Racial/Ethnic and Geographic Variations in Long-Term Survival Among Medicare Beneficiaries After Acute Ischemic Stroke

Xin Tong, MPH; Linda Schieb, MPH; Mary G. George, MD, MSPH; Cathleen Gillespie, MS; Robert K. Merritt, MA; Quanhe Yang, PhD


Prev Chronic Dis. 2021;18(2):e15 

In This Article

Abstract and Introduction


Introduction: Little information is available about racial/ethnic and geographic variations in long-term survival among older patients (≥65) after acute ischemic stroke (AIS).

Methods: We examined data on 1,019,267 Medicare fee-for-service (FFS) beneficiaries aged 66 or older, hospitalized with a primary diagnosis of AIS from 2008 through 2012. Survival was defined as the time from the date of AIS to date of death, or an end of follow-up date of December 31, 2017. We used Cox proportional hazard models to estimate 5-year survival after AIS, adjusted for age, sex, race and Hispanic ethnicity, poverty level, Charlson Comorbidity Index, and state.

Results: Among 1,019,267 Medicare FFS beneficiaries hospitalized with AIS from 2008 through 2012, we documented 701,718 deaths (68.8%) during a median of 4 years of follow-up with 4.08 million person-years. The overall adjusted 5-year survival was 44%. Non-Hispanic Black men had the lowest 5-year survival, and 5-year survival varied significantly by state, from the highest at 49.1% (North Dakota) to the lowest at 40.5% (Hawaii). The ranges between the highest and lowest 5-year survival rates across states also varied significantly by racial/ethnic groups, with percentage point differences of 9.6 among non-Hispanic White, 11.3 among non-Hispanic Black, 17.7 among Hispanic, and 28.5 among other racial/ethnic beneficiaries.

Conclusion: We identified significant racial/ethnic and geographic variations in 5-year survival rates after AIS among 2008–2012 Medicare FFS beneficiaries. Further study is needed to understand the reasons for these variations and develop prevention strategies to improve survival and racial disparities in survival after AIS.


Stroke is the fifth leading cause of death in the United States with approximately 795,000 new or recurrent acute strokes occurring every year. The annual direct medical cost for stroke was estimated at $30.8 billion from 2016 through 2017.[1] Although stroke risks and mortality have declined considerably, racial/ethnic and geographic disparities remain significant.[1] Recent studies suggest that the decline in stroke mortality stalled in recent years and that demographic and geographic variations remained substantial.[2,3] However, limited studies examined the long-term survival after stroke and racial/ethnic and geographic variations in stroke survival among older adults (defined as ≥65 y) in the United States.

The aim of our study was to assess long-term (5-year) survival among patients aged 66 or older after acute ischemic stroke (AIS) and to examine racial/ethnic differences and geographic variations in stroke survival. Our findings may provide information to improve survival and reduce survival disparities after stroke among older adults in the United States.