Allostatic load predicts racial disparities in intracerebral hemorrhage cognitive outcomes

A large portion of stroke disparities remains unexplained, even after adjusting for demographic, comorbidity, and health care access variables. There is a critical need to close this knowledge gap by investigating novel factors that may contribute to stroke disparities. Allostatic load (AL) is the lifetime adverse physiologic impact of needing to adjust to socially structured stressors such as racism. AL has been shown to increase health vulnerability and worsen outcomes in marginalized populations. We sought to assess the differential impact of AL on cognitive outcomes post intracerebral hemorrhage (ICH) across race-ethnicity. The Intracerebral Hemorrhage Outcomes Project (ICHOP) prospectively collected data from patients presenting to Columbia Medical Center with ICH from 3/2009 to 5/2016. Data included demographics, stroke scores, labs, complications, neuroimaging, medical history, and discharge data. Five markers of AL (HbA1c, WBC, SBP, HR, ALB) were obtained. An AL score was generated by summing the elements in each patient that fell outside normal ranges, with AL score ranging 0–5. A linear regression model, adjusted for stroke severity and ICH volumes, was used to evaluate the relationship between AL and Modified Telephone Interview for Cognitive Status (TICS-m) at discharge, stratified by race-ethnicity. Among 248 white, 195 black, and 261 Hispanic ICH patients, neither mean AL nor mean TICS differed by race/ethnicity (p = 0.51, p = 0.79 respectively). In the overall cohort AL did not predict TICS at discharge (Beta -1.0, SE 1.1, p = 0.353). In Whites (beta 1.18, SE 2.5, p = 0.646) and Hispanics (beta -0.95, SE 1.6, p = 0.552) AL was not associated with TICS at discharge. In Black patients, higher AL was associated with a decrease in TICS at discharge (beta -3.2, SE 1.5, p = 0.049). AL is an important determinant of post ICH outcomes for certain minority populations. AL may explain some of the unexplained health disparities in stroke populations.

Abstract P876: Allostatic Load Predicts Racial Disparities in Intracerebral Hemorrhage Outcomes

Introduction: A large portion of stroke disparities remains unexplained, even after controlling for an array of demographic, comorbidity, and health care access variables. There is a need to close this knowledge gap by investigating novel factors that may contribute to stroke disparities. Allostatic load (AL) is the lifetime adverse physiologic impact of needing to adjust to socially structured stressors such as racism. AL has been shown to increase health vulnerability and worsen outcomes in marginalized populations. We sought to assess the differential impact of AL on cognitive outcomes post intracerebral hemorrhage (ICH) across race-ethnicity.

Methods: The Columbia University Intracerebral Hemorrhage Outcomes Project (ICHOP) prospectively collected data from patients presenting to Columbia University Medical Center with a diagnosis of ICH from March 2009 to May 2016. Data included demographics, stroke scores, labs, neurological deterioration, hospital complications, neuroimaging, medical history, and discharge data. Ten markers of AL (BMI, A1c, SBP, triglycerides, CRP, HDL, LDL, HGB, HR, albumin) were obtained. An AL score was generated by summing the elements in each patient that fell outside normal clinical ranges, with an AL score range from 0-10. We used linear regression models to evaluate the relationship between AL and Telephone Interview for Cognitive Status (TICS) at discharge in the entire population, and then stratified by race-ethnicity.

Results: Among 248 White, 195 Black, and 261 Hispanic ICH patients, neither mean AL nor mean TICS differed by race/ethnicity (p=0.55, p=0.21 respectively). In the overall ICHOP cohort AL was associated with TICS at discharge (Beta -0.939, SE 0.46, p=0.043). In Whites and Hispanics AL was not associated with TICS at discharge (beta 0.267, SE 0.75, p=0.725, beta -0.71, SE 0.73, p=0.33 respectively). In Black patients, higher AL was associated with a decrease in TICS at discharge (beta -2.24, SE 0.90, p=0.016).

Conclusion: AL was associated with cognitive scores at discharge for Black patients but not Hispanics or Whites, suggesting that AL is an important determinant of post ICH outcomes for certain minority populations. AL may explain some of the unexplained health disparities in stroke populations.

Comparison of Acute Stroke Preparedness Strategies to Decrease Emergency Department Arrival Time in a Multiethnic Cohort

Background and Purpose—

Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window. Stroke Warning Information and Faster Treatment (SWIFT) compared an interactive intervention (II) with enhanced educational (EE) materials on recurrent stroke arrival times in a prospective cohort of multiethnic stroke/transient ischemic attack survivors.

Methods—

A single-center randomized controlled trial (2005–2011) randomized participants to EE (bilingual stroke preparedness materials) or II (EE plus in-hospital sessions). We assessed differences by randomization in the proportion arriving to emergency department <3 hours, prepost intervention arrival <3 hours, incidence rate ratio for total events, and stroke knowledge and preparedness capacity.

Results—

SWIFT randomized 1193 participants (592 EE, 601 II): mean age 63 years; 50% female, 17% black, 51% Hispanic, 26% white. At baseline, 28% arrived to emergency department <3 hours. Over 5 years, first recurrent stroke (n=133), transient ischemic attacks (n=54), or stroke mimics (n=37) were documented in 224 participants. Incidence rate ratio=1.31 (95% confidence interval=1.05–1.63; II to EE). Among II, 40% arrived <3 hours versus 46% EE ( P =0.33). In prepost analysis, there was a 49% increase in the proportion arriving <3 hours ( P =0.001), greatest among Hispanics (63%, P <0.003). II had greater stroke knowledge at 1 month (odds ratio=1.63; 1.23–2.15). II had higher preparedness capacity at 1 month (odds ratio=3.36; 1.86, 6.10) and 12 months (odds ratio=7.64; 2.49, 23.49).

Conclusions—

There was no difference in arrival <3 hours overall between II and EE; the proportion arriving <3 hours increased in both groups and in race-ethnic minorities.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00415389.