Disparities In Stroke Research Articles

Abstract WP247: Racial Disparities in Stroke Risk Among Older Adults in the Southern Community Cohort Study

Introduction: Racial disparities in stroke among older adults have been inconsistently reported, with sparse data for low-income adults. We examined racial disparities in stroke among low-income older adults and potential modification by age and sex. Methods: Participants were self-identified black and white adults in the Southern Community Cohort Study, a cohort of largely low-income adults from the southeastern US. Analyses were restricted to Medicare beneficiaries aged > 65 years and free of stroke at baseline (2002-2009). Covariates were self-reported at baseline with follow-up through 2014 (mean=8 + 3 years). Incident fatal and non-fatal total, ischemic and hemorrhagic strokes were identified by validated algorithms using hospital discharge codes from Medicare linkage (ICD-9: 430-431, 433.x1, 434.x1, 436). Hazard ratios (HR) and 95% confidence intervals (CI) were estimated with Cox models. Results: Among 6,228 participants, 752 total strokes were observed (incidence rate=152 per 10,000 person-years). The mean age was 70 + 4 years, 66% were female and 59% were black. Compared to whites, blacks had a 65% significantly higher age-adjusted risk of total stroke (Table). In multivariable analysis, a >20% racial disparity persisted. Excess risk was largely attributable to a higher prevalence of risk factors (e.g. hypertension, obesity) that may be in the causal pathway. Racial disparities in total stroke were consistent across age groups and sex in minimally adjusted models. In fully adjusted models, racial disparities were significant only among men (HR=1.35, 95% CI:1.01-1.80) and those aged > 75 years (HR=1.52, 95% CI: 1.18-1.96). Conclusions: In this low-income population with a high incidence of stroke, racial disparities in stroke persisted among older adults, even after controlling for established risk factors. More research is needed to examine how stroke prevention interventions can be tailored to meet the needs of low-income older adults.

Abstract WP235: Hepatocyte Growth Factor and Risk of Stroke in the Reasons for Geographic and Racial Differences in Stroke Study

Introduction: Hepatocyte growth factor (HGF) is a cytokine produced in response to tissue injury and endothelial dysfunction and is correlated with cardiovascular risk factors including hypertension and diabetes. Hypothesis: HGF is associated with risk of stroke, and racial disparities in stroke may be explained by differences in HGF level. Methods: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study enrolled 30,239 black (42%) and white (58%) Americans age 45 and older from 2003-2007. In participants free of baseline stroke, HGF level was measured in a case-cohort study of 534 participants who developed ischemic stroke over 5.4 years and a cohort random sample of 1017 participants. Multivariable linear regression was used to determine correlates of HGF in the cohort random sample. Hazard ratios of stroke by HGF quintile were calculated using Cox proportional hazards models adjusting for stroke risk factors and correlates of HGF. Results: HGF was higher with older age, male sex, cardiovascular disease, smoking, warfarin use and higher CRP, but did not differ by race. Main results are in the figure. Those with HGF in the highest vs. lowest quintile had an HR of incident stroke of 2.12 (CI 1.31-3.41) in the model adjusted for Framingham stroke risk factors. There was no difference in the association by sex or race ( p- interaction > 0.2). As HGF did not differ by race it did not mediate the black-white disparity in stroke incidence. Conclusion: In REGARDS, HGF in the top quintile was associated with a doubling of incident ischemic stroke risk after adjusting for other stroke risk factors. HGF did not mediate the black-white disparity in stroke risk.

Abstract WMP57: Geographic Disparities in Stroke and Life Expectancy Significantly Attributable to Ambient PM2.5 Pollution Across the Counties of the United States

Background: We aimed to test the hypotheses that ambient particulate matter (PM2.5) is significantly associated with the risk of stroke mortality and life expectancy (LE) reduction, and the degrees of these associations differ across the counties and regions of the United States (U.S). Methods: Annual average county-level data (n=1561 counties) from U.S. Centers for Disease Control and Prevention, and Environmental Protection Agency on PM2.5 measures in 2005-2010, age-adjusted stroke mortality in adults aged ≥35 in 2013-2015, and LE in 2010, as well as % of poverty rate, number of primary care physicians per 1000 residents (as a marker of healthcare support) and county-level % of rural population as covariates were analyzed using linear and multilevel hierarchical regression analyses. Results: Significant county-level variations in annual average PM2.5 levels (range: 7.2-14.7 ug/ 3 ), stroke mortality (30.1-219.0 per 100,000 population in males, and 35.0-249.0 in females), and LE (65.0-81.7 years in males and 72.7-85.0 in females) were observed across the nation. Population-weighted PM2.5 levels were significantly and positively associated with stroke mortality in males (r=0.49, p<.0001), and in females (r=0.42, p<.0001), and negatively associated with LE in males (r=-0.39, p<.0001) and females (r=-0.37, p<.0001). Adjusted multilevel analysis indicates that PM2.5 was significantly associated with stroke mortality rates (β=1.27, p<.0001) in both sexes, and with LE in males (β=-0.18, p=<.001), and in females (β=-0.09, p<.001). The adverse impacts of PM2.5 were even worse in counties with higher % of poverty rates and poorer healthcare support compared to their counterparts. Analyses by regions indicate that the highest risk of PM2.5 for stroke (assessed by regression coefficients) was shown for males and females living in the South, followed by Midwest, Northeast, and West. Similar results of the risk of PM2.5 for LE reduction were observed across the regions. Conclusion: The study, using U.S. national representative datasets provides new and important evidence that geographic disparities in stroke mortality and LE are significantly attributable to ambient PM2.5 pollution across the nation.

Abstract TP458: Stroke Disparities: Longer Lengths of Stay in Acute Stroke Patients With Medicaid

Introduction: Prolonged hospital stays expose stroke patients to hospital-acquired infections, increase overall cost of care, and delay the initiation of rehabilitation therapies. We sought to examine the factors associated with length of stay (LOS) in acute ischemic stroke (AIS) patients at a comprehensive stroke center (CSC) in an urban center. We hypothesized that patients being discharged to subacute rehabilitation (SAR) or nursing home facilities would have longer LOS. Methods: Consecutive patients admitted to our stroke service from April to July 2018 with a principal diagnosis of AIS were included. Patients with transient ischemic attack, intracerebral hemorrhage or subarachnoid hemorrhage were excluded. Demographics, admission NIHSS, baseline modified Rankin Scale (mRS), discharge mRS, and discharge disposition were collected. LOS was calculated from date/time of patient registration to discharge. Results: Baseline characteristics are shown in table 1. LOS and NIHSS were significantly correlated ( r s 0.745, p <0.001). Medicaid as primary insurance on admission was associated with longer LOS (21.9 days) as compared to Medicare (6.5 days) or commercial insurance (2.6 days) [p=0.017]. Higher discharge mRS was associated with longer LOS [p=0.002]. Discharge to SAR was associated with longer LOS (22.9 days) as compared to acute rehab (8.8 days), home with home health (3.2 days), or home (2.6 days) [p = 0.001]. There was no difference in LOS according to baseline mRS, age, gender, or race. Conclusions: Higher admission NIHSS, Medicaid insurance on admission, discharge to SAR, and discharge mRs &gt4 were significantly associated with longer LOS in AIS patients. Systems of care interventions are needed to address disparity in LOS for Medicaid patients.

Abstract TMP57: Racial Disparities in Recurrent Stroke Rates: Preliminary Results From the Greater Cincinnati/Northern Kentucky Population in 2015

Introduction: The REGARDS study previously reported a lack of racial disparity in recurrent ischemic stroke (IS) events, despite large racial differences in incident IS. We sought to evaluate recurrent stroke rates at 1 year after an index ischemic (IS) or hemorrhagic (ICH and SAH) stroke or TIA within a large, biracial population representative of the US in terms of % blacks and sociodemographics with a large number of index events Methods: The Greater Cincinnati/Northern Kentucky Stroke Study ascertained all hospitalized strokes and TIAs among residents of a 5-county population of 1.3 million in 7/1/14-12/31/14 (blacks only) and 2015 (all residents), as well as recurrent strokes (but not TIAs) in 2016. One year risk of recurrent stroke was estimated by Kaplan-Meier analysis. Association between recurrent stroke and demographics/risk factors was assessed by proportional hazards analysis. Results: Among the 2014-15 cases, there were 3883 index events (2512 IS, 374 ICH, 92 SAH, 900 TIA, 5 unknown type). Median age was 70 (IQR 59, 81); 27% were black and 54% female. Recurrent events within 12 months of the index event occurred in 319 patients (276 IS, 38 ICH, 5 SAH). Those with recurrence were more likely black than those without (34% vs 27%, p<0.01). No differences between those with recurrence and those without was seen for age at index event (median 70 vs 70, p=0.33) or sex (female 56% vs 54%, p=0.44). One-year risk of recurrent stroke was 9.3% overall (11.3% black, 8.6% white); 10.0% after index IS, 11.2% for ICH/SAH, 7.2% after TIA. Hazard ratio for risk of recurrent stroke for blacks compared with whites, adjusted for age and sex, was 1.38 (95% CI 1.09, 1.75). Discussion: The risk of recurrent stroke was significantly associated with index event type and stroke risk factors (hypertension, diabetes, smoking, and prior stroke). Black race was not a significant independent predictor of recurrent stroke after adjusting for other known stroke risk factors.

Abstract TMP53: Mexican Americans and Non-Hispanic Whites Have Different Prestroke Comorbidity Profiles: Results From the Brain Attack Surveillance in Corpus Christi Project

Introduction: Multiple comorbid conditions (MCC) explain variation in stroke outcomes beyond the damage caused by the stroke. Mexican Americans (MAs) and non-Hispanic Whites (NHWs) may have a different spectrum and severity of MCC, which may contribute to ethnic differences in stroke outcomes. We sought to determine the clustering of MCC in ischemic stroke patients as well as ethnic differences. Methods: MA and NHWs with ischemic stroke (2008-2017) from the Brain Attack Surveillance in Corpus Christi Project were studied. Twenty-two prestroke comorbidities (prevalence >1%) were identified using ICD codes and medical records from acute hospitalizations. Latent class analysis was used to identify comorbidity clusters (class). Multinomial logistic regression was used to assess age-adjusted ethnic differences in class membership. Results: Of 1,670 patients, 49% were male, 68% were MA, mean age was 69 (SD=13). MAs were younger, more likely to be obese, and have hypertension, diabetes, and renal and liver failure, but less likely to have arrhythmia and chronic pulmonary disease. Three latent classes were identified (Figure). Class 1 had a high prevalence of uncomplicated hypertension and diabetes but low prevalence of other comorbidities. Class 2 and 3 had similarly higher prevalence for most comorbidities, except that the prevalence of renal failure, and complicated hypertension and diabetes in Class 2 and arrhythmia in Class 3 were relatively higher. Compared with NHWs, MAs were more likely to be in Class 1 (OR 1.72, 95%CI: 1.15-2.56) and Class 2 (OR 2.18, 95%CI: 1.63-3.10) versus Class 3. Conclusion: Distinct MCC clusters, patterned by ethnicity, were identified. Efforts to target specific minority populations to reduce stroke disparities may benefit from addressing the ethnic-specific MCC clusters.

Abstract WMP92: Stroke Quality of Care Measures in Relation to Long-term Mortality in the Florida Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study

Introduction: In the FL-PR CReSD Study, there were race/ethnic disparities in the receipt of defect-free care. How race/ethnic disparities in acute stroke care contribute to disparities in outcomes after stroke is not well understood. We examined the relationship between acute stroke quality of care measures and mortality within the first year by race/ethnicity. Methods: The study included fee-for-service Medicare beneficiaries age ≥65 discharged with a primary diagnosis of ischemic stroke in 2010-2013 who were propensity matched with data from 66 CReSD hospitals in FL. Defect-free care included IV tPA treatment, in-hospital antithrombotic therapy, DVT prophylaxis, discharge antithrombotic therapy, appropriate anticoagulation therapy, statin use, and smoking cessation counseling. We used mixed logistic models to assess the associations between stroke care and outcomes (in-hospital, 30 day, 6 month, and 1 year mortality) by race/ethnicity, adjusted for demographics and stroke severity. Results: Among 14,100 stroke patients (73% white, 12% black, 15% Hispanic), mortality was 3% in-hospital, 12% at 30d, 21% at 6m, and 26% at 1y. Compared to whites, Hispanics had a greater odds of mortality at all time points, even after adjustment for defect-free care and individual stroke care metrics. Defect-free care was only associated with a lower risk of death within the first year among blacks (OR=0.67, p=0.004). Early antithrombotic use and antithrombotic use at discharge were associated with a lower risk of mortality at all time points, and the protective association for early antithrombotic use was strongest among whites. Statin therapy at discharge was associated with decreased 6m and 1y mortality, but this association was specific to whites and blacks. Conclusions: Acute stroke process of care measures, particularly antithrombotic use and statin therapy, were associated with a reduced odds of long-term mortality, particularly among non-Hispanics. Hispanic stroke survivors were at an increased risk of death within the first year, independent of acute stroke care measures. Results underscore the importance of optimizing acute stroke care.

Racial/Ethnic Disparities in Mortality Among Medicare Beneficiaries in the FL - PR CR eSD Study.

BackgroundRacial/ethnic disparities in acute stroke care may impact stroke outcomes. We compared outcomes by race/ethnicity among elderly Medicare beneficiaries in hospitals participating in the FL‐PR CReSD (Florida–Puerto Rico Collaboration to Reduce Stroke Disparities) registry with those in hospitals not participating in any quality improvement programs (non‐QI) in Florida and Puerto Rico (PR).Methods and ResultsThe population included fee‐for‐service Medicare beneficiaries age 65+ in Florida and PR, discharged with primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD‐9‐CM], codes 433, 434, 436) in 2010–2013. We used mixed logistic models to assess racial/ethnic differences in outcomes (in‐hospital, 30‐day, and 1‐year mortality, and 30‐day readmission) for CReSD and non‐QI hospitals, adjusted for demographic and clinical characteristics. The study included 62 CReSD hospitals (N=44 013, 84% white, 9% black, 4% Florida Hispanic, 1% PR Hispanic) and 113 non‐QI hospitals (N=14 422, 78% white, 7% black, 5% Florida Hispanic, 8% PR Hispanic). For patients treated at CReSD hospitals, there were no differences in risk‐adjusted in‐hospital mortality by race/ethnicity; blacks had lower 30‐day mortality versus whites (odds ratio, 0.86; 95% confidence interval, 0.77–0.97), but higher 30‐day readmission (hazard ratio, 1.09; 1.00–1.18) and 1‐year mortality (odds ratio, 1.13; 1.04–1.23); Florida Hispanics had lower 30‐day readmission (hazard ratio, 0.87; 0.78–0.98). PR Hispanic and black stroke patients treated at non‐QI hospitals had higher risk‐adjusted in‐hospital, 30‐day and 1‐year mortality, but similar 30‐day readmission versus whites treated in non‐QI hospitals.ConclusionsDisparities in outcomes were less common in CReSD than non‐QI hospitals, suggesting the benefits of quality improvement programs, particularly those focusing on racial/ethnic disparities.

Efficacy of a Discharge Educational Strategy vs Standard Discharge Care on Reduction of Vascular Risk in Patients With Stroke and Transient Ischemic Attack

Despite secondary prevention strategies with proven efficacy, recurrent stroke rates remain high, particularly in racial/ethnic minority populations who are disproportionately affected by stroke. To determine the efficacy of a culturally tailored skills-based educational intervention with telephone follow-up compared with standard discharge care on systolic blood pressure reduction in a multiethnic cohort of patients with mild/moderate stroke/transient ischemic attack. Randomized clinical trial with 1-year follow-up. Participants were white, black, and Hispanic patients with mild/moderate stroke/transient ischemic attack prospectively enrolled from 4 New York City, New York, medical centers during hospitalization or emergency department visit between August 2012 and May 2016. Through screening of stroke admissions and emergency department notifications, 1083 eligible patients were identified, of whom 256 declined to participate and 275 were excluded for other reasons. Analyses were intention to treat. The Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) intervention is a skills-based, culturally tailored discharge program with follow-up calls delivered by a community health coordinator. This intervention was developed using a community engagement approach. The primary outcome was systolic blood pressure reduction at 12 months postdischarge. A total of 552 participants were randomized to receive intervention or usual care (281 women [51%]; mean [SD] age, 64.61 [2.9] years; 180 Hispanic [33%], 151 non-Hispanic white [27%], and 183 non-Hispanic black [33%]). At 1-year follow-up, no significant difference in systolic blood pressure reduction was observed between intervention and usual care groups (β = 2.5 mm Hg; 95% CI, -1.9 to 6.9). Although not powered for subgroup analysis, we found that among Hispanic individuals, the intervention arm had a clinically and statically significant 9.9 mm Hg-greater mean systolic blood pressure reduction compared with usual care (95% CI, 1.8-18.0). There were no significant differences between arms among non-Hispanic white (β = 3.3; 95% CI, -4.1 to 10.7) and non-Hispanic black participants (β = -1.6; 95% CI, -10.1 to 6.8). Few behavioral intervention studies in individuals who have had stroke have reported clinically meaningful reductions in blood pressure at 12 months, and fewer have focused on a skills-based approach. Results of secondary analyses suggest that culturally tailored, skills-based strategies may be an important alternative to knowledge-focused approaches in achieving sustained vascular risk reduction and addressing racial/ethnic stroke disparities; however, these findings should be tested in future studies. ClinicalTrials.gov identifier: NCT01836354.

Identification of reversible causes of minority inequity in stroke: severity related to race and socio-economic status

ABSTRACTObjectives: Previous reports of a higher incidence and risk of stroke in minorities were associated primarily with race and ethnicity, yet the relationship between socio-economic status (SES) and racial disparities in stroke is less well known. We have investigated the effects of SES on the incidence of stroke type and its severity in minorities.Methods: The clinical and demographic data on 140 patients diagnosed with a stroke in the North Lawndale neighbourhood of Chicago, one of the city’s poorest communities, were collected prospectively over a 13-month period and then were retrospectively analysed.Results: Overall, haemorrhagic stroke occurred in 31% of cases, differing from the previously reported haemorrhagic stroke incidence of 15%. When accounting for SES, the incidence of haemorrhagic stroke in the uninsured versus the privately or Medicaid-insured increased to 50%. Uninsured African-American patients experienced even higher rates of haemorrhagic stroke at 55%.Conclusions: Patients who are uninsured minorities may be at an increased risk for severe strokes. This increase in risk appears to be related to the increased incidence of risk factors and lack of treatment. The lack of funds, care access, and limited education in these patients may be related to their increase in risk factors. This paper identifies potentially reversible environmental and societal factors that can lead to improved outcomes in indigent minority patients.

Can Survival Bias Explain the Age Attenuation of Racial Inequalities in Stroke Incidence?: A Simulation Study.

In middle age, stroke incidence is higher among black than white Americans. For unknown reasons, this inequality decreases and reverses with age. We conducted simulations to evaluate whether selective survival could account for observed age patterning of black-white stroke inequalities. We simulated birth cohorts of 20,000 blacks and 20,000 whites with survival distributions based on US life tables for the 1919-1921 birth cohort. We generated stroke incidence rates for ages 45-94 years using Reasons for Geographic and Racial Disparities in Stroke (REGARDS) study rates for whites and setting the effect of black race on stroke to incidence rate difference (IRD) = 20/10,000 person-years at all ages, the inequality observed at younger ages in REGARDS. We compared observed age-specific stroke incidence across scenarios, varying effects of U, representing unobserved factors influencing mortality and stroke risk. Despite a constant adverse effect of black race on stroke risk, the observed black-white inequality in stroke incidence attenuated at older age. When the hazard ratio for U on stroke was 1.5 for both blacks and whites, but U only directly influenced mortality for blacks (hazard ratio for U on mortality =1.5 for blacks; 1.0 for whites), stroke incidence rates in late life were lower among blacks (average observed IRD = -43/10,000 person-years at ages 85-94 years versus causal IRD = 20/10,000 person-years) and mirrored patterns observed in REGARDS. A relatively moderate unmeasured common cause of stroke and survival could fully account for observed age attenuation of racial inequalities in stroke.

Endovascular Therapy and Ethnic Disparities in Stroke Outcomes

Background and Purpose: Ethnic disparities in stroke are well described, with a higher incidence of disability and increased mortality in Blacks versus Whites. We sought to compare the clinical outcomes between those ethnic groups after stroke endovascular therapy (ET). Methods: We performed a retrospective review of the prospectively acquired Grady Endovascular Stroke Outcomes Registry between September 1, 2010 and September 30, 2015. Patients were dichotomized into two groups – Caucasians and African-Americans – and matched for age, pretreatment glucose level, and baseline National Institutes of Health Stroke Scale (NIHSS) score. Baseline characteristics as well as procedural and outcome parameters were compared. Results: Out of the 830 patients treated with ET, 308 pairs of patients (n = 616) underwent primary analysis. African-Americans were younger (p < 0.01), had a higher prevalence of hypertension (p < 0.01) and diabetes (p = 0.04), and had higher Alberta Stroke Program Early CT Score values (p = 0.03) and shorter times to treatment (p = 0.01). Blacks more frequently had Medicaid coverage and less private insurance (29.6 vs. 11.4% and 41.5 vs. 60.3%, respectively, p < 0.01). The remaining baseline characteristics, including baseline NIHSS score and CT perfusion-derived ischemic core volumes, were well balanced. There were no differences in the overall distribution of 90-day modified Rankin scale scores (p = 0.28), rates of successful reperfusion (84.7 vs. 85.7%, p = 0.91), good outcomes (49.1 vs. 44%, p = 0.24), or parenchymal hematomas (6.5 vs. 6.8%, p = 1.00). Blacks had lower 90-day mortality rates (18 vs. 24.6%, p = 0.04) in univariate analysis, which persisted as a nonsignificant trend after adjustment for potential confounders (OR 0.52, 95% CI 0.26–1.03, p = 0.06). Conclusions: Despite unique baseline characteristics, African-Americans treated with ET for large vessel occlusion strokes have similar outcomes as Caucasians. Greater availability of ET may diminish the ethnic/racial disparities in stroke outcomes.

Abstract TP180: Racial/Ethnic Differences in Sleep Duration and Sleep Disturbances Among Stroke Survivors

Introduction: Sleep disorders and short sleep duration have been associated with increased incidence of stroke. Despite evidence of racial/ethnic disparities in stroke, few studies have examined differences in sleep duration and disturbances by race/ethnicity among stroke survivors. Methods: Data on self-reported sleep duration and sleep disturbances came from the baseline interview of the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) study, a randomized clinical trial of a skills-based intervention to reduce vascular risk in a multi-ethnic cohort of 552 mild stroke/TIA patients. Sleep duration was defined as average hours of sleep per night in the past month, and sleep disturbances were measured using the Medical Outcomes Study (MOS) Sleep Disturbances Index, which ranges from 0-100, with higher scores indicating more frequent disturbances. Differences in sleep duration and disturbance score by race/ethnicity were assessed using t-tests and multiple linear regression adjusted for age, sex, education, current smoking and alcohol consumption, body mass index, marital/cohabitation status, number of household members, and depression score. Results: Overall, patients reported an average of 6.37 hours of sleep per night, and mean Sleep Disturbance Index score was 35.8. Mean sleep duration was significantly lower among non-Hispanic blacks than non-Hispanic whites (6.12 vs. 6.69 hours, p=0.004). Mean disturbance score was significantly higher among both non-Hispanic blacks and Hispanics compared to non-Hispanic whites (35.7 vs. 27.8, p=0.013 and 42.6 vs. 27.8, p&lt;0.001, respectively). In adjusted models, sleep duration was no longer significantly associated with race/ethnicity. However, mean sleep disturbance scores remained significantly greater among non-Hispanic blacks and Hispanics compared to non-Hispanic whites (β=11.6, p=0.006, and β=8.8, p=0.039, respectively). Conclusion: Sleep disturbances were more frequent among Hispanics and non-Hispanic blacks, two populations that are disproportionately affected by stroke. Further research is warranted to understand the role differences in sleep may play in racial/ethnic disparities in stroke.

Abstract TMP111: Physical Activity among Stroke Patients in the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) Study

Introduction: Previous research has emphasized the importance of physical activity in preventing secondary stroke. However, approaches to improving physical activity after stroke have been suboptimal, particularly among race-ethnic groups. Methods: The DESERVE study was an RCT of a skills-based educational intervention in a multi-ethnic cohort of mild stroke/ TIA patients. The current analysis compared physical activity at one year post-discharge between intervention and usual care arms in DESERVE. Patients reported whether or not they participated in any moderate or vigorous physical activity for at least 10 minutes in the past month. Participation in any physical activity was compared between trial arms overall and stratified by race/ethnicity using chi-square tests. Results: A total of 338 patients were included in the analysis (n=171 intervention, n=167 usual care; 29.2% non-Hispanic white, 34.2% non-Hispanic black, 33.9% Hispanic). Overall, 50.3% of patients participated in any physical activity in the past month. There was no difference in physical activity between the trial arms (p=0.91). Among Hispanics, participating in any physical activity was significantly greater in the intervention arm than in the usual care (intervention 43.6% vs. usual care 22.4%, p=0.01). There was no association between intervention arm and physical activity among non-Hispanic whites (intervention 58.1% vs. usual care 72.0%, p=0.16) and non-Hispanic blacks (intervention 50.9% vs. usual care 54.2%, p=0.74). Conclusion: Participation in a skills-based intervention was associated with significantly greater physical activity one year post-discharge among Hispanic stroke/TIA patients. Providing culturally-tailored, skills-based tools and strategies that focus on behavior modification, such as improving physical activity, has the potential to improve stroke outcomes and reduce stroke disparities.

Abstract TP23: Safety and Outcome of Endovascular Therapy in Patients With Minor Stroke: Florida Puerto Rico Collaboration to Reduce Stroke Disparities Study

Background: Patients with minor ischemic stroke were largely excluded from the randomized trials of endovascular therapy (EVT) in stroke. In the Florida-Puerto Rico Registry we sought to determine the utilization of EVT in this population. Methods: From January 2010 to March 2017, 57,750 acute ischemic stroke patients within 24 hours of symptom onset were prospectively included from 88 sites in four Florida regions (south, west central, north and panhandle, east central) and Puerto Rico. Differences between minor (NIHSS ≤ 5) and moderate/severe (NIHSS&gt;5) stroke patients who received EVT were evaluated using multivariable logistic regression with generalized estimating equations. Results: Among 2,845 EVT patients (50% women, mean age ±SD 71±14 years), 347 (12%) had NIHSS ≤ 5. As compared to NIHSS&gt;5, minor stroke patients were younger (mean age 67 vs. 71, p&lt;0.01), more men (58% vs. 49%, p=0.01) more privately insured (47% vs. 35%, p&lt;0.01), having more HTN (69% vs. 63%, p=0.03) and prior strokes (25% vs. 20%, p=0.02) but less atrial fibrillation (25% vs. 38%, p&lt;0.01). Minor stroke EVT patients arrived later to the hospital (median 128 vs. 102 min, p=0.02) and during working hours (51% vs. 46%,p=0.09). They were less likely to receive IV tPA (29% vs. 42%, p&lt;0.01), had a longer door to puncture time (median 192 vs. 128 min, p&lt;0.01). In multivariable analysis, young age (OR=1.02, 95%CI 1.01-1.03), early arrival (OR=1.64, 95% CI 1.15-2.33) and FL regions (south vs. west central) (OR=2.67, 95% CI 1.07-6.62) were independently associated with EVT in minor stroke. Symptomatic ICH occurred in 4.6% of minor stroke EVT patients and 6.4% in those with NIHSS&gt;5. Majority of minor stroke patients who received EVT were discharged home or to rehab (75%) while 53% of those with NIHSS&gt;5. Conclusions: More than 1 in 10 cases that received EVT had mild neurological symptoms. Many factors including hospital expertise and time of presentation affect the use of this treatment. Further study of EVT in minor stroke is warranted.

Abstract WP306: Race-Ethnic Disparities in 30-Day Readmission After Ischemic Stroke Among Medicare Beneficiaries in the Florida Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study

Background: 30-day readmission after ischemic stroke is an important health quality of care metric, but little is known about potential race-ethnic disparities for this outcome. We examined 30-day rates and causes for readmission among Medicare beneficiaries in the NINDS-funded Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (CReSD) Study. Methods: We examined 30-day all-cause readmission for Medicare fee-for-service beneficiaries treated for ischemic stroke (ICD-9 433,434, 436) in FL CReSD hospitals from 2010-2013. We fit a Cox proportional hazards model that censored for death and adjusted for age, sex, and comorbidities to assess race-ethnic differences in readmission, and identified reasons for readmissions. Results: Among 16,952 unique ischemic stroke patients (54% women, 75% white, 8% black, 15% Hispanic), all-cause 30-day readmission was 15%. Readmission rates were 17.2% for Blacks, 16.7% for Hispanics, 14.4% for Whites, and 14.7% for Others (p=0.003). There was a median of 11 days between discharge and first readmission. In risk-adjusted analyses, there was no significant difference in 30-day readmission for Blacks (hazard ratio 1.15, 95% confidence interval 0.99-1.33), Hispanics (1.00, 0.90-1.13), and those of other race (0.91, 0.71-1.16) compared to Whites. Nearly 1 in 4 readmissions were attributable to an acute cerebrovascular event: 16.6% ischemic stroke or transient ischemic attack, 1.5% hemorrhagic stroke, and 5.2% cerebral artery intervention (carotid endarterectomy or stenting, endovascular). Interventions were more common among Whites (6.0%) and those of other race (7.5%) than among Blacks (1.8%) and Hispanics (3.8%; p=0.029). Readmission due to pneumonia or urinary tract infection was 8.2%. Conclusions: Readmissions varied by race/ethnicity, but generally occurred within two weeks of hospital discharge. Our results underscore the importance of post-discharge transition of care and the need for better secondary stroke prevention strategies early after ischemic stroke. Implementation of effective transition of care after acute stroke hospitalization may reduce potentially preventable readmissions, particularly among minority populations.

Abstract WMP59: Sleep Apnea is Associated with the Combined Endpoint of Recurrent Stroke and Post-Stroke Mortality

Introduction: No data are available about the relationship between sleep apnea (SA) and recurrent stroke and mortality from population-based studies, large samples, or ethnically diverse populations. Methods: In the Brain Attack Surveillance in Corpus Christi (BASIC) project, we identified patients with ischemic stroke between 2010-2015. Subjects who enrolled were offered screening for SA with the ApneaLink Plus device from which an apnea-hypopnea index (AHI) was derived (≥10 defined SA). Demographics and baseline characteristics were determined from chart review and interview. Recurrent ischemic stroke was identified through active and passive surveillance and confirmed by study neurologists. All-cause mortality was identified through Texas Department of State Health Services records. Cox proportional-hazards models were used to assess the association between AHI (modeled linearly) and combined ischemic stroke recurrence and mortality unadjusted and adjusted for multiple potential confounders. Results: Of the 842 subjects, the median age was 65 (IQR: 57, 76), 47% were female, 58% were Mexican American, and 34% were non-Hispanic white. The median AHI was 14 (IQR: 6, 26); 63% had SA. SA was associated with male sex, Mexican American ethnicity, being insured, nonsmoking status, diabetes, hypertension, lower educational attainment, and higher BMI. In the time period (median time to event 584 days), 90 (10.7%) recurrent strokes and 125 (14.8%) deaths occurred with a cumulative incidence of recurrence or death of 202 (24%). AHI was associated with the combined endpoint in unadjusted (HR=1.09 per one unit increase in AHI (95%CI: 1.08, 1.10)) and fully adjusted models (HR=1.09 (95%CI: 1.08, 1.10)). Mexican American ethnicity was associated with the endpoint (HR=1.71 (95%CI: 1.16, 2.54) in the fully adjusted model. Conclusion: SA is associated with the combined endpoint of recurrent ischemic stroke and mortality in this population-based study. Mexican Americans are also at higher risk of recurrent stroke and death following ischemic stroke than non-Hispanic whites. SA may therefore represent an important modifiable risk factor for poor stroke outcomes and a target to reduce ethnic stroke disparities.

Incidence of first stroke and ethnic differences in stroke pattern in Bradford, UK: Bradford Stroke Study.

Background Information on ethnic disparities in stroke between White and Pakistani population in Europe is scarce. Bradford District has the largest proportion of Pakistani people in England; this provides a unique opportunity to study the difference in stroke between the two major ethnic groups. Aim To determine the first-ever-stroke incidence and examine the disparities in stroke patterns between Whites and Pakistanis in Bradford. Methods Prospective 12 months study consisting of 273,327 adults (≥18 years) residents. Stroke cases were identified by multiple overlapping approaches. Results In the study period, 541 first-ever-strokes were recorded. The crude incidence rate was 198 per 100,000 person-years. Age adjusted-standardized rate to the World Health Organization world population of first-ever-stroke is 155 and 101 per 100,000 person-years in Pakistanis and Whites respectively. Four hundred and thirty-eight patients (81%) were Whites, 83 (15.3%) were Pakistanis, 11 (2%) were Indian and Bangladeshis, and 9 (1.7%) were of other ethnic origin. Pakistanis were significantly younger and had more obesity ( p = 0.049), and diabetes mellitus (DM) ( p = <0.001). They were less likely to suffer from atrial fibrillation ( p = <0.001), be ex- or current smokers ( p = <0.001), and drink alcohol above the recommended level ( p = 0.007) compared with Whites. In comparison with Whites, higher rates of age-adjusted stroke (1.5-fold), lacunar infarction (threefold), and ischemic infarction due to large artery disease (twofold) were found in the Pakistanis. Conclusions The incidence of first-ever-stroke is higher in the Pakistanis compared with the Whites in Bradford, UK. Etiology and vascular risk factors vary between the ethnic groups. This information should be considered when investigating stroke etiology, and when planning prevention and care provision to improve outcomes after stroke.

Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association.

Population-wide reductions in cardiovascular disease incidence and mortality have not been shared equally by African Americans. The burden of cardiovascular disease in the African American community remains high and is a primary cause of disparities in life expectancy between African Americans and whites. The objectives of the present scientific statement are to describe cardiovascular health in African Americans and to highlight unique considerations for disease prevention and management. The primary sources of information were identified with PubMed/Medline and online sources from the Centers for Disease Control and Prevention. The higher prevalence of traditional cardiovascular risk factors (eg, hypertension, diabetes mellitus, obesity, and atherosclerotic cardiovascular risk) underlies the relatively earlier age of onset of cardiovascular diseases among African Americans. Hypertension in particular is highly prevalent among African Americans and contributes directly to the notable disparities in stroke, heart failure, and peripheral artery disease among African Americans. Despite the availability of effective pharmacotherapies and indications for some tailored pharmacotherapies for African Americans (eg, heart failure medications), disease management is less effective among African Americans, yielding higher mortality. Explanations for these persistent disparities in cardiovascular disease are multifactorial and span from the individual level to the social environment. The strategies needed to promote equity in the cardiovascular health of African Americans require input from a broad set of stakeholders, including clinicians and researchers from across multiple disciplines.

Impact of Stroke Risk Factors on Ethnic Stroke Disparities Among Midlife Mexican Americans and Non-Hispanic Whites.

We examined the contribution of stroke risk factors to midlife (age 45-59 years) Mexican American and non-Hispanic White ischemic stroke (IS) rate disparities from 2000 to 2010. Incident IS cases (n=707) and risk factors were identified from the Brain Attack Surveillance in Corpus Christi Project, Nueces County, TX (2000-2010). US Census data (2000-2010) were used to estimate the population at-risk for IS, and the Behavioral Risk Factor Surveillance System (2000-2010) was used to estimate risk factor prevalence in the stroke-free population. Poisson regression models combined IS counts (numerator) and population at-risk counts (denominator) classified by ethnicity and risk factor status to estimate unadjusted and risk factor-adjusted associations between ethnicity and IS rates. Separate models were run for each risk factor and extended to include an interaction term between ethnicity and risk factor. The crude rate ratio (RR) for ethnicity (Mexican American versus non-Hispanic White) was 2.01 (95% confidence interval [CI], 1.71-2.36) and was attenuated in models that adjusted for diabetes mellitus (RR: 1.50; 95% CI, 1.26-1.78) and hypertension (RR: 1.84; 95% CI, 1.50-2.26). In addition, diabetes mellitus had a stronger association with IS rates among Mexican Americans (RR: 6.42; 95% CI, 5.31-7.76) compared with non-Hispanic Whites (RR: 4.07; 95% CI, 3.68-4.51). The higher prevalence of diabetes mellitus and hypertension and stronger association of diabetes mellitus with IS among midlife Mexican Americans likely contribute to persistent midlife ethnic stroke disparities.