Disparities In Stroke Outcomes Research Articles

Abstract WP253: Prevalence of Undiagnosed and Uncontrolled Hypertension Among Low-Wage Workers in North Carolina With Elevated Stroke Risk

Introduction: Compared to the rest of the United States, North Carolina has an elevated stroke mortality rate. Risk factors, including uncontrolled hypertension (HTN), associated with disparities in stroke outcomes are also prevalent in North Carolina. We sought to determine the prevalence of undiagnosed and uncontrolled HTN among a sample of low-wage workers with elevated stroke risk. Methods: Between February 2021 and June 2023, we partnered with 35 business to provide worksite-based health screenings to rural, low-wage workers. Demographic information and a brief medical history were collected. A physical assessment included automated blood pressure measurement. Risk of stroke was assessed using the CHA 2 DS 2 -VASc. Results: A total of 930 screened individuals (52.5% Black) are included in this report. Among the 488 Black participants screened, 29.1 percent (n=142) had a CHA 2 DS 2 -VASc score ≥2. In comparison, less than 20 percent (n=79, 17.9%) of the 442 White participants had an elevated stroke risk (Figure 1). Of the 221 participants with a CHA 2 DS 2 -VASc score ≥2, stage 1 HTN (systolic blood pressure (SBP) = 130-139) and stage 2 HTN (SBP ≥ 140) was found among 19.5 and 52 percent of participants, respectively. We identified previously undiagnosed HTN among 6.3 percent of Black participants and 15.2 percent of White participants. In addition, over 60 percent of participants (Black = 62.7%, White = 60.8%) had been previously diagnosed with HTN, but screening results indicated their HTN was not well controlled. Conclusions: The prevalence of elevated stroke risk was 11.2 percent greater among Black participants compared to White participants. Using a worksite-based approach to health screening, we found high rates of undiagnosed and uncontrolled HTN among both Black and White participants with elevated stroke risk. This novel approach to care delivery facilitates screening among individuals who may otherwise underutilize or avoid engagement with the healthcare system.

Abstract WMP99: A Novel Network Analysis of County- and Individual-Level Factors Associated With Functional Outcomes After Stroke

Background: Social circumstances may contribute to health disparities in patients with stroke through indirect and interdependent mechanisms that are not well understood. Objective: This study used complexity science methodology to examine the interplay between county- and individual-level social and clinical factors influencing stroke functional outcomes. Methods: As part of the Get With the Guidelines-Stroke (GWTG-S) Data Challenge, the GWTG-S Registry was merged with county-level Institute for Health Metrics and Evaluation data. Patients diagnosed with stroke (ischemic, subarachnoid, or intracerebral hemorrhage) were included. Multilayer networks were constructed by estimating mixed graphical models of 32 nodes across four layers, including social (county- and patient-level) and clinical (comorbidities and encounter) factors. Social determinant networks were estimated for patients with less favorable (ie., functional dependence or death, modified Rankin Score [mRS] 3-6) versus favorable outcomes (ie., functional independence, mRS 0-2). Network structure and node centrality were compared between mRS groups using bootstrap permutation analyses. Hub nodes were defined by betweenness centrality and facilitate effects across the network. Results: From 2013-2019, 990 721 (62.3%) stroke patients had mRS of 3-6 and 597 477 (37.6%) had mRS 0-2 at discharge. Compared to the mRS 0-2 group, the mRS 3-6 group’s social determinants network had greater global connectivity (p<0.001), and homelessness (p<0.001) and Black race (p<0.001) were hub nodes. Unique to the mRS 3-6 group, younger patients were more likely to identify as homeless (p=0.031), uninsured (p=0.001), and live in a county with lower per capita income (p<0.001). Conclusions: The effects of social determinants were significantly greater in patients with less favorable functional outcomes. Homelessness and race play critical roles in mediating the impacts of county- and individual-level social determinants on downstream disparities in stroke outcomes. Particularly among younger patients, housing, insurance status, and income may serve as a critical leverage point for county-level interventions to improve function after stroke.

Achieving Equity in Stroke Care and Outcomes: A Comment on an AHA Scientific Statement.

Racial disparities in stroke outcomes have been described for over a century. Racial and ethnic inequities in care and disparities in outcomes exist across the continuum of stroke care. In this commentary, I discuss several themes that emerged from the recent article, Strategies to Reduce Racial and Ethnic Inequities in Stroke Preparedness, Care, Recovery, and Risk Factor Control: A Scientific Statement From the American Heart Association. This statement provides a comprehensive overview of interventions aimed at reducing racial and ethnic disparities and highlights gaps in knowledge and research priorities.

Was COVID-19 Associated With Worsening Inequities in Stroke Treatment and Outcomes?

Background COVID-19 stressed hospitals and may have disproportionately affected the stroke outcomes and treatment of Black and Hispanic individuals. Methods and Results This retrospective study used 100% Medicare Provider Analysis and Review file data from between 2016 and 2020. We used interrupted time series analyses to examine whether the COVID-19 pandemic exacerbated disparities in stroke outcomes and reperfusion therapy. Among 1 142 560 hospitalizations for acute ischemic strokes, 90 912 (8.0%) were Hispanic individuals; 162 752 (14.2%) were non-Hispanic Black individuals; and 888 896 (77.8%) were non-Hispanic White individuals. The adjusted odds of mortality increased by 51% (adjusted odds ratio [aOR], 1.51 [95% CI, 1.34-1.69]; P<0.001), whereas the rates of nonhome discharges decreased by 11% (aOR, 0.89 [95% CI, 0.82-0.96]; P=0.003) for patients hospitalized during weeks when the hospital's proportion of patients with COVID-19 was >30%. The overall rates of motor deficits (P=0.25) did not increase, and the rates of reperfusion therapy did not decrease as the weekly COVID-19 burden increased. Black patients had lower 30-day mortality (aOR, 0.70 [95% CI, 0.69-0.72]; P<0.001) but higher rates of motor deficits (aOR, 1.14 [95% CI, 1.12-1.16]; P<0.001) than White individuals. Hispanic patients had lower 30-day mortality and similar rates of motor deficits compared with White individuals. There was no differential increase in adverse outcomes or reduction in reperfusion therapy among Black and Hispanic individuals compared with White individuals as the weekly COVID-19 burden increased. Conclusions This national study of Medicare patients found no evidence that the hospital COVID-19 burden exacerbated disparities in treatment and outcomes for Black and Hispanic individuals admitted with an acute ischemic stroke.

Non-English primary language and disparities in stroke outcomes after mechanical thrombectomy: a single institution study

BackgroundDelays in acute treatment of ischemic stroke have been associated with worse outcomes. While having a non-English primary language has not been shown to delay receiving thrombolytic therapy, we assessed whether non-English primary language was associated with worse functional outcomes in patients receiving mechanical thrombectomy (MT).MethodThis is a retrospective study of our MT database from two comprehensive stroke centers from January 2016 to May 2021. Primary endpoint was discharge modified Rankin Scale (mRS) 0-2. Differences between English primary language (EPL) and non-English primary language (nEPL) groups were evaluated using an analysis of variance (ANOVA), Kruskal-Wallis and chi square test. Multivariable logistic regression was used to evaluate EPL vs. nEPL patients using data driven models determined by stepwise selection approach.ResultWe identified 276 patients receiving MT with 83% EPL and 17% nEPL patients. nEPL patients had higher mean hemoglobin A1c, were less likely to have insurance, and more likely to have symptomatic intracranial hemorrhage compared to EPL patients (Table). We observed a longer median ED arrival to groin puncture time in the nEPL group. No differences were observed in discharge or mRS 0-2 in the univariate or multivariable logistic regression.DiscussionDespite finding longer ED length of stay among nEPL patients, there was no difference between nEPL and EPL in good functional outcome rates in patients treated with MT.

Telehealth Trials to Address Health Equity in Stroke Survivors.

Telehealth has seen rapid expansion into chronic care management in the past 3 years because of the COVID-19 pandemic. Telehealth for acute care management has expanded access to equitable stroke care to many patients over the past two decades, but there is limited evidence for its benefit for addressing disparities in the chronic care of patients living with stroke. In this review, we discuss advantages and disadvantages of telehealth use for the outpatient management of stroke survivors. Further, we explore opportunities and potential barriers for telehealth in addressing disparities in stroke outcomes related to various social determinants of health. We discuss two ongoing large randomized trials that are utilizing telehealth and telemonitoring for management of blood pressure in diverse patient populations. Finally, we discuss strategies to address barriers to telehealth use in patients with stroke and in populations with adverse social determinants of health.

Abstract HUP9: Racial Disparities In Acute Ischemic Stroke At A Large Metropolitan Stroke Center

Background: Race and ethnicity can have a major impact on the quality of care patients with acute ischemic stroke (AIS) receive. We sought to assess the impact of race and ethnicity on quality benchmarks of AIS therapy and clinical outcomes at a comprehensive stroke center (CSC). Methods: A retrospective analysis of AIS patients presenting to a CSC between 2015 to 2020 was performed. Data included demographics, NIH Stroke Scale scores, time to thrombolysis, discharge diabetic and hypertensive medications, length of stay (LOS), discharge functional status, 30-day readmission, and 30-day mortality. Quality benchmarks and outcomes were analyzed by the five most prevalent racial-ethnic groups including Non-Hispanic White (NHW), Hispanic, Black, Asian, Other and Unknown. Results: 3,735 AIS patients were identified. NHW represented 53.3% (n=1992),Black 21.3% (n=797), Hispanic 10.4% (n=390), Asian 7.2% (n=267), Other 4.6% (n=170) and Unknown 3.2% (n=119). There were no significant differences in door to needle (P=0.93), door to puncture time (P=0.98), intravenous thrombolysis (P=0.32) and mechanical thrombectomy utilization (P=0.19) by race-ethnicity. In univariable analysis, there was a higher rate of 30-day mortality in Unknown 23.5% vs NHW 7.3% (P&lt; 0.0001). A significantly (P&gt;0.05) higher rate of 30-day readmission was noted in NHW 20.3% vs Black 15.7%, Hispanics 15.6%, Others 11.8% and Unknown 8.4%. Black 67.6%, Hispanic 64.9% and Unknown 80.5% had a significantly (P&lt;0.05) higher rate of post stroke disability (mrs&gt;2) vs NHW 60.3%. A significant difference (P&lt;0.05) in LOS with Black patients staying 8.4, Hispanic 10.8, Asians 11.9 and Unknown 11.2 days vs NHW 7.7.Adjusting for age, sex, NIHSS and comorbidities, multivariable logistic regression continued to show differences in post stroke disability for Black (OR=1.40, P=0.003), Hispanic (OR=1.49, P=0.008) and Unknown (OR=2.03, P=0.016) vs NHW. Median LOS was 0.85 and 0.77 days longer for Asian and Hispanic (P=0.006, P=0.014) respectively vs NHW. Conclusions: Our analysis reveals persistent disparities in stroke outcomes, with Black and Hispanic patients suffering greater disability post stroke. Further investigation is needed to uncover how race-ethnicity mediates stroke care and outcomes.

Poststroke Disability: Association Between Sex and Patient-Reported Outcomes.

Ischemic stroke (IS) is a leading cause of long-term disability with sex-specific differences in outcomes. Identifying the influential factors that contribute to sex-specific disparities in stroke outcomes, therefore, holds potential to develop individualized interventions for reducing long-term disability. Further, investigating the association between sex and Patient-Reported Outcome Measures (PROMs) provides additional information on the individual impact and heterogeneity of IS. We aimed to identify sex-specific differences in stroke outcomes and relationship with PROMs in IS patients with 3-month follow-up. Between February 2017 and February 2020, a total of 410 patients admitted with IS to the Massachusetts General Hospital, in Boston, were enrolled in this prospective cohort. At 3-month poststroke, patients were assessed for Barthel Index, modified Rankin Scale, and PROM-10 questionnaires. T scores for physical and mental health were determined from the summing of PROM-10 responses in each domain. Regression analysis was performed to identify sex-specific determinants of functional and patient-reported outcomes. At baseline, 242 participants were male (mean age, 65 years) and 168 were female (mean age, 70 years). Groups had similar rates of cardiovascular risk factors, admission National Institutes of Health Stroke Scale, and discharge modified Rankin Scale. At follow-up, male participants were more likely to have better rates of T Physical and Barthel Index. In regression analysis, PROMs T Physical (odds ratio, 1.06; P=0.01), Barthel Index (odds ratio, 1.06; P=0.01), and modified Rankin Scale score of ≥2 (odds ratio, 2.60; P=0.01) were associated with female sex. Female sex was also associated with lower scores for PROMs Physical subcomponents and with patient-reported general health and emotional problems. Women have worse outcomes after ischemic stroke, including objective measures of functional disability and patient-reported outcomes. Incorporating PROMs into IS outcome measures may offer additional insight into sex-specific differences in stroke recovery and outcomes.

Stroke in women between 2006 and 2018: Demographic, socioeconomic, and age disparities.

Black Americans have a higher prevalence of stroke and stroke-related deaths than any other racial group. Racial disparities in stroke outcomes are even wider among women than men. Conventional studies have cited differences in lifestyle (i.e. smoking, alcohol consumption, etc.) and vascular risk factors between races as the source of these disparities. However, these studies fail to account for the higher prevalence of minoritized populations at the lower end of the socioeconomic distribution. This study explores differences in stroke risk factors across age and socioeconomic cohorts to determine whether comorbidities can sufficiently explain disparities at all ages and income levels. Using the 2006-2018 National Health Interview Survey data, statistical analysis evaluated differences in risk factors among a full sample cohort (aged 18-85 years; n = 131,091) and a "young" subsample cohort (aged 18-59 years; n = 6183) of women. Logistics and unconditional quantile regression models assessed the relationship between stroke and comorbid, demographic, and behavioral characteristics across socioeconomic classes. Results suggest that Black women had a 1.415-fold (confidence interval = 1.259, 1.591) higher likelihood of stroke compared with White women after controlling for age, behavior, and comorbidities. Racial disparities were not statistically significant at the higher income ranges for either the full (odds ratio = 1.404, p = 0.3114) or young samples (odds ratio = 1.576, p = 0.7718). However, Blacks had significantly higher odds of stroke in the lower quartiles (lower odds ratio: 1.329, p = 0.0242; lower middle odds ratio: 1.233, p = 0.0486; and upper middle odds ratio: 1.994, p = 0.0005). Disparities were larger among young women (odds ratio = 1.449, confidence interval = 1.211, 1.734). While comorbidities were highly associated with stroke prevalence in all socioeconomic cohorts, Blacks only had higher relative odds in the lower income classes. Lack of biological or behavioral explanations for these findings suggests that unobserved or uncontrolled factors such as systemic racism, prejudicial institutions, or differential treatment may contribute to this.

Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States

Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant. To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities. This study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022. Hospitals' likelihood of adopting stroke care certification. A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51). In this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.

Racial and Ethnic Differences in Short- and Long-term Mortality by Stroke Type.

Racial and ethnic disparities in stroke outcomes exist, but differences by stroke type are less understood. We studied the association of race and ethnicity with stroke mortality, by stroke type, in a national sample of hospitalized patients in the Veterans Health Administration. A retrospective observational study was performed including non-Hispanic White, non-Hispanic Black, and Hispanic patients with a first hospitalization for stroke between 2002 and 2012. Stroke was determined using ICD-9 codes and date of death was obtained from the National Death Index. For each of acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), we constructed a piecewise multivariable model for all-cause mortality, using follow-up intervals of ≤30 days, 31-90 days, 91 days to 1 year, and >1 year. Among 37,790 patients with stroke (89% AIS, 9% ICH, 2% SAH), 25,492 (67%) were non-Hispanic White, 9,752 (26%) were non-Hispanic Black, and 2,546 (7%) were Hispanic. The cohort was predominantly male (98%). Compared with White patients, Black patients experienced better 30-day survival after AIS (hazard ratio [HR] 0.80, 95% CI 0.73-0.88; 1.4% risk difference) and worse 30-day survival after ICH (HR 1.24, 95% CI 1.06-1.44; 3.2% risk difference). Hispanic patients experienced reduced risk for >1-year mortality after AIS (HR 0.87, 95% CI 0.80-0.94), but had greater risk of 30-day mortality after SAH compared with White patients (HR 1.61, 95% CI 1.03-2.52; 10.3% risk difference). Among US Veterans, absolute risk of 30-day mortality after ICH was 3.2% higher for Black patients and after SAH was 10.3% higher for Hispanic patients compared with White patients. These findings underscore the importance of investigating stroke outcomes by stroke type to better understand the factors driving observed racial and ethnic disparities.

Abstract 10122: 'Young' Stroke Related Mortality in the United States: A 'Wake-Up' Call

Introduction: Important disparities in stroke outcomes persist based on sex, race, and ethnicity. The aim of this study was to examine trends in stroke (ischemic and hemorrhagic) related deaths among young adults in the United States from 1999 to 2019 by sex and race/ethnicity. Methods: We used CDC Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) to access National Vital Statistics System data from 1999 to 2019. Stroke related deaths among individuals age 15- 44 years were identified from multiple causes of death and were represented as age-adjusted mortality rates (AAMR) per 100,000 population. Joinpoint regression was used to examine changes in trend and annual percentage change (APC) overall and stratified by sex and race/ethnicity. Results: AAMR was higher in men (3.3) than women (2.8). AAMR was highest in non-Hispanic Black (NHB) (6.6) followed by non-Hispanic American Indian or Alaska Native (NH-AIAN) (4.36), Hispanic (2.65), non-Hispanic White (NHW) (2.45) and lastly non-Hispanic Asian or Pacific Islander (NH-API) (2.24) ethnic groups. AAMR was highest in NHB males (7.07). AAMR related to stroke decreased from 3.7 in 1999 to 2.69 in 2011 and then increased to 2.87 in 2019 (APC 1.0[95% CI, 0.4 to 1.5]). After initial decline, AAMR increased in men (APC 1.2) since 2011, and women (APC 1.8) since 2013 (Figure, Panel A). AAMR increased among NHW (APC 2.4) persons since 2013 and Hispanic (APC 1.5) persons since 2011 (Figure, Panel B). AAMR decreased in NHB (APC -3.9) persons from 1999-2012, and remained stable thereafter. AAMR decreased in NH-API (APC -0.9) persons and did not change significantly in NH-AIAN persons during the entire study period. Conclusion: After initial decline, stroke-related mortality among young adults has increased over the past decade. Stratification by sex and racial/ethnic status reveals significant disparities. Further research is needed to understand and mitigate the factors driving these trends.

Racial Disparities in Stroke Readmissions Reduced in Hospitals With Better Nurse Staffing.

Racial minorities are disproportionately affected by stroke, with Black patients experiencing worse poststroke outcomes than White patients. A modifiable aspect of acute stroke care delivery not yet examined is whether disparities in stroke outcomes are related to hospital nurse staffing levels. The aim of this study was to determine whether 7- and 30-day readmission disparities between Black and White patients were associated with nurse staffing levels. We conducted a secondary analysis of 542 hospitals in four states. Risk-adjusted, logistic regression models were used to determine the association of nurse staffing with 7- and 30-day all-cause readmissions for Black and White ischemic stroke patients. Our sample included 98,150 ischemic stroke patients (87% White, 13% Black). Thirty-day readmission rates were 10.4% (12.7% for Black patients, 10.0% for White patients). In models accounting for hospital and patient characteristics, the odds of 30-day readmissions were higher for Black than White patients. A significant interaction was found between race and nurse staffing, with Black patients experiencing higher odds of 30- and 7-day readmissions for each additional patient cared for by a nurse. In the best-staffed hospitals (less than three patients per nurse), Black and White stroke patients' disparities were no longer significant. Disparities in readmissions between Black and White stroke patients may be linked to the level of nurse staffing in the hospitals where they receive care. Tailoring nurse staffing levels to meet the needs of Black ischemic stroke patients represents a promising intervention to address systemic inequities linked to readmission disparities among minority stroke patients.

Multiple Chronic Conditions Explain Ethnic Differences in Functional Outcome Among Patients With Ischemic Stroke.

Mexican Americans (MAs) have worse stroke outcomes and a different profile of multiple chronic conditions (MCC) compared with non-Hispanic White people. MCC has implications for stroke treatment, complications, and poststroke care, which impact poststroke functional outcome (FO). We sought to assess the contribution of MCC to the ethnic difference in FO at 90 days between MAs and non-Hispanic White people. In a prospective cohort of ischemic stroke patients (2008-2016) from Nueces County, Texas, data were collected from patient interviews, medical records, and hospital discharge data. MCC was assessed using a stroke-specific and function-relevant index (range, 0-35; higher scores greater MCC burden). Poststroke FO was measured by an average score of 22 activities of daily living (ADLs) and instrumental ADLs at 90 days (range, 1-4; higher scores worse FO). The contribution of MCC to the ethnic difference in FO was assessed using Tobit regression. Effect modification by ethnicity was examined. Among the 896 patients, 70% were MA and 51% were women. Mean age was 68±12.2 years; 33% of patients were dependent in ADL/instrumental ADLs (FO score >3, representing a lot of difficulty with ADL/instrumental ADLs) at 90 days. MAs had significantly higher age-adjusted MCC burden compared with non-Hispanic White people. Patients with high MCC score (at the 75th percentile) on average scored 0.70 points higher in the FO score (indicating worse FO) compared with those with low MCC score (at the 25th percentile) after adjusting for age, initial National Institutes of Health Stroke Scale, and sociodemographic factors. MCC explained 19% of the ethnic difference in FO, while effect modification by ethnicity was not statistically significant. MAs had a higher age-adjusted MCC burden, which partially explained the ethnic difference in FO. The prevention and treatment of MCC could potentially mitigate poststroke functional impairment and lessen ethnic disparities in stroke outcomes.

Program to Avoid Cerebrovascular Events through Systematic Electronic Tracking and Tailoring of an Eminent Risk factor: Protocol of a RCT

BackgroundGeographical and racial disparities in stroke outcomes are especially prominent in the Southeastern United States, which represents a region more heavily burdened with stroke compared to the rest of the country. While stroke is eminently preventable, particularly via blood pressure control, fewer than one third of patients with a stroke have their blood pressure controlled ≥ 75% of the time, and low consistency of blood pressure control is linked to higher stroke risk. ObjectiveTo demonstrate that a mHealth technology-centered, integrated approach can effectively improve sustained blood pressure control among stroke patients (half of whom will be Black). DesignThe Program to Avoid Cerebrovascular Events through Systematic Electronic Tracking and Tailoring of an Eminent Risk-factor is a prospective randomized controlled trial, which will include a cohort of 200 patients with a stroke, encountered at two major safety net health care systems in South Carolina. The intervention comprises utilization of a Vaica electronic pill tray & blue-toothed UA-767Plus BT blood pressure device and a dedicated app installed on patients’ smart phones for automatic relay of data to a central server. Providers will follow care protocols based on expert consensus practice guidelines to address optimal blood pressure management. Study outcomesPrimary outcome is systolic blood pressure at 12-months, which is the major modifiable step to stroke event rate reduction. Secondary endpoints include control of other stroke risk factors, medication adherence, functional status, and quality of life. DiscussionWe anticipate that a successful intervention will serve as a scalable model of effective chronic blood pressure management after stroke, to bridge racial and geographic disparities in stroke outcomes in the United States. Trial registrationClinicalTrials.gov - NCT03401489

Evidence-based stroke rehabilitation: do priorities for practice change and feasibility of implementation vary across high income, upper and lower-middle income countries?

Purpose The context of implementation plays an important role in the delivery of optimal treatments in stroke recovery and rehabilitation. Considering that stroke systems of care vary widely across the globe, the goal of the present paper is to compare healthcare providers’ priority of key areas in translating stroke research to clinical practice among High Income Countries, Upper Middle- and Lower Middle-Income Countries (HICs, UMICs, LMICs). We also aimed to compare perceptions regarding the key areas’ feasibility of implementation, and formulate recommendations specific to each socioeconomic region. Methods Data related to recommendations for knowledge translation in stroke, from a primary survey from the second Stroke Recovery and Rehabilitation Roundtable were segregated based on socioeconomic region. Frequency distribution was used to compare the key areas for practice change and examine the perceived feasibility of implementation of the same across HIC, UMIC and LMICs. Results A total of 632 responses from healthcare providers across 28 countries were received. Interdisciplinary care and access to services were high priorities across the three groups. Transitions in Care and Intensity of Practice were high priority areas in HICs, whereas Clinical Practice Guidelines were a high priority in LMICs. Interventions specific to clinical discipline, screening and assessment were among the most feasible areas in HICs, whereas Intensity of practice and Clinical Practice Guidelines were perceived as most feasible to implement in LMICs. Conclusion We have identified healthcare providers’ priorities for addressing international practice change across socioeconomic regions. By focusing on the most feasible key areas, we can aid the channeling of appropriate resources to bridge the disparities in stroke outcomes across HICs, UMICs and LMICs. IMPLICATIONS FOR REHABILITATION It is pertinent to examine the differences in priorities of stroke rehabilitation professionals and the feasibility of implementing evidence-based practice across socioeconomic regions. There is an urgent necessity for the development of clinical practice guidelines for stroke rehabilitation in Low-Middle Income Countries, taking into consideration the cultural, economic and geographical constraints. In upper-middle income countries, encouraging family support and timely screening and assessment for aphasia, cognition and depression appear to be the low hanging fruits to enhance quality of life after stroke. Innovative ways to increase intensity of practice and channelling of resources to improve transitions in care may prove to be the most beneficial in advancing stroke rehabilitation in high income countries.

00001 Demographic disparities in proximity to stroke care in the United States

ABSTRACT IMPACT: Given the association between lower time to treatment and better clinical outcomes in stroke patients, identifying factors correlated with reduced proximity and thus greater time to stroke care can aid efforts to reduce disparities in stroke outcomes. OBJECTIVES/GOALS: The objective of this study is to quantify the relationship between distance to the nearest certified stroke hospital and census-derived demographics of age, race/ethnicity, income, and insurance status. METHODS/STUDY POPULATION: This is a cross-sectional study. Population data for all census tracts in the contiguous United States were obtained from the US Census Bureau’s 2014-2018 American Community Survey. Stroke hospitals were identified from national or state level certification databases and were required to offer at least IV tPA. The main outcome is driving distance in kilometers from each census tract to the nearest certified stroke center, which was calculated using OSMnx, a Python package to retrieve, model and analyze real-world street networks. Quantile regression analysis was used to compare relationships between distances and tract-level demographics of age, race/ethnicity, income, and insurance status. RESULTS/ANTICIPATED RESULTS: 2,423 stroke centers and 71,929 census tracts containing 316,995,649 individuals were included. 49,918 (69%) tracts were urban. Demographic disparities in proximity to certified stroke care were greater in non-urban areas than in urban areas. Higher representation of individuals with age ≤65 years were associated with increased median distance to a certified stroke center in non-urban areas, but not urban areas. Median distance was greater with greater representation of American Indian or uninsured populations in urban and non-urban census tracts. Higher median income was associated with decreased median distance in non-urban census tracts and greater median distance in urban census tracts. DISCUSSION/SIGNIFICANCE OF FINDINGS: Reduced proximity to stroke care exists in areas with greater representation of elderly, American Indian, or uninsured persons; and low median income. These disparities are magnified in non-urban settings. Such knowledge can aid efforts to address and reduce disparities in stroke outcomes.

Considerations in Addressing Social Determinants of Health to Reduce Racial/Ethnic Disparities in Stroke Outcomes in the United States.

We write this article amid a global pandemic and a heightened awareness of the underlying structural racism in the United States, unmasked by the recent killing of George Floyd and multiple other unarmed Black Americans (Spring 2020). Our purpose is to highlight the role of social determinants of health (SDOH) on stroke disparities, to inspire dialogue, to encourage research to deepen our understanding of the mechanism by which SDOH impact stroke outcomes, and to develop strategies to address SDOH and reduce stroke racial/ethnic disparities. We begin by defining SDOH and health disparities in today's context; we then move to discussing SDOH and stroke, particularly secondary stroke prevention, and conclude with possible approaches to addressing SDOH and reducing stroke disparities. These approaches include (1) building on prior work; (2) enhancing our understanding of populations and subpopulations, including intersectionality, of people who experience stroke disparities; (3) prioritizing populations and points along the stroke care continuum when racial/ethnic disparities are most prominent; (4) understanding how SDOH impact stroke disparities in order to test SDOH interventions that contribute to the disparity; (5) partnering with communities; and (6) exploring technological innovations. By building on the prior work and expanding efforts to address SDOH, we believe that stroke disparities can be reduced.

Author response: Racial/ethnic disparities in the risk of intracerebral hemorrhage recurrence.

We thank Dr. Hinson for the interest in our article1 and agree that the mechanisms underlying the associations of race and insurance payer with risk of intracerebral hemorrhage recurrence are complex and likely involve social, economic, and structural factors. An inherent limitation of using administrative data sets for purposes other than they were intended is a lack of data on all variables of interest. Although we were not able to test whether medication adherence is a mediator of the observed associations, we agree that it is likely an important factor, regardless of the insurance payer. Previous studies have demonstrated that racial and ethnic differences in antihypertensive medication adherence are modified by insurance status and age, with the largest racial differences in adherence seen among uninsured and young patients.2 As Dr. Hinson acknowledges, well-designed interventions at multiple levels of influence are needed to address barriers to medication adherence and improve racial and ethnic disparities in stroke outcomes.

Abstract TP455: Race-Ethnic Disparities in Subarachnoid Hemorrhage Outcomes

Introduction: Identification of race/ethnic disparities in stroke outcomes is essential in achieving equity of patient care across demographic subgroups. We sought to identify disparities by race/ethnicity in patient outcomes following subarachnoid hemorrhage (SAH). Methods: Records obtained from the Florida Stroke Registry (FSR), a multi-hospital Get With the Guidelines (GWTG)-Stroke data collaborative, were used to compare descriptive statistics and outcomes by race/ethnicity. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics by race/ethnicity. Outcomes included in-hospital mortality, discharge location, ambulation at discharge, modified Rankin Scale (mRS) score at discharge, and receiving comfort measures only. Logistic regression models with generalized estimating equations accounted for age, insurance, smoking, hypertension, diabetes, dyslipidemia, atrial fibrillation/flutter, coronary artery disease, peripheral vascular disease, prior stroke/TIA, carotid stenosis, prior anticoagulation or antiplatelet use, prior ambulatory status, arrival mode, admission NIHSS, Florida region, number of beds, years in GWTG, and teaching hospital status. Results: The sample consisted of 10, 559 records with SAH discharged between 2010-2018; 63% were non-Hispanic White (NHW), 19.4% non-Hispanic Black (NHB), and 17.6% Hispanic. NHB were younger at onset (median age=54, IQR=45-65; NHW: 62, 53-73; Hispanic: 58, 48-71; p &lt; 0.0001) and had the highest rate of hypertension (62%; NHW: 50%, Hispanic: 51%; p &lt; 0.001), while NHW had the highest rate of smoking (24%; NHB: 20%; Hispanic: 17%; p &lt; 0.0001). NHB had lower odds of in-hospital mortality compared to NHW (adjusted OR 0.8, 95% CI 0.68-0.94), but were less likely to have been discharged home/rehab (0.83, 0.73-0.94), to ambulate independently at discharge (0.71, 0.60-0.84), and to have a discharge mRS score of 0-2 (0.67, 0.49-0.92). Conclusions: While NHB have lowered odds of dying in-hospital from SAH, survivors have worse functional outcomes. These race/ethnic disparities highlight the need for further research into the causes of these differences and to refine approaches to improve acute care of SAH.