Many published studies have demonstrated racial disparities in the incidence, treatment and outcomes of patients with relation to acute ischemic stroke (AIS). Despite improvements in diagnosis and treatment, African Americans, Hispanics, Asians and Native Americans continue to have poorer outcomes as compared to white patients. The quality of stroke care for minorities is impacted by many factors that lead to racial disparities.
One of the most notable factors is access to quality health care, which is driven by patient-, provider- and system-level factors. A recent paper by Hammond et al. studied racial inequities in rural and urban settings from 2012 and 2017 and noted that intravenous thrombolysis (IVT) and endovascular therapy (EVT) were used less frequently in African American patients than for white patients, and less often for rural patients as opposed to urban patients. African American patients living in rural areas were the least likely to receive IVT and/or EVT.
A systematic literature review of studies of racial disparities in stroke metrics and outcomes in the United States identified potential barriers to minority access to stroke care. A primary obstacle identified was the time it takes for minority stroke patients to receive treatment.
Stroke deserts
During my time practicing in Arkansas, a largely rural state, one of the major obstacles to providing timely stroke care was the time it took for patients to receive treatment after AIS was diagnosed. Despite a statewide telemedicine network supporting rural hospitals and emergency rooms by providing 24/7 stroke neurology expertise, there was limited access to centers that could provide IVT/EVT. The time required for patients to be transferred to one of these centers was a significant limiting factor in patient outcomes.
Outside of the two urban areas in the state with Comprehensive Stroke Centers, there were a handful of hospitals where IRs provided EVT, but there remained geographical regions in the state devoid of expertise needed to provide endovascular treatment. Even more concerning was that patients near to comprehensive stroke centers across state lines could not take advantage of these centers due to restrictions on interstate transport significantly delaying patient care.
Understanding stroke
Despite improved access to hospitals that can provide IVT/EVT in urban areas, there remain barriers to treatment such as health literacy. As opposed to trauma and myocardial infarction (MI), AIS is painless, and patients may ignore the signs of stroke and transient ischemic attack (TIA). I recall a patient who had lost vision in one eye due to a childhood accident. I had treated her postradiation therapy vasculopathy of the contralateral carotid artery several years previously. During a routine follow-up clinic visit, I asked about her vision. She told me she had been having episodes for 2 months, during which she lost vision in her remaining eye while driving. She would pull over until it got better and then resume driving. We admitted her directly from clinic and ended up stenting a new, pre-occlusive stenosis that had developed. This could have had a very different outcome.
There have been projects aimed at improving stroke literacy that have demonstrated sustained benefits. However, few interventions are designed to increase stroke awareness knowledge within non-English speaking populations.
Notwithstanding public education campaigns for AIS, EMS continues to be underutilized, with approximately 50% of patients with AIS arriving at emergency rooms via personally owned vehicles, with a greater occurrence amongst minority patients. Reasons include lack of insurance, availability of EMS resources, and awareness of TIA and AIS symptoms. Sadly, this trend is also noted in patients with acute MI.
Future solutions
There is no one solution for these various challenges. Patient and provider education will continue to play an important role in both diagnosis and treatment of AIS. As a result of the COVID pandemic, patients and physicians became more familiar with telemedicine. And while there are limitations, telemedicine has the potential to provide patients suffering from AIS more timely access to medical care.
Additional opportunities to improve access exist. Why is patient access to stroke treatment restricted by state lines? Why are patients suffering from AIS not taken directly to hospitals capable of providing the highest level of care? A parallel can be drawn to trauma networks in which patients are transferred to the nearest trauma center, even if across state lines. Changes in health policy that target access to AIS care are needed.
References
- Ikeme S, Kottenmeier E, Uzochukwu G, Brinjikji W. Evidence-Based disparities in stroke care metrics and outcomes in the United States: A systemic review. Stroke. 2022;53:6 70–679.
- Hammond G, Waken RJ, Johnson DY, Towfighi A, Joynt Maddox KEJ. Racial inequities across rural strata in acute stroke care and in-hospital mortality: National trends over 6 years. Stroke. 2022;53:1711–1719.
- Gardner H, Sacco RL, Rundek T, Battistella V, Cheung YK, Elkind MSV. Race and ethnic disparities in stroke incidence in the Northern Manhattan Study. Stroke. 2020;51:1064–1069.
