Treatment for ischemic stroke differs by race, ethnicity, health insurance status

Race, ethnicity and health insurance status all appeared to impact receipt of treatment for ischemic stroke among patients in California, Florida and New York, according to a retrospective analysis of more than 1 million hospitalizations.

Researchers presented their findings during the American Academy of Neurology annual meeting, which is being held virtually.

“We know that racial disparities both in thrombolysis and endovascular therapy vary across states and that low or no insurance status is associated with a lower likelihood for receiving these treatment interventions — regardless of race,” Alison Herman, BS (Hon), a postgraduate researcher in neurocritical care and emergency neurology at Yale University, said during her presentation.

Herman and colleagues sought to assess the association between race and ethnicity and receipt of thrombolysis and endovascular therapy among 1,051,522 hospitalized patients receiving care across California between 2006 and 2011, Florida between 2006 and 2014 and New York between 2006 and 2014.

Overall, 39,959 patients received thrombolysis treatment alone, 2,624 received endovascular therapy alone and 2,193 received both thrombolysis and endovascular therapy.

After adjusting for age, sex, significant comorbidities, markers of stroke severity, insurance status and the interaction between race and insurance status, researchers found that compared with white patients, Black patients in Florida (OR = 0.82; P < .001) and both Black (OR = 0.65; P < .001) and Hispanic patients (OR = 0.73; P < .001) in California were less likely to receive thrombolysis, whereas Black (OR = 0.69; P < .01) and Hispanic (OR = 0.65; P < .01) patients in New York were less likely to receive endovascular therapy.

Moreover, Medicare and Medicaid beneficiaries across all three states were less likely to receive thrombolysis and endovascular therapy. Patients in Florida who were uninsured were also less likely to receive thrombolysis and endovascular therapy.

“There are many different factors that may be contributing to these racial disparities,” Herman said. “One argument would be whether potential access to health care is causing these disparities or contributing to them.”

For this reason, Herman and colleagues next conducted a geographical analysis to see if the distance from a thrombectomy center to patients’ homes impacted the likelihood of receiving treatment for ischemic stroke.

“Ultimately, Black patients were more likely to live closer to a thrombectomy center compared with white patients and the same was true for Hispanic patients in New York and Florida,” she said. “Therefore, the distance to a thrombectomy center does not appear to impact the likelihood of receiving treatment. Ultimately, our data show that these disparities are not caused by physical access to treatment.”

Limitations of the study included the fact that the analysis was limited to showing associations and generating future hypotheses, and administrative claims data were used, which did not provide detailed information on stroke severity, Herman noted.

“In particular, we only had data through 2014, which is a limitation in terms of endovascular therapy since the positive trials in thrombectomy were mostly published in 2015,” Herman said. “We therefore considered looking at state and patient data for more recent years but ultimately opted to look at these disparities in a nationwide sample because this work is hypothesis-generating and we thought additional work on future years should be conducted across all 50 states so that we can observe racial disparities and any inconsistencies in racial disparities across states.”

Future research should also assess whether stroke severity accounts for any of the treatment differences observed in this study, Herman added.

“It would also be worthwhile to assess the impact of other socioeconomic status proxies, such as level of education and median income,” she said. “We also want to evaluate the trends in more recent years and throughout time. However, the most pressing need is to look at features that account for the presence or absence of racial disparities to develop effective policies and programs at the state level.”