Rachel Forman, MD
I was excited for the chance to review this article, as this topic is near and dear to my heart as someone who does community stroke education to help improve healthcare disparities in this area. From my experience in providing stroke education to more diverse communities, there is much less knowledge in terms of recognizing stroke symptoms and the importance of prompt care to be eligible for tPA and mechanical thrombectomy (MT). Unfortunately, I was not surprised when I read the results of this paper.
It has already been established that minority patients receive less MT; however, this study looked at updated data (2016-2018) to see if this still held true following the publication of multiple positive MT trials in 2015. MT has become increasingly utilized after a series of positive trials published in 2015 and is now the standard of care for treatment of stroke due to large vessel occlusion. For more information on these trials, the HERMES collaboration is a meta-analysis of five major trials in The Lancet, published in 2016.
The study used a national database and analyzed demographic data on 206,853 patients who were admitted to endovascular centers with acute ischemic stroke. They compared different factors between minority patients (black/Hispanic) and non-minority patients (white/non-Hispanic). Overall, 8.4% of patients underwent MT. Minority patients received less MT compared to non-minority patients (7.0 versus 9.8%; P<0.001). Also of note, these patients were less likely to receive IV-tPA (16.2% versus 30.1%; P<0.001). Using multivariate linear regression analysis, the following factors were independently associated with lower use of MT: female gender, insurance with Medicaid or uninsured, and being black/Hispanic.
Also of interest: 27.3% of patients were transferred to an endovascular center from another hospital; among those who received MT, the number climbed to 44.3%. I found this interesting, as the number at my current institution is closer to 75% that are outside hospital transfers. The study identified another statistically significant disparity in black/Hispanic patients in that less of these patients were transferred. One explanation for this is that the hospitals where these patients have a higher presence have fewer resources and insufficient redirection to endovascular institutions. Another explanation may be that this population presents later in their stroke symptoms after the infarct has already been established. This last point is listed as one of the study limitations.
Dr. Salvador Cruz-Flores wrote an editorial about this article and brings up what I was thinking while reading it: What can we do about this? He specifically notes, “there has been an increase in the number of articles addressing racial disparities focusing mostly on whether disparities are present or absent with not enough attention placed on the impact of social determinants of heath on racial disparities, on interventions to minimize disparities, and much less on the impact of implicit bias.” One theme that has been brought to my attention as far as improving this issue is protocol standardization when it comes to emergency care for stroke patients; however, this may be difficult to implement across hospital and geographic systems. Overall, this is an important study to continue to highlight an ongoing issue in stroke care that needs to be addressed.
