Sohei Yoshimura, MD, PhD

Otite FO, Saini V, Sur NB, Patel S, Sharma R, Akano EO, Anikpezie N, Albright K, Schmidt E, Hoffman H, et al. Ten-Year Trend in Age, Sex, and Racial Disparity in tPA (Alteplase) and Thrombectomy Use Following Stroke in the United States. Stroke. 2021;52:2562-2570. 

Stroke is a common disease, but there have been reports of common stroke treatment disparities related to several factors, such as age, gender, and race. This study evaluated national trends in age-, sex-, and race-specific use of IV tPA and mechanical thrombectomy (MT), the most important quality indicators for standardized stroke treatment. The data was obtained from National Inpatients Samples (NIS), the largest publicly available inpatient healthcare database in the United States.  The authors used ICD-9-CM and ICD-10-MC/procedure coding system to identify exposures and outcomes. This study revealed that the overall frequency of IV tPA and MT utilization in the U.S. increased in all age, sex, and race groups over the last decade. The pace of the increase was more pronounced in ≥80 year old patients and in Black and Hispanic patients, leading to a decline in age- and race-associated treatment gaps over time. The faster increase of IV rPA usage in women also led to narrowing of sex-related treatment gaps.

NIS was designed to produce U.S. regional and national estimates of inpatient utilization, access, cost, quality, and outcomes. The authors were able to evaluate trends of IV tPA and MT over time, using this big, standardized and longitudinal database. Needless to say, the authors defined covariates carefully using many codes, such as ICD-9 and ICD-10, partly because NIS was redesigned and updated over and over.

As anticipated, utilization of IV tPA and MT increased across the study period in all groups. However, the rate of this increase was revealed to be more obvious in octogenarians by joinpoint and multivariable-adjusted logistic regression models. For example, IV tPA usage increased annually by 11.5% in 18 to 39 year olds, and usage in patients ≥90 years old increased by 15.4% annually. One thing to be noted was that sex disparity in utilization of MT in women persisted and sex-by-time interaction in MT use was not significant (p interaction 0.106). Gender differences research in stroke medicine remains an important topic.

A lot of other observational studies and registries have reported the disparities in stroke care and the potential reasons of the gaps. Based on these results, multiple interventions to tackle the disparities are ongoing in the United States, including targeted behavior change strategies, kids’ education, and approaches to community health workers. Participating in the Get With The Guidelines may be one of the solutions. This study suggests that these interventions are producing steady results in the U.S.

In countries other than the U.S., there should be other regional and cultural issues that make gaps in stroke care. Identifying reasons for gaps and implementing effective solutions to tackle disparities in stroke will require sustainable effort by researchers and policymakers. Reducing disparities in the burden of stroke appears to be an urgent issue, especially for aging countries.