Racial Disparities in Endovascular Therapy for Stroke Persist 

Erik Greb

May 14, 2021

Although the use of endovascular therapy (EVT) for ischemic stroke has increased in recent years, patients who belong to ethnic minorities are less likely to receive it than White patients, research suggests.

And while short-term outcomes of EVT were more favorable among minorities than among White patients, the investigators found that White patients were more likely to achieve functional independence at 3 months than minority patients.

"There need to be concerted efforts to convert these observations of race and ethnic disparities into actions," Faheem G. Sheriff, MD, assistant professor of neurology at Texas Tech University Health Sciences Center El Paso, said during his presentation. "I think such a lifesaving therapy needs to be more uniformly distributed and more uniformly available to ensure that the benefits are available to all groups and that the population has equal benefits."

The findings were presented at the International Stroke Conference (ISC) 2021.

After the publication in 2015 of trials such as MR CLEAN, ESCAPE, and EXTEND-IA showing the benefits of EVT, the therapy gained wider use for the treatment of acute ischemic stroke. The American Heart Association (AHA) updated its stroke treatment guidelines in 2018 to recommend this approach for certain patients in whom it would enable improved function. Data have suggested, however, that patients of certain ethnic or racial groups are less likely to receive EVT than others.

The researchers hypothesized that the increasing use of EVT since 2015 had narrowed racial disparities in treatment. To test their hypothesis, they examined data from the AHA's Get with the Guidelines–Stroke database. Eligible patients presented with acute ischemic stroke between April 2012 and June 2019, arrived at the hospital at fewer than 6 hours after stroke onset, and had a National Institutes of Health Stroke Scale score greater than 6.

The researchers evaluated associations between race and ethnicity, EVT administration, discharge disposition, 90-day modified Rankin Scale (mRS) score, and compared patient outcomes before and after 2015.

Divergent Outcomes

The investigators identified 302,965 potentially eligible patients during the study period. Of this population, 42,422 (14%) underwent EVT. EVT use increased over time in all racial and ethnic groups.

However, the likelihood of undergoing EVT was significantly lower for Black patients, compared with non-Hispanic White patients (adjusted odds ratio [aOR] before 2015 = 0.68; aOR after 2015 = 0.83; P = .02).

Still, the rate of in-hospital mortality or discharge to hospice was lower in Black (aOR = 0.61, P < .0001), Hispanic (aOR = 0.77, P < .0001), and Asian (aOR = 0.78, P = .0006) patients, compared with non-Hispanic White patients.

Discharge home was also more frequent in Hispanic (aOR = 1.28, P < .0001), Asian (aOR = 1.23, P = .001), and Black (aOR = 1.08, P = .05) patients, compared with non-Hispanic White individuals.

Although short-term outcomes were better among racial and ethnic minorities, long-term outcome was better among White patients. The likelihood of functional independence, defined as an mRS of 0-2 at 3 months was lower in Black (aOR = 0.84, P = .006) and Asian (aOR = 0.7, P = .03) patients, compared with non-Hispanic White patients.

As part of their analysis, the investigators examined data on participants' insurance status and on sociodemographic factors such as zip code. "Despite correcting for all of these other markers of socioeconomic status and, most importantly, insurance status, the differences persisted," Sheriff told Medscape Medical News.

The researchers have not yet examined differences in treatment and outcomes within ethnic groups. But a previous study by the US Department of Veterans Affairs provides insight into this question.

"Regardless of socioeconomic status, particularly poor Black patients seem to have a worse impact post-stroke, in terms of admission to inpatient rehab and outcomes after discharge from inpatient rehab," said Sheriff. The initiation of inpatient rehab is delayed among Black patients compared with White patients. And among all patients who were admitted to rehab more than 3 days later, Black patients had much worse outcomes than their White counterparts, Sheriff added.

"We have to capitalize on the gains and continue to address the disparities," said Sheriff.

Risk Factors Differ

Dr Chia-Chun Chiang

A 2011 scientific statement by the AHA and American Stroke Association reviewed factors that may contribute to racial and ethnic disparities in stroke. "The burden of vascular risk factors, such as hypertension, diabetes, and metabolic syndrome, are higher in African Americans and Hispanics," Chia-Chun Chiang, MD, senior associate consultant and assistant professor of neurology at Mayo Clinic in Rochester, Minnesota, told Medscape Medical News.

The incidence and prevalence of stroke are higher among African Americans, Hispanics, and American Indians or Alaskan Natives than among Whites, especially at a younger age, she added. Racial and ethnic minorities also have higher rates of stroke mortality in the United States.

"Furthermore, lack of awareness of stroke symptoms and signs, unwillingness to seek medical care due to distrust, patient compliance, and limited access to acute, preventive, and rehabilitation care could all play a role in the racial and ethnic disparities in stroke care," said Chiang.

One potential concern about the current study is whether the numbers of Black, Asian, and Hispanic patients were large enough for analysis of further questions, she added.

Among the questions that this study raises is whether the time from symptom onset to arrival in the emergency department (ED) is longer for minorities. Such a discrepancy could be improved by promoting stroke awareness and patient education, said Chiang.

Another question is whether minorities face a longer ED wait time, lower stroke code activation rate, or longer door-to-needle time. If they did, it would reflect bias in the healthcare system that needs to be addressed, said Chiang.

Other questions for future research are whether access to rehabilitation and post-stroke follow up care is different in minorities and whether medication compliance is different in minorities.

"We need better understanding of the biologic and genetic differences between different races to better achieve personalized medicine in stroke care," Chiang concluded.

The study was funded by the Get with the Guidelines–Stroke initiative of the American Heart Association/American Stroke Association. Sheriff and Chiang have disclosed no relevant financial relationships.  

International Stroke Conference (ISC) 2021. Late-breaking abstract 9. Presented March 19, 2021.

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