Socioeconomic Disparities in the Utilization of Mechanical Thrombectomy for Acute Ischemic Stroke in US Hospitals

W Brinjikji,H.J Cloft,J.S Mcdonald,A.A Rabinstein

doi:10.3174/ajnr.a3708

Abstract

Previous studies have demonstrated that socioeconomic disparities in the treatment of cerebrovascular diseases exist. We studied a large administrative data base to study disparities in the utilization of mechanical thrombectomy for acute ischemic stroke. With the utilization of the Perspective data base, we studied disparities in mechanical thrombectomy utilization between patient race and insurance status in 1) all patients presenting with acute ischemic stroke and 2) patients presenting with acute ischemic stroke at centers that performed mechanical thrombectomy. We examined utilization rates of mechanical thrombectomy by race/ethnicity (white, black, and Hispanic) and insurance status (Medicare, Medicaid, self-pay, and private). Multivariate logistic regression analysis adjusting for potential confounding variables was performed to study the association between race/insurance status and mechanical thrombectomy utilization. The overall mechanical thrombectomy utilization rate was 0.15% (371/249,336); utilization rate at centers that performed mechanical thrombectomy was 1.0% (371/35,376). In the sample of all patients with acute ischemic stroke, multivariate logistic regression analysis demonstrated that uninsured patients had significantly lower odds of mechanical thrombectomy utilization compared with privately insured patients (OR = 0.52, 95% CI = 0.25-0.95, P = .03), as did Medicare patients (OR = 0.53, 95% CI = 0.41-0.70, P < .0001). Blacks had significantly lower odds of mechanical thrombectomy utilization compared with whites (OR = 0.35, 95% CI = 0.23-0.51, P < .0001). When considering only patients treated at centers performing mechanical thrombectomy, multivariate logistic regression analysis demonstrated that insurance was not associated with significant disparities in mechanical thrombectomy utilization; however, black patients had significantly lower odds of mechanical thrombectomy utilization compared with whites (OR = 0.41, 95% CI = 0.27-0.60, P < .0001). Significant socioeconomic disparities exist in the utilization of mechanical thrombectomy in the United States.

Highlights

BACKGROUND AND PURPOSEPrevious studies have demonstrated that socioeconomic disparities in the treatment of cerebrovascular diseases exist
In the sample of all patients with acute ischemic stroke, multivariate logistic regression analysis demonstrated that uninsured patients had significantly lower odds of mechanical thrombectomy utilization compared with privately insured patients (OR ϭ 0.52, 95% CI ϭ 0.25– 0.95, P ϭ .03), as did Medicare patients (OR ϭ 0.53, 95% CI ϭ 0.41– 0.70, P Ͻ .0001)
Blacks had significantly lower odds of mechanical thrombectomy utilization compared with whites (OR ϭ 0.35, 95% CI ϭ 0.23– 0.51, P Ͻ .0001)

Summary

Methods

With the utilization of the Perspective data base, we studied disparities in mechanical thrombectomy utilization between patient race and insurance status in 1) all patients presenting with acute ischemic stroke and 2) patients presenting with acute ischemic stroke at centers that performed mechanical thrombectomy. We examined utilization rates of mechanical thrombectomy by race/ethnicity (white, black, and Hispanic) and insurance status (Medicare, Medicaid, self-pay, and private). Multivariate logistic regression analysis adjusting for potential confounding variables was performed to study the association between race/insurance status and mechanical thrombectomy utilization. Patients were only included if the stroke code was listed as the primary hospitalization diagnosis to avoid including patients with a history of stroke. Patients were stratified into 4 groups on the basis of insurance status: 1) uninsured, 2) Medicaid, 3) Medicare, and 4) private insurance, and 3 groups on the basis of race: 1) white, 2) black, and 3) Hispanic. Patients who received mechanical thrombectomy were identified by utilization of ICD-9 procedural code 39.74.

Results

Discussion

Conclusion