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

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.

Patterns and Outcomes of Endovascular Thrombectomy Among Patients Over Age 80 Years: The Florida Stroke Registry

BACKGROUND

Older patients (≥80 years of age) were under-represented in randomized trials of endovascular thrombectomy (EVT). In the large Florida Stroke Registry (FSR), we aimed to evaluate the characteristics of the older patients receiving EVT in routine practice and to study the impact of age on EVT outcomes.

METHODS AND RESULTS

Data prospectively collected from Get With The Guidelines-Stroke hospitals in the FSR from January 2010 to December 2022 were analyzed for EVT outcomes. Among patients receiving EVT, characteristics associated with age ≥80 years and the impact of age on EVT outcomes of discharge directly to home or acute inpatient rehabilitation, and independent ambulation at discharge were studied using multivariable analysis with generalized estimating equations. Among 20 004 EVT FSR patients (mean age 71±15, 50% women), 29% were ≥80 years of age. In multivariable analysis, older patients with EVT had a similar rate of symptomatic intracerebral hemorrhage and in hospital mortality but were less likely to achieve independent ambulation at discharge (odds ratio [OR]: 0.44 [95% CI, 0.39-0.49]), be discharged directly home (OR: 0.46 [95% CI, 0.42-0.51]) or to a rehabilitation facility (OR: 0.68 [95% CI, 0.61-0.75]).

CONCLUSIONS

In routine practice, close to 30% of EVT treated stroke patients are over the age of 80 years. Our data shows that EVT is safe in this population; however, age remains an independent predictor of poor discharge outcomes post EVT.

Multicenter study of association between socioeconomic status and treatment of ruptured cerebral aneurysms compared to unruptured cerebral aneurysms: insights from 4,517 patients using the area deprivation index

BACKGROUND

Socioeconomic status influences health outcomes, including cerebrovascular diseases. Patients from socioeconomically deprived areas may present with more severe conditions due to delayed access to care. This study evaluates the association between neighborhood-level deprivation, measured by the Area Deprivation Index (ADI), and the treatment of ruptured intracranial aneurysms (RIAs) compared with unruptured intracranial aneurysms (UIAs) across multiple centers.

METHODS

This retrospective cohort study analyzed data from 4517 patients treated for cerebral aneurysms at 10 US comprehensive stroke centers between 2018 and 2024. Patients were stratified by national ADI decile based on their residential addresses. Multivariable logistic regression was used to examine the relationship between ADI and aneurysm rupture (reference being unruptured aneurysms) and controlled for age, sex, smoking history, family history, and race.

RESULTS

Of 4517 total patients, 1260 (27.9%) underwent treatment of RIAs. Multivariable analysis confirmed ADI as an independent predictor of presentation for treatment of RIA (odds ratio (OR)=1.100, 95% confidence interval (CI)=1.068-1.133, P<0.0001) after adjusting for age, sex, smoking history, and race. This corresponds to a 10% increase in likelihood of presenting for treatment of a ruptured vs unruptured intracranial aneurysm with each ADI decile.

CONCLUSION

Socioeconomic deprivation independently predicts treatment of RIAs compared with the treatment of UIAs. These findings highlight disparities in aneurysm detection and management, emphasizing the need for targeted preventive care and accessible screening programs to mitigate the impact of socioeconomic disadvantage on cerebral aneurysm outcomes.

Low Household Income Increases Hospital Length of Stay and Decreases Home Discharge Rates in Lumbar Fusion

STUDY DESIGN

Retrospective Matched Cohort Study.

OBJECTIVES

Low median household income (MHI) has been correlated with worsened surgical outcomes, but few studies have rigorously controlled for demographic and medical factors at the patient level. This study isolates the relationship between MHI and surgical outcomes in a lumbar fusion cohort using coarsened exact matching.

METHODS

Patients undergoing single-level, posterior lumbar fusion at a single institution were consecutively enrolled and retrospectively analyzed (n = 4263). Zip code was cross-referenced to census data to derive MHI. Univariate regression correlated MHI to outcomes. Patients with low MHI were matched to those with high MHI based on demographic and medical factors. Outcomes evaluated included complications, length of stay, discharge disposition, 30- and 90 day readmissions, emergency department (ED) visits, reoperations, and mortality.

RESULTS

By univariate analysis, MHI was significantly associated with 30- and 90 day readmission, ED visits, reoperation, and non-home discharge, but not mortality. After exact matching (n = 270), low-income patients had higher odds of non-home discharge (OR = 2.5, P = .016) and higher length of stay (mean 100.2 vs 92.6, P = .02). There were no differences in surgical complications, ED visits, readmissions, or reoperations between matched groups.

CONCLUSIONS

Low MHI was significantly associated with adverse short-term outcomes from lumbar fusion. A matched analysis controlling for confounding variables uncovered longer lengths of stay and higher rates of discharge to post-acute care (vs home) in lower MHI patients. Socioeconomic disparities affect health beyond access to care, worsen surgical outcomes, and impose costs on healthcare systems. Targeted interventions must be implemented to mitigate these disparities.

Racial and ethnic disparities in post-acute care service utilization after stroke

Evidence examining disparities in post-acute care (PAC) utilization among various racial and ethnic groups after stroke and the influence of social determinants of health (SDOH) in these decisions is lacking. Thus, we searched the literature from January 2000 to November 2023 regarding PAC among individuals after stroke through: 1) Pubmed, 2) Scopus, 3) Web of Science, 4) Embase, and 5) CINAHL. We found 14 studies. Black individuals were more likely than White individuals to be discharged home with home health (HH) and skilled nursing facilities (SNF). Hispanic individuals were more likely than White individuals to be discharged home with HH, but less likely to be discharged to institutions. Lower socioeconomic status, Medicaid insurance, urban residence, area PAC supply and hospital characteristics were associated with increased institutional discharges among racial and ethnic minority individuals. Future policy should improve access to appropriate PAC commensurate with an individual's medical/social complexity.

Racial disparities in access to, and outcomes of, acute ischaemic stroke treatments in the USA

BACKGROUND

Racism contributes to higher comorbid risk factors and barriers to preventive measures for black Americans. Advancements in systems of care, tissue plasminogen activator (tPA) availability and endovascular thrombectomy (ET) have impacted practice and outcomes while outpacing contemporary investigation into acute ischaemic stroke (AIS) care disparities. We examined whether recent data suggest ongoing disparity in AIS interventions and outcomes, and if hospital characteristics affect disparities.

METHODS

We examined 2016-2019 fee-for-service Medicare inpatient data. We ran unadjusted logistic regression models to calculate ORs and 95% CI for two interventions (tPA and ET) and four outcomes (inpatient mortality, 30-day mortality, discharge home and outpatient visit within 30 days), with the main predictor black versus white race, additionally adjusting for demographics, hospital characteristics, stroke severity and comorbidities.

RESULTS

805 181 AIS admissions were analysed (12.4% black, 87.6% white). Compared with white patients, black patients had reduced odds of receiving tPA (OR 0.71, 95% CI 0.69 to 0.74, p<0.0001) and ET (0.69, 95% CI 0.65 to 0.72, p<0.0001). After tPA, black patients had reduced odds of 30-day mortality (0.77, 95% CI 0.72 to 0.82, p<0.0001), discharge home (0.72, 95% CI 0.68 to 0.77, p<0.0001) and outpatient visit within 30 days (0.89, 95% CI 0.84 to 0.95, p=0.0002). After ET, black patients had reduced odds of 30-day mortality (0.71, 95% CI 0.63 to 0.79, p<0.0001) and discharge home (0.75, 95% CI 0.64 to 0.88, p=0.0005). Adjusted models showed little difference in the magnitude, direction or significance of the main effects.

CONCLUSIONS

Black patients were less likely to receive AIS treatments, and if treated had lower likelihood of 30-day mortality, discharge home and outpatient visits. Despite advancements in practice and therapies, racial disparities remain in the modern era of AIS care and are consistent with inequalities previously identified over the last 20 years. The impact of hospital attributes on AIS care disparities warrants further investigation.

Neighborhood Deprivation is Associated With Hospital Length of Stay, Discharge Disposition, and Readmission Rates for Patients Who Survive Hospitalization With Traumatic Brain Injury

BACKGROUND AND OBJECTIVES

Traumatic brain injury (TBI) is a leading cause of disability in the United States. Limited research exists on the influence of area-level socioeconomic status and outcomes after TBI. This study investigated the correlation between the Area Deprivation Index (ADI) and (1) 90-day hospital readmission rates, (2) facility discharge, and (3) prolonged (≥5 days) hospital length of stay (LOS).

METHODS

Single-center retrospective review of adult (18 years or older) patients who were admitted for TBI during 2018 was performed. Patients were excluded if they were admitted for management of a chronic or subacute hematoma. We extracted relevant clinical and demographic data including sex, comorbidities, age, body mass index, smoking status, TBI mechanism, and national ADI. We categorized national ADI rankings into quartiles for analysis. Univariate, multivariate, and area under the receiver operating characteristic curve (AUROC) analyses were performed to assess the relationship between ADI and 90-day readmission, hospital LOS, and discharge disposition.

RESULTS

A total of 523 patients were included in final analysis. Patients from neighborhoods in the fourth ADI quartile were more likely to be Black ( P = .007), have a body mass index ≥30 kg/m 2 ( P = .03), have a Charlson Comorbidity Index ≥5 ( P = .004), and have sustained a penetrating TBI ( P = .01). After controlling for confounders in multivariate analyses, being from a neighborhood in the fourth ADI quartile was independently predictive of 90-day hospital readmission (odds ratio [OR]: 1.35 [1.12-1.91], P = .011) (model AUROC: 0.82), discharge to a facility (OR: 1.46 [1.09-1.78], P = .03) (model AUROC: 0.79), and prolonged hospital LOS (OR: 1.95 [1.29-2.43], P = .015) (model AUROC: 0.85).

CONCLUSION

After adjusting for confounders, including comorbidities, TBI mechanism/severity, and age, higher ADI was independently predictive of longer hospital LOS, increased risk of 90-day readmission, and nonhome discharge. These results may help establish targeted interventions to identify at-risk patients after TBI.

Mechanical Thrombectomy in Africa: A Challenging Future

Mechanical thrombectomy (MT) has revolutionized the management of proximal large vessel occlusions (LVOs) in patients with acute ischemic stroke (AIS), improving long-term outcomes compared to standard treatments. However, despite its success in high-income countries, the widespread implementation of MT in Africa remains limited. With Africa experiencing one of the highest stroke burdens globally, this study examines the barriers impeding the adoption of MT in the region. These challenges include insufficient healthcare infrastructure, lack of specialized training, and economic constraints, which hinder timely access to care. The review highlights significant disparities in stroke management across African countries and proposes strategies to enhance access to stroke care, emphasizing the need for policy reforms, infrastructure investment, and specialized training to improve outcomes for African stroke patients.

Effects of Social Determinants of Health on Acute Stroke Care Among Patients With Acute Ischemic Stroke: A Retrospective Cohort Study

BACKGROUND AND OBJECTIVES

Social determinants of health (SDOH) are important contributors to poor stroke-related outcomes. While some have suggested that this association is driven by the increased incidence of stroke observed with poor SDOH, others have raised concerns regarding disparities in acute stroke care. This study aimed to determine the association between SDOH and the administration of thrombolytic therapy and mechanical thrombectomy among patients with acute ischemic stroke.

METHODS

A retrospective cohort analysis was conducted using Texas Emergency Department Public Use Data (2016-2019), including adult patients diagnosed with acute ischemic stroke. The risk ratios (RRs) of administering thrombolysis and thrombectomy based on variables representing SDOH and a collective measure (Social Vulnerability Index [SVI]) were computed using mixed-effects Poisson regression models accounting for the nested nature of patients in hospitals and neighborhoods. The Charlson comorbidity score was considered as a covariate.

RESULTS

Of the 139,852 patients with ischemic stroke (female, 51.7%; White, 67.2%; Black, 16.6%; Hispanic, 25.1%), 16,831 (12.3%) received thrombolytic therapy and 5,951 (4.3%) received mechanical thrombectomy. Age older than 65 years (RR 0.578 [0.537-0.621]) vs 18-45 years, Black (RR 0.801 [0.761-0.844]) vs White, Hispanic (RR 0.936 [0.895-0.98]) vs non-Hispanic, Medicare/Medicaid/Veterans Affairs (VA) (RR 0.917 [0.882-0.954]) or uninsured (RR 0.883 [0.833-0.935]) vs private insurance, and rural (RR 0.782 [0.723-0.845]) vs urban dwelling were less likely to be associated with thrombolysis. Patients in the highest quintile based on the SVI were less likely to receive thrombolysis than those in the lowest quintile (RR 0.926 [0.867-0.989]). Patients were less likely to receive thrombectomy if they were 65 years and older (RR 0.787 [0.691-0.895]), belonged to the Black race (RR 0.745 [0.679-0.818]) or Hispanic ethnicity (RR 0.919 [0.851-0.992]), had Medicare/Medicaid/VA insurance (RR 0.909 [0.851-0.971]), or were from a rural area (RR 0.909 [0.851-0.971]). Similarly, SVI decreased the likelihood of undergoing mechanical thrombectomy (RR 0.842 [0.747-0.95]).

DISCUSSION

Despite many improvements in stroke management, SDOH continue to be a significant driver of treatment access for acute ischemic stroke. While our findings are limited to Texas, our results should raise awareness and promote more studies regarding the effects of these SDOH at the national and international levels.

Ten-year trends, disparities, and clinical impact of stroke thrombectomy and thrombolysis: A single center experience 2012-2021

OBJECTIVES

As indications for acute ischemic stroke treatment expand, it is unclear whether disparities in treatment utilization and outcome still exist. The main objective of this study was to investigate disparities in acute ischemic stroke treatment and determine impact on outcome.

MATERIALS AND METHODS

Retrospective observational cohort study of consecutive ischemic stroke admissions to a comprehensive stroke center from 2012-2021 was performed. Primary exposure was intravenous thrombolysis and/or endovascular thrombectomy. Primary end points were discharge modified Rankin Scale, home disposition, and expired/hospice. Multivariable logistic regression analyses were conducted to elucidate disparities in treatment utilization and determine impact on outcome.

RESULTS

Of 517,615 inpatient visits, there were 7,540 (1.46 %) ischemic stroke admissions, increasing from 1.14 % to 1.79 % from 2012-2021. Intravenous thrombolysis significantly decreased from 14.4 % to 9.8 % while endovascular thrombectomy significantly increased from 0.8 % to 10.5 %. Both intravenous thrombolysis and endovascular thrombectomy increased odds of discharge home and modified Rankin Scale 0-2, and thrombectomy decreased odds of expired/hospice. After adjusting for covariates, decreased odds of thrombectomy was associated with Medicaid insurance (Odds Ratio [95 % Confidence Interval] 0.55 [0.32-0.93]), age 80+ (0.49 [0.35-0.69]), prior stroke (0.49 [0.31-0.77]), and diabetes mellitus (0.55 [0.39-0.79]), while low median household income (<$80,000/year) increased odds of no acute treatment (1.34 [1.16-1.56]). No sex or racial disparities were observed. Medicaid and low-income were not associated with worse clinical outcomes.

CONCLUSIONS

Less endovascular thrombectomy occurred in Medicaid, older, prior stroke, and diabetic patients, while low-income was associated with no treatment. The observed socioeconomic disparities did not impact discharge outcome.

Impact and determinants of door in-door out time for stroke thrombectomy transfers in a large hub-and-spoke network

INTRODUCTION

The mantra "time is brain" cannot be overstated for patients suffering from acute ischemic stroke. This is especially true for those with large vessel occlusions (LVOs) requiring transfer to an endovascular thrombectomy (EVT) capable center. We sought to evaluate the spoke hospital door in-door out (DIDO) times for patients transferred to our hub center for EVT.

METHODS

Individuals who first presented with LVO to a spoke hospital and were then transferred to the hub for EVT were retrospectively identified from a prospectively maintained database from January 2019 to November 2022. DIDO was defined as the time between spoke hospital door in arrival and door out exit. Baseline characteristics, treatments, and outcomes were compared, dichotomizing DIDO at 90 minutes based in the American Heart Association goal for DIDO ≤90 minutes for 50% of transfers. Multivariable regression analyses were performed for determinants of the 90-day ordinal modified Rankin Scale (mRS) and DIDO.

RESULTS

We identified 194 patients transferred for EVT with available DIDO. The median age was 67 years (IQR 57-80), and 46% were female. The median National Institutes of Health Stroke Scale (NIHSS) was 16 (10-20), 50% were treated with intravenous thrombolysis at a spoke, and TICI 2B-3 reperfusion was achieved in 87% at the hub. The median DIDO was 120 minutes (97-149), with DIDO ≤90 minutes achieved in 18%. DIDO was a significant determinant of 90-day ordinal mRS (B = 0.007, 95% CI = 0.001-0.012, p = 0.013), even when accounting for the last known well-to-spoke door in, spoke door out-to-hub arrival, hub arrival-to-puncture, puncture-to-first pass, age, NIHSS, intravenous thrombolysis, TICI 2B-3, and symptomatic intracranial hemorrhage. Importantly, determinants of DIDO included Black race or Hispanic ethnicity (B = 0.918, 95% CI = 0.010-1.826, p = 0.048), atrial fibrillation or heart failure (B = 0.793, 95% CI = 0.257-1.329, p = 0.004), and basilar LVO location (B = 2.528, 95% CI = 1.154-3.901, p < 0.001).

CONCLUSION

Spoke DIDO was the most important period of time for long-term outcomes of LVO stroke patients treated with EVT. Targets were identified to reduce DIDO and improve patient outcomes.

Extracranial-Intracranial Bypass for Moyamoya Disease: The Influence of Racial and Socioeconomic Disparities on Outcomes - A National Inpatient Sample Analysis

BACKGROUND

Extracranial-intracranial (EC-IC) bypass is an established therapeutic option for Moyamoya disease (MMD). However, little is known about the effects of racial and ethnic disparities on outcomes. This study assessed trends in EC-IC bypass outcomes among MMD patients stratified by race and ethnicity.

METHODS

Utilizing the US National Inpatient Sample, we identified MMD patients undergoing EC-IC bypass between 2002 and 2020. Demographic and hospital-level data were collected. Multivariable analysis was conducted to identify independent factors associated with outcomes. Trend analysis was performed using piecewise joinpoint regression.

RESULTS

Out of 14,062 patients with MMD, 1771 underwent EC-IC bypass. Of these, 60.59% were White, 17.56% were Black, 12.36% were Asians, 8.47% were Hispanic, and 1.02% were Native Americans. Nonhome discharge was noted in 21.7% of cases, with a 6.7% death and 3.8% postoperative neurologic complications rates. EC-IC bypass was more commonly performed in Native Americans (23.38%) and Asians (17.76%). Hispanics had the longest mean length of stay (8.4 days) and lower odds of nonhome discharge compared to Whites (odds ratio: 0.64; 95% confidence interval: 0.40-1.03; P = 0.04). Patients with Medicaid, private insurance, self-payers, and insurance paid by other governments had lower odds of nonhome discharge than those with Medicare.

CONCLUSION

This study highlights racial and socioeconomic disparities in EC-IC bypass for patients with MMD. Despite these disparities, we did not find any significant difference in the quality of care. Addressing these disparities is essential for optimizing MMD outcomes.

Referral to Community-Based Rehabilitation Following Acute Stroke: Findings From the COMPASS Pragmatic Trial

BACKGROUND

Few studies on care transitions following acute stroke have evaluated whether referral to community-based rehabilitation occurred as part of discharge planning. Our objectives were to describe the extent to which patients discharged home were referred to community-based rehabilitation and identify the patient, hospital, and community-level predictors of referral.

METHODS

We examined data from 40 North Carolina hospitals that participated in the COMPASS (Comprehensive Post-Acute Stroke Services) cluster-randomized trial. Participants included adults discharged home following stroke or transient ischemic attack (N=10  702). In this observational analysis, COMPASS data were supplemented with hospital-level and county-level data from various sources. The primary outcome was referral to community-based rehabilitation (physical, occupational, or speech therapy) at discharge. Predictor variables included patient (demographic, stroke-related, medical history), hospital (structure, process), and community (therapist supply) measures. We used generalized linear mixed models with a hospital random effect and hierarchical backward model selection procedures to identify predictors of therapy referral.

RESULTS

Approximately, one-third (36%) of stroke survivors (mean age, 66.8 [SD, 14.0] years; 49% female, 72% White race) were referred to community-based rehabilitation. Rates of referral to physical, occupational, and speech therapists were 31%, 18%, and 10%, respectively. Referral rates by hospital ranged from 3% to 78% with a median of 35%. Patient-level predictors included higher stroke severity, presence of medical comorbidities, and older age. Female sex (odds ratio, 1.24 [95% CI, 1.12-1.38]), non-White race (2.20 [2.01-2.44]), and having Medicare insurance (1.12 [1.02-1.23]) were also predictors of referral. Referral was higher for patients living in counties with greater physical therapist supply. Much of the variation in referral across hospitals remained unexplained.

CONCLUSIONS

One-third of stroke survivors were referred to community-based rehabilitation. Patient-level factors predominated as predictors. Variation across hospitals was notable and presents an opportunity for further evaluation and possible targets for improved poststroke rehabilitative care.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.

Association of Neighborhood Deprivation With Thrombolysis and Thrombectomy for Acute Stroke in a Health System With Universal Access

BACKGROUND AND OBJECTIVES

The association between socioeconomic status and acute ischemic stroke treatments remain uncertain, particularly in countries with universal health care systems. This study aimed to investigate the association between neighborhood-level material deprivation and the odds of receiving IV thrombolysis or thrombectomy for acute ischemic stroke within a single-payer, government-funded health care system.

METHODS

We conducted a population-based cohort study using linked administrative data from Ontario, Canada. This study involved all community-dwelling adult Ontario residents hospitalized with acute ischemic stroke between 2017 and 2022. Neighborhood-level material deprivation, measured in quintiles from least to most deprived, was our main exposure. We considered the receipt of thrombolysis or thrombectomy as the primary outcome. We used multivariable logistic regression models adjusted for baseline differences to estimate the association between material deprivation and outcomes. We performed a sensitivity analysis by additionally adjusting for hospital type at initial assessment. Furthermore, we tested whether hospital type modified the associations between deprivation and outcomes.

RESULTS

Among 57,704 patients, those in the most materially deprived group (quintile 5) were less likely to be treated with thrombolysis or thrombectomy compared with those in the least deprived group (quintile 1) (16.6% vs 19.6%, adjusted odds ratio [aOR] 0.76, 95% CI 0.63-0.93). The association was consistent when evaluating thrombolysis (13.0% vs 15.3%, aOR 0.78, 95% CI 0.64-0.96) and thrombectomy (6.4 vs 7.8%, aOR 0.73, 95% CI 0.59-0.90) separately. There were no statistically significant differences between the middle 3 quintiles and the least deprived group. These associations persisted after additional adjustment for hospital type, and there was no interaction between material deprivation and hospital type (p interaction >0.1).

DISCUSSION

We observed disparities in the use of thrombolysis or thrombectomy for acute ischemic stroke by socioeconomic status despite access to universal health care. Targeted health care policies, public health messaging, and resource allocation are needed to ensure equitable access to acute stroke treatments for all patients.

Neighbourhood deprivation, distance to nearest comprehensive stroke centre and access to endovascular thrombectomy for ischemic stroke: a population-based study

BACKGROUND

Endovascular thrombectomy (EVT) has revolutionized ischemic stroke care. We aimed to assess whether neighbourhood socioeconomic status is predictive of access to EVT after receipt of alteplase for ischemic stroke among patients living in Alberta, Canada, and whether this relation is mediated by the distance a person lives to the nearest comprehensive stroke centre (CSC).

METHODS

We performed a retrospective study including all people older than 18 years living in Alberta who were admitted to hospital with an ischemic stroke and who received intravenous alteplase treatment between Jan. 1, 2017, and Dec. 31, 2019. Data were obtained through administrative data sets. The primary outcome was treatment with EVT. We assigned neighbourhood deprivation quintile based on the Material and Social Deprivation Index. We used logistic regression modelling to assess for a relation between deprivation and treatment with EVT. We adjusted for age, sex, stroke severity and distance to the nearest CSC. We calculated the average causal mediation effect of distance to the nearest CSC on the relation between neighbourhood deprivation level and treatment with EVT.

RESULTS

The study cohort consisted of 1335 patients, of whom 181 (13.6%) had missing data and were excluded from the main regression analysis. Endovascular thrombectomy was performed or attempted in 314 patients (23.5%). In the primary model, patients from the most deprived neighbourhoods were less likely than those from less deprived neighbourhoods to have received EVT (adjusted odds ratio 0.43, 95% confidence interval 0.24 to 0.77). Neighbourhood deprivation level was not significantly associated with EVT when distance to the nearest CSC was included as a covariate. Mediation analysis suggested that 48% of the total effect that neighbourhood deprivation level had on the odds of receiving EVT was attributable to the distance a person lived from the nearest CSC.

INTERPRETATION

The results suggest that people from more deprived neighbourhoods in Alberta were less likely to be treated with EVT than those from less deprived neighbourhoods. Improving access to EVT for people living in remote locations may improve the equitable distribution of this treatment.

Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Importance

Treatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED).

Objective

To evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times.

Design, Setting, and Participants

US registry-based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals.

Exposure

Patient- and hospital-level characteristics.

Main Outcomes and Measures

The primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, >120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy.

Results

Among 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (-20.1 minutes; 95% CI, -22.1 to -18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (-66.7 minutes; 95% CI, -68.7 to -64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (-16.8 minutes; 95% CI, -21.0 to -12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times.

Conclusions and Relevance

In this US registry-based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.

Mortality following mechanical thrombectomy for ischemic stroke in patients with COVID-19

OBJECTIVES

Multiple prior studies have shown a relationship between COVID-19 and strokes; further, COVID-19 has been shown to influence both time-to-thrombectomy and overall thrombectomy rates. Using large-scale, recently released national data, we assessed the association between COVID-19 diagnosis and patient outcomes following mechanical thrombectomy.

MATERIALS AND METHODS

Patients in this study were identified from the 2020 National Inpatient Sample. All patients with arterial strokes undergoing mechanical thrombectomy were identified using ICD-10 coding criteria. Patients were further stratified by COVID diagnosis (positive vs. negative). Other covariates, including patient/hospital demographics, disease severity, and comorbidities were collected. Multivariable analysis was used to determine the independent effect of COVID-19 on in-hospital mortality and unfavorable discharge.

RESULTS

5078 patients were identified in this study; 166 (3.3%) were COVID-19 positive. COVID-19 patients had a significantly higher mortality rate (30.1% vs. 12.4%, p < 0.001). When controlling for patient/hospital characteristics, APR-DRG disease severity, and Elixhauser Comorbidity Index, COVID-19 was an independent predictor of increased mortality (OR 1.13, p = 0.002). COVID-19 was not significantly related to discharge disposition (p = 0.480). Older age and increased APR-DRG disease severity were also correlated with increase morality.

CONCLUSIONS

Overall, this study indicates that COVID-19 is a predictor of mortality among mechanical thrombectomy. This finding is likely multifactorial but may be related to multisystem inflammation, hypercoagulability, and re-occlusion seen in COVID-19 patients. Further research would be needed to clarify these relationships.

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.

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

Background

There are significant racial and ethnic disparities in receipt of reperfusion interventions for acute ischemic stroke. Our objective was to determine whether there are disparities in access to stroke center care by race or ethnicity that help explain differences in reperfusion therapy and to understand whether interhospital patient transfer plays a role in improving access.

Methods

Using statewide administrating data including all emergency department and hospital discharges in California from 2010 to 2017, we identified all acute ischemic stroke patients. Primary outcomes of interest included presentation to primary or comprehensive stroke center (PSC or CSC), interhospital transfer, discharge from PSC or CSC, and discharge from CSC alone. We used hierarchical logistic regression modeling to identify the relationship between patient- and hospital-level characteristics and outcomes of interest.

Results

Of 336,247 ischemic stroke patients, 55.4% were non-Hispanic White, 19.6% Hispanic, 10.6% non-Hispanic Asian/Pacific Islander, and 10.3% non-Hispanic Black. There was no difference in initial presentation to stroke center hospitals between groups. However, adjusted odds of reperfusion intervention, interhospital transfer and discharge from CSC did vary by race and ethnicity. Adjusted odds of interhospital transfer were lower among Hispanic (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98) and non-Hispanic Asian/Pacific Islander patients (OR 0.84, 95% CI 0.79 to 0.90) and odds of discharge from a CSC were lower for Hispanic (OR 0.91, 95% CI 0.85 to 0.97) and non-Hispanic Black patients (OR 0.74, 95% CI 0.67 to 0.81).

Conclusions

There are racial and ethnic disparities in reperfusion intervention receipt among stroke patients in California. Stroke system of care design, hospital resources, and transfer patterns may contribute to this disparity.