Although the use of endovascular therapy (EVT) for ischemic stroke has increased in recent years, patients belonging to ethnic minorities are less likely to receive it than white patients, according to research.
And while short-term EVT outcomes were more favorable among minorities than among white patients, the researchers found that white patients were more likely to achieve functional independence at 3 months than minority patients.
“Joint efforts need to be made to turn these observations of racial and ethnic differences into action,” said Faheem G. Sheriff, MD, assistant professor of neurology at the Texas Tech University Health Center El Paso, during his presentation. “I think this rescue therapy needs to be distributed more evenly and have a more uniform way to ensure that the benefits are available to all groups and that the population has the same benefits.”
He the results were presented at the International Stroke Conference (ISC) 2021.
After the publication in 2015 of tests as MR CLEAN, TO ESCAPE, i EXTEND-IA showing the benefits of EVT, the therapy had a wider use for the treatment of acute ischemic stroke. The American Heart Association (AHA) updated its stroke treatment guidelines in 2018, to recommend this approach to certain patients in whom it would improve function. The data have suggested, however, that patients of certain ethnic or racial groups are less likely to receive EVT than others.
The researchers hypothesized that the increasing use of EVT since 2015 had reduced racial disparities in treatment. To test their hypothesis, they examined data from the AHA’s Get with the Guidelines – Stroke database. Eligible patients who had an acute ischemic stroke between April 2012 and June 2019 arrived at the hospital less than 6 hours after the onset of the stroke and had a score on the scale of ‘stroke of the National Institutes of Health.
Researchers evaluated associations between race and ethnicity, EVT administration, discharge disposition, 90 days modified Rankin scale (mRS) and compared patient outcomes before and after 2015.
The researchers identified 302,965 eligible patients during the study period. Of this population, 42,422 (14%) suffered from EVT. The use of EVT increased over time in all ethnic and racial groups.
However, the likelihood of developing EVT was significantly lower for black patients, compared with non-Hispanic white patients (adjusted probability) [aOR] before 2015 = 0.68; aOR after 2015 = 0.83; Pg = 0.02).
However, the hospital or high hospice mortality rate was lower in black (aOR = 0.61, Pg <.0001), Hispanic (aOR = 0.77, Pg <.0001) and Asian (aOR = 0.78, Pg = .0006) patients, compared with non-Hispanic white patients.
Home discharge was also more common in Hispanics (aOR = 1.28, Pg <.0001), Asian (aOR = 1.23, Pg = .001) and Black (aOR = 1.08, Pg = 0.05) patients, compared with non-Hispanic white individuals.
Although short-term outcomes were better among racial and ethnic minorities, long-term outcomes were better among white patients. The probability of functional independence, defined as mRS of 0-2 at 3 months, was lower in black (aOR = 0.84, Pg = .006) and Asian (aOR = 0.7, Pg = 0.03) patients, compared with non-Hispanic white patients.
As part of their analysis, the researchers examined data on participants ’insurance status and on sociodemographic factors such as the zip code. “Despite correcting all these other markers of socioeconomic status and, most importantly, insurance status, the differences persisted,” the sheriff said. Medscape Medical News.
Researchers have not yet examined differences in treatment and outcomes in ethnic groups. But a previous study by the U.S. Department of Veterans Affairs provides information on this issue.
“Regardless of socioeconomic status, especially poor black patients appear to have a worse impact after stroke, in terms of admission to hospital rehabilitation and outcomes after hospital rehabilitation discharge,” the sheriff said . Initiation of hospital rehabilitation is delayed among black patients compared to white patients. And, among all patients admitted to rehabilitation more than 3 days later, black patients had far worse outcomes than their white counterparts, the sheriff added.
“We need to capitalize on the gains and continue to address the disparities,” the sheriff said.
The risk factors are different
A 2011 Scientific Statement by the AHA and the American Stroke Association reviewed factors that may contribute to racial and ethnic disparities in stroke. “The burden of vascular risk factors, such as hypertension, diabetes i metabolic syndrome, are higher in African Americans and Hispanics, “said Chia-Chun Chiang, MD, senior associate consultant and assistant professor of neurology at the Mayo Clinic in Rochester, Minnesota. Medscape Medical News.
The incidence and prevalence of stroke are higher among African Americans, Hispanics, and Native Americans or Alaska Natives than among whites, especially at younger ages, he added. Racial and ethnic minorities also have higher stroke mortality rates in the United States.
“In addition, the lack of awareness of the symptoms and signs of stroke, the unwillingness to seek medical attention due to distrust, patient compliance, and limited access to acute, preventive, and care rehabilitation could play a role in racial and ethnic disparities in stroke care, ”Chiang said.
One potential concern about the current study is whether the number of black, Asian and Hispanic patients was large enough for the analysis of additional questions, he added.
Among the questions posed by this study is whether the time from the onset of symptoms to the arrival at the emergency department (ED) is longer for minorities. This discrepancy could be improved by promoting stroke awareness and patient education, Chiang said.
Another question is whether minorities face a longer ED wait time, a lower stroke code activation rate, or a longer door-to-needle time. If they did, it would reflect the bias that needs to be addressed in the health care system, Chiang said.
Other questions for future research are whether access to rehabilitation and post-stroke care is different in minorities and whether medication compliance is different in minorities.
“We need a better understanding of the biological and genetic differences between different races to achieve personalized medicine in the treatment of stroke,” Chiang concluded.
The study was funded by the Get with the Guidelines – Stroke initiative of the American Heart Association / American Stroke Association. The sheriff and Chiang have not revealed any relevant financial relationship.
International Stroke Conference (ISC) 2021. Last minute summary 9. Filed March 19, 2021.