, type and route of administration may differ. However, most data originate in the USA and UK studies have not replicated these findings, even after controlling for multiple confounding factors. Similarly, antidepressant prescribing and access to treatment may differ by ethnicity. These differences may have complex causes that are not well understood. Overall, prescribing of antipsychotics appears to be broadly equitable in Black and minority ethnic groups.

Disparities and Trends in Door-to-Needle Time: The FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities)

BACKGROUND AND PURPOSE

In the United States, about half of acute ischemic stroke patients treated with tPA (tissue-type plasminogen activator) receive treatment within 60 minutes of hospital arrival. We aimed to determine the proportion of patients receiving tPA within 60 minutes (door-to-needle time [DTNT] ≤60) and 45 minutes (DTNT ≤45) of hospital arrival by race/ethnicity and sex and to identify temporal trends in DTNT ≤60 and DTNT ≤45.

METHODS

Among 65 654 acute ischemic stroke admissions in the National Institute of Neurological Disorders and Stroke-funded FL-PR CReSD study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) from 2010 to 2015, we included 6181 intravenous tPA-treated cases (9.4%). Generalized estimating equations were used to determine predictors of DTNT ≤60 and DTNT ≤45.

RESULTS

DTNT ≤60 was achieved in 42% and DTNT ≤45 in 18% of cases. After adjustment, women less likely received DTNT ≤60 (odds ratio, 0.81; 95% confidence interval, 0.72-0.92) and DTNT ≤45 (odds ratio, 0.73; 95% confidence interval, 0.57-0.93). Compared with Whites, Blacks less likely had DTNT ≤45 during off hours (odds ratio, 0.68; 95% confidence interval, 0.47-0.98). Achievement of DTNT ≤60 and DTNT ≤45 was highest in South Florida (50%, 23%) and lowest in West Central Florida (28%, 11%).

CONCLUSIONS

In the FL-PR CReSD, achievement of DTNT ≤60 and DTNT ≤45 remains low. Compared with Whites, Blacks less likely receive tPA treatment within 45 minutes during off hours. Treatment within 60 and 45 minutes is lower in women compared with men and lowest in West Central Florida compared with other Florida regions and Puerto Rico. Further research is needed to identify reasons for delayed thrombolytic treatment in women and Blacks and factors contributing to regional disparities in DTNT.

Race-Ethnic Disparities in Hospital Arrival Time after Ischemic Stroke

OBJECTIVE

Conflicting reports exist about hospital arrival time after stroke onset in Hispanics compared with African Americans and Caucasians. Our current study investigates race-ethnic disparities in hospital arrival times after stroke onset.

METHODS

We performed a retrospective analysis of hospital arrival times in Hispanic, African American, and Caucasian acute ischemic stroke patients (N=1790) presenting to a tertiary-care hospital in the Bronx, New York. A multivariable logistic regression model was used to identify the association between race-ethnicity and hospital arrival time adjusting for age, sex, socioeconomic status (SES), NIH stroke scale (NIHSS), history of stroke, preferred language and transportation mode to the hospital.

RESULTS

There were 338 Caucasians, 662 Hispanics, and 790 African Americans in the cohort. Compared with Caucasians, African Americans and Hispanics were younger (P<.0001 respectively), had lower SES (P<.001 respectively) and were less likely to use EMS (P=.003 and P=.001, respectively). A greater proportion of Hispanic and African American women had delayed hospital arrival times (≥3 hours) after onset of stroke symptoms compared with Caucasian women (74% of Hispanic, 72% of African American, and 59% of Caucasian women), but this difference between race-ethnicities is no longer present after adjusting for socioeconomic status. Compared with Caucasian men, hospital arrival ≥3 hours after symptom onset was more likely for African American men (OR 1.72, 95% CI:1.05-2.79) but not Hispanic men (OR .80, 95% CI .49-1.30).

CONCLUSIONS

African American men and socially disadvantaged women delay in presenting to the hospital after stroke onset. Future research should focus on identifying the factors contributing to pre-hospital delay among race-ethnic minorities.

Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment

Background

Intravenous thrombolysis for patients with acute ischaemic stroke is underused (only 80% of eligible patients receive it) and there is variation in its use across the UK. Previously, variation might have been explained by structural differences; however, continuing variation may reflect differences in clinical decision-making regarding the eligibility of patients for treatment. This variation in decision-making could lead to the underuse, or result in inappropriate use, of thrombolysis.

Objectives

To identify the factors which contribute to variation in, and influence, clinicians’ decision-making about treating ischaemic stroke patients with intravenous thrombolysis.

Methods

A discrete choice experiment (DCE) using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted to better understand the influence of patient-related and clinician-related factors on clinical decision-making. An online DCE was developed following an iterative five-stage design process. UK-based clinicians involved in final decision-making about thrombolysis were invited to take part via national professional bodies of relevant medical specialties. Mixed-logit regression analyses were conducted.

Results

A total of 138 clinicians responded and opted to offer thrombolysis in 31.4% of cases. Seven patient factors were individually predictive of the increased likelihood of offering thrombolysis (compared with reference levels in brackets): stroke onset time of 2 hours 30 minutes (50 minutes); pre-stroke dependency modified Rankin Scale score (mRS) of 3 (mRS4); systolic blood pressure (SBP) of 185 mmHg (140 mmHg); stroke severity scores of National Institutes of Health Stroke Scale (NIHSS) 5 without aphasia, NIHSS 14 and NIHSS 23 (NIHSS 2 without aphasia); age 85 years (65 years); and Afro-Caribbean (white). Factors predictive of not offering thrombolysis were age 95 years; stroke onset time of 4 hours 15 minutes; severe dementia (no memory problems); and SBP of 200 mmHg. Three clinician-related factors were predictive of an increased likelihood of offering thrombolysis (perceived robustness of the evidence for thrombolysis; thrombolysing more patients in the past 12 months; and high discomfort with uncertainty) and one factor was predictive of a decreased likelihood of offering treatment (clinicians’ being comfortable treating patients outside the licensing criteria).

Limitations

We anticipated a sample size of 150–200. Nonetheless, the final sample of 138 is good considering that the total population of eligible UK clinicians is relatively small. Furthermore, data from the Royal College of Physicians suggest that our sample is representative of clinicians involved in decision-making about thrombolysis.

Conclusions

There was considerable heterogeneity among respondents in thrombolysis decision-making, indicating that clinicians differ in their thresholds for treatment across a number of patient-related factors. Respondents were significantly more likely to treat 85-year-old patients than patients aged 68 years and this probably reflects acceptance of data from Third International Stroke Trial that report benefit for patients aged > 80 years. That respondents were more likely to offer thrombolysis to patients with severe stroke than to patients with mild stroke may indicate uncertainty/concern about the risk/benefit balance in treatment of minor stroke. Findings will be disseminated via peer-review publication and presentation at national/international conferences, and will be linked to training/continuing professional development (CPD) programmes.

Future work

The nature of DCE design means that only a subset of potentially influential factors could be explored. Factors not explored in this study warrant future research. Training/CPD should address the impact of non-medical influences on decision-making using evidence-based strategies.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Emerging temporal trends in tissue plasminogen activator use: Results from the BASIC project

OBJECTIVE

To explore temporal trends in tissue plasminogen activator (tPA) administration for acute ischemic stroke (AIS) in a biethnic community without an academic medical center and variation in trends by age, sex, ethnicity, and stroke severity.

METHODS

Cases of AIS were identified from 7 hospitals in the Brain Attack Surveillance in Corpus Christi (BASIC) project, a population-based surveillance study between January 1, 2000, and June 30, 2012. tPA, demographics, and stroke severity as assessed by the NIH Stroke Scale (NIHSS) were ascertained from medical records. Temporal trends were explored using generalized estimating equations, and adjustment made for age, sex, ethnicity, and NIHSS. Interaction terms were included to test for effect modification.

RESULTS

There were 5,277 AIS cases identified from 4,589 unique individuals. tPA use was steady at 2% and began increasing in 2006, reaching 11% in subsequent years. Stroke severity modified temporal trends (p = 0.003) such that cases in the highest severity quartile (NIHSS > 8) had larger increases in tPA use than those in lower severity quartiles. Although ethnicity did not modify the temporal trend, Mexican Americans (MAs) were less likely to receive tPA than non-Hispanic whites (NHWs) due to emerging ethnic differences in later years.

CONCLUSIONS

Dramatic increases in tPA use were apparent in this community without an academic medical center. Primary stroke center certification likely contributed to this rise. Results suggest that increases in tPA use were greater in higher severity patients compared to lower severity patients, and a gap between MAs and NHWs in tPA administration may be emerging.

Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry

OBJECTIVE

To determine patient and hospital characteristics associated with not providing IV tissue plasminogen activator (tPA) to eligible patients with acute ischemic stroke (AIS) in clinical practice.

METHODS

We performed a retrospective cohort study of patients with AIS arriving within 2 hours of onset to hospitals participating in Get With The Guidelines-Stroke without documented contraindications to IV tPA from April 2003 through December 2011, comparing those who received tPA to those who did not. Multivariable generalized estimating equation logistic regression modeling identified factors associated with not receiving tPA.

RESULTS

Of 61,698 eligible patients with AIS presenting within 2 hours of onset (median age 73 years, 51% female, 74% non-Hispanic white, median NIH Stroke Scale score 11, interquartile range 6-18), 15,282 (25%) were not treated with tPA within 3 hours. Failure to give tPA decreased over time from 55% in 2003 to 2005 to 18% in 2010 to 2011 (p < 0.0001). After adjustment for all covariates, including stroke severity, factors associated with failure to treat included older age, female sex, nonwhite race, diabetes mellitus, prior stroke, atrial fibrillation, prosthetic heart valve, NIH Stroke Scale score <5, arrival off-hours and not via emergency medical services, longer onset-to-arrival and door-to-CT times, earlier calendar year, and arrival at rural, nonteaching, non-stroke center hospitals located in the South or Midwest.

CONCLUSIONS

Overall, about one-quarter of eligible patients with AIS presenting within 2 hours of stroke onset failed to receive tPA treatment. Thrombolysis has improved dramatically over time and is strongly associated with stroke center certification. Additionally, some groups, including older patients, milder strokes, women, and minorities, may be undertreated.

Where to Focus Efforts to Reduce the Black-White Disparity in Stroke Mortality: Incidence Versus Case Fatality?

BACKGROUND AND PURPOSE

At age 45 years, blacks have a stroke mortality ≈3× greater than their white counterparts, with a declining disparity at older ages. We assess whether this black-white disparity in stroke mortality is attributable to a black-white disparity in stroke incidence versus a disparity in case fatality.

METHODS

We first assess if black-white differences in stroke mortality within 29 681 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort reflect national black-white differences in stroke mortality and then assess the degree to which black-white differences in stroke incidence or 30-day case fatality after stroke contribute to the disparities in stroke mortality.

RESULTS

The pattern of stroke mortality within the study mirrors the national pattern, with the black-to-white hazard ratio of ≈4.0 at age 45 years decreasing to ≈1.0 at age 85 years. The pattern of black-to-white disparities in stroke incidence shows a similar pattern but no evidence of a corresponding disparity in stroke case fatality.

CONCLUSIONS

These findings show that the black-white differences in stroke mortality are largely driven by differences in stroke incidence, with case fatality playing at most a minor role. Therefore, to reduce the black-white disparity in stroke mortality, interventions need to focus on prevention of stroke in blacks.

Stroke Ready Intervention: Community Engagement to Decrease Prehospital Delay

BACKGROUND

Time-limited acute stroke treatments are underused, primarily due to prehospital delay. One approach to decreasing prehospital delay is to increase stroke preparedness, the ability to recognize stroke, and the intention to immediately call emergency medical services, through community engagement with high-risk communities.

METHODS AND RESULTS

Our community-academic partnership developed and tested "Stroke Ready," a peer-led, workshop-based, health behavior intervention to increase stroke preparedness among African American youth and adults in Flint, Michigan. Outcomes were measured with a series of 9 stroke and nonstroke 1-minute video vignettes; after each video, participants selected their intended response (primary outcome) and symptom recognition (secondary outcome), receiving 1 point for each appropriate stroke response and recognition. We assessed differences between baseline and posttest appropriate stroke response, which was defined as intent to call 911 for stroke vignettes and not calling 911 for nonstroke, nonemergent vignettes and recognition of stroke. Outcomes assessments were performed before workshop 1 (baseline), at the conclusion of workshop 2 (immediate post-test), and 1 month later (delayed post-test). A total of 101 participants completed the baseline assessment (73 adults and 28 youths), 64 completed the immediate post-test, and 68 the delayed post-test. All participants were African American. The median age of adults was 56 (interquartile range 35-65) and of youth was 14 (interquartile range 11-16), 65% of adults were women, and 50% of youths were women. Compared to baseline, appropriate stroke response was improved in the immediate post-test (4.4 versus 5.2, P<0.01) and was sustained in the delayed post-test (4.4 versus 5.2, P<0.01). Stroke recognition did not change in the immediate post-test (5.9 versus 6.0, P=0.34), but increased in the delayed post-test (5.9 versus 6.2, P=0.04).

CONCLUSIONS

Stroke Ready increased stroke preparedness, a necessary step toward increasing acute stroke treatment rates.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01499173.

The Effect of Emergency Medical Service Use and Inter-hospital Transfer on Prehospital Delay among Ischemic Stroke Patients: A Multicenter Observational Study

The time between symptom onset and arrival at an emergency department (ED) (S2D) is a crucial time for optimal intravenous reperfusion care for ischemic stroke. We aimed to analyze the effect of emergency medical services (EMS) utilization and inter-hospital transfer on S2D in Korea. Ischemic stroke patients were prospectively enrolled from November 2007 to December 2012 in 23 tertiary and teaching hospital EDs in Korea. Of 31,443 adult ischemic stroke patients, 20,780 were categorized into 4 groups based on modes of EMS utilization and inter-hospital transfer: direct transport to destination ED by EMS (EMS direct; n=6,257, 30.1%), transfer after transport to another ED by EMS (EMS indirect; n=754, 3.6%), direct transport to the ED without using EMS (non-EMS direct; n=8,928, 43.0%), and transfer after visiting another hospital without using EMS (non-EMS indirect; n=4,841, 23.3%). Our primary outcome variable was of S2D within 2 hr (S2D ≤ 2 hr) and found that 30.8% of all patients and 52.3%, 16.4%, 25.9%, and 13.9% of EMS direct, EMS indirect, non-EMS direct, and non-EMS indirect, respectively, achieved S2D ≤ 2 hr. Adjusted odds ratio for S2D ≤ 2 hr were 6.56 (95% confidence interval [CI], 5.94-7.24), 2.27 (95% CI, 2.06-2.50), and 1.07 (95% CI, 0.87-1.33) for EMS direct, non-EMS direct, and EMS indirect, respectively. Patients directly transported to destination hospitals by the EMS show the highest proportion of therapeutic time window for optimal care in ischemic stroke.

Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers

BACKGROUND

Primary stroke centers (PSCs) utilize more recombinant tissue plasminogen activator (rt-PA) than non-PSCs. The impact of PSCs on racial disparities in rt-PA use is unknown.

METHODS AND RESULTS

We used data from the Nationwide Inpatient Sample from 2004 to 2010, limited to states that publicly reported hospital identity and race. Hospitals certified as PSCs by The Joint Commission were identified. Adults with a diagnosis of ischemic stroke were analyzed. Rt-PA use was defined by the International Classification of Diseases, 9th Revision procedure code 99.10. Discharges (304 152 patients) from 26 states met eligibility criteria, and of these 71.5% were white, 15.0% black, 7.9% Hispanic, and 5.6% other. Overall, 24.7% of white, 27.4% of black, 16.2% of Hispanic, and 29.8% of other patients presented to PSCs. A higher proportion received rt-PA at PSCs than non-PSCs in all race/ethnic groups (white 7.6% versus 2.6%, black 4.8% versus 2.0%, Hispanic 7.1% versus 2.4%, other 7.2% versus 2.5%, all P<0.001). In a multivariable model adjusting for year, age, sex, insurance, medical comorbidities, a diagnosis-related group-based mortality risk indicator, ZIP code median income, and hospital characteristics, blacks were less likely to receive rt-PA than whites at non-PSCs (odds ratio=0.58, 95% CI 0.50 to 0.67) and PSCs (odds ratio=0.63, 95% CI 0.54 to 0.74) and Hispanics were less likely than whites to receive rt-PA at PSCs (odds ratio=0.77, 95% CI: 0.63 to 0.95). In the fully adjusted model, interaction between race and presentation to a PSC for likelihood of receiving rt-PA did not reach significance (P=0.98).

CONCLUSIONS

Racial disparities in intravenous rt-PA use were not reduced by presentation to PSCs. Black patients were less likely to receive thrombolytic treatment than white patients at both non-PSCs and PSCs. Hispanic patients were less likely to be seen at PSCs relative to white patients and were less likely to receive intravenous rt-PA in the fully adjusted model.