Disparities in Acute Stroke Care: Role of Race and Insurance Status

Abstract

Background: Minorities constitute groups with higher risk of stroke and stroke severity. Disparities in stroke care may result from greater prevalence of risk factors, barriers to medical care, and lower utilization of preventive therapies. Insurance status may be one limiting factor in access to care and preventive measures.
 Purpose: We hypothesize that vascular risk factors differ between racial groups and that insurance status may affect stroke treatment, secondary prevention measures, stroke severity, and outcomes.
 Methods: We included 1061 consecutive patients with ischemic stroke (2005-2008) in our local Get-With-The-Guidelines (GWTG) database. Multivariate logistic regression analysis was used to evaluate the relation of race and insurance status to risk factors, intravenous thrombolytic therapy (IV-tPA) use, stroke severity (National Institute of Health Stroke Scale [NIHSS]), hospital complications, and ambulatory status at discharge.
 Results: Whites were older than Non-Whites (mean age 65 vs 62 years, p<0.001), and had higher prevalence of atrial fibrillation, coronary artery disease, and carotid stenosis (p<0.01). Non-whites were more likely to have hypertension and diabetes (p<0.01), peripheral arterial disease (p<0.05), and be uninsured (p<0.001). More IV-tPA was used in insured patients (24 vs 2). Blacks and other groups were more likely to be discharged on antihypertensive treatment (OR 1.9, 95% CI 1.0-3.6, and OR 3.8, 95% CI 1.1-13.4 respectively, p=0.04). Blacks were more likely to be discharged on lipid lowering treatment than Whites (OR 3.5, 95% CI 1.4-8.6, p=0.02). There were no significant differences on hospital complications, ambulatory status on discharge or discharge location.
 Conclusion: Data at this safety-net hospital suggests racial disparities in stroke risk factors and insurance status, both of which are potential targets for prevention of stroke. Follow up studies are required to clarify the role of universal insurance coverage in reduction of stroke risk and its complications.