Saurav Das, MD
Cummings C, Almallouhi E, Al Kasab S, Spiotta AM, Holmstedt CA. Blacks Are Less Likely to Present With Strokes During the COVID-19 Pandemic: Observations From the Buckle of the Stroke Belt. Stroke. 2020.
During our monthly institutional journal club, we recently discussed a provocative health affairs blog post on systemic racism and the need for new standards for publishing on racial health inequities.1 The blog made a strong case regarding how biological factors and physician mistrust have been inaccurately named as an explanation for racial disparities in health outcomes without pronouncing the root cause as “systemic racism.” Subsequently, I read this brief report by Cummings et al. published in Stroke about racial disparities in telestroke consults in a large registry maintained at the Medical University of South Carolina during the COVID-19 pandemic. In this post, I will discuss the findings of the authors and reflect in light of the aforementioned blog.
The authors performed a retrospective chart review of 5852 patients in their telestroke registry comprising a network of 27 centers during the period of March 2019 to April 2020. The patients were grouped by months in which consult occurred, as well as into two groups: before and after the pandemic (March 1, 2020). The weekly census of patients presenting with stroke was significantly lower during the COVID-19 epoch (77 [interquartile range, IQR 69-84] vs 112 [IQR 102-120], p=0.002). There was a lower percentage of Black patients presenting during the pandemic (13.9% vs 29% before, p<0.001). Interestingly, a higher percentage of patients that presented received intravenous tissue Plasminogen Activator (tPA) during the pandemic (15.5% before vs 12.5% during the pandemic, P= 0.037), but the number of mechanical thrombectomies (MT) per week was lower during the pandemic (1 [IQR, 0.5-1] vs 3 [IQR, 1-4], P=0.022). This increased rate of tPA administered during the pandemic was seen in the Black patients as well (22.4% during the pandemic vs 13.5% before the pandemic, P=0.022). There were no differences in median age, sex, time from symptom onset to presentation, baseline NIHSS, rate of transfer to a MT capable center and rate of MT between Black patients presenting before and after the pandemic.
The authors discuss that the presented data is relevant because it is from a geographical area that experiences high stroke and stroke mortality rates — “buckle of the stroke belt.” Also, they refer to a paper reporting spatial patterns in racial disparities in cardiovascular health in this region. The authors report that the increase in rate of tPA administration in their population could be attributed to lower symptom onset to hospital arrival times (though statistically insignificant). In one paragraph dedicated to discussion of these disparities, the authors report that the reluctance of Black patients to avoid emergency rooms in spite of possibly larger strokes could be due to the higher incidence of COVID-19 and COVID-19 related mortality among the Black population. The authors mention limitations of the study to be its retrospective nature and the unavailability of certain data like number of large vessel occlusion strokes during the COVID-19 pandemic. They conclude that the decrease in the number of patients presenting with strokes during the COVID-19 pandemic is due to the fear of exposure in healthcare facilities, and this concern is more alarming in the Black patients. They propose this problem can be addressed by public health education.
The paper does bring to light how a pandemic can accentuate pre-existing racial disparities in stroke care. However, it falls short of reflecting on how these disparities could result from loss of jobs, financial shock, reduced access to tele-health, perceived mistreatment in hospitals, and historical deprivation of certain communities more than others. The research design does not solicit patient inputs from the affected communities. Scientific discussion on racial disparities should acknowledge the socio-political context of race. Future research on stroke disparities could benefit from defining “race” and “systemic racism” as study variables.
1. Boyd RW, Lindo EG, Weeks LD, McLemore MR. On Racism: A New Standard For Publishing On Racial Health Inequities. Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/. Published July 2, 2020. Accessed August 5, 2020.