Ethnic Disparities In Stroke Research Articles

Abstract HUP8: Mobile Stroke Unit Management Associated With Reduction In Racial Disparities In Stroke Treatment Metrics

Background: Racial and ethnic disparities in stroke exist across the continuum of care, including prehospital care. The impact of Mobile Stroke Units (MSUs) on racial disparities in thrombolytic treatment metrics is not reported. Methods: A pre-specified sub-study of ischemic stroke patients enrolled in BEST-MSU was conducted. MSU and standard management (SM) groups were divided into Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic (H) cohorts. Other racial groups were excluded (small n). Primary outcome was last seen normal to tPA time . Secondary outcomes included 90-day utility-weighted modified Rankin Scale (uw-mRS), functional independence (mRS 0-1), and mortality. Results: A total of 1420 patients were included: 557 NHW, 586 NHB, and 277 H. NHB and H groups were younger, had lower education, and higher proportions uninsured. In SM, NHB and H patients received slower care and less frequent tPA compared to NHW (Table 1). In contrast, MSU management reduced time to treatment (19 min NHW vs 46.5 min NHB vs 46 min H; p=<0.001) in NHB and H, and led to more frequent tPA (13% more NHW, 11% more NHB, 25% more H) in H. MSU management was associated with better uw-mRS across all groups (Figure 1). More functional independence was seen in NHW and NHB (adjusted OR NHW 1.79 [1.10-2.95] p=0.019; NHB 2.13 [1.38-3.33] p=0.0007). Mortality benefit was seen in H (p=0.03). Conclusion: MSUs overcome known disparities in thrombolytic utilization and treatment metrics in Non-Hispanic Black and Hispanic groups. Further studies are needed to evaluate care inequities that are overcome through integration of a MSU into the prehospital setting.

Abstract 88: Mobile Stroke Unit Management Associated With Reduction in Racial Disparities in Stroke Treatment Metrics

Background: Racial and ethnic disparities in stroke exist across the continuum of care, including prehospital care. The impact of Mobile Stroke Units (MSUs) on racial disparities in thrombolytic treatment metrics is not reported. Methods: A pre-specified sub-study of ischemic stroke patients enrolled in BEST-MSU was conducted. MSU and standard management (SM) groups were divided into Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic (H) cohorts. Other racial groups were excluded (small n). Primary outcome was last seen normal to tPA time[GJ1] . Secondary outcomes included 90-day utility-weighted modified Rankin Scale (uw-mRS), functional independence (mRS 0-1), and mortality. Results: A total of 1420 patients were included: 557 NHW, 586 NHB, and 277 H. NHB and H groups were younger, had lower education, and higher proportions uninsured. In SM, NHB and H patients received slower care and less frequent tPA compared to NHW (Table 1). In contrast, MSU management reduced time to treatment (19 min NHW vs 46.5 min NHB vs 46 min H; p=<0.001) in NHB and H, and led to more frequent tPA (13% more NHW, 11% more NHB, 25% more H) in H. MSU management was associated with better uw-mRS across all groups (Figure 1). More functional independence was seen in NHW and NHB (adjusted OR NHW 1.79 [1.10-2.95] p=0.019; NHB 2.13 [1.38-3.33] p=0.0007). Mortality benefit was seen in H (p=0.03). Conclusion: MSUs overcome known disparities in thrombolytic utilization and treatment metrics in Non-Hispanic Black and Hispanic groups. Further studies are needed to evaluate care inequities that are overcome through integration of a MSU into the prehospital setting.

Abstract P192: Disparities In Stroke And Mortality In Children With Congenital Heart Defects

Background: Critical congenital heart defects (CCHD) are a subset of cyanotic lesions that require intervention within the first days to weeks of life for survival. For children born with CCHD, the neonatal period is considered the time of highest risk for stroke and overall poor outcomes. Prior studies have identified racial differences in neonatal outcomes among children with CCHD. Whether these differences persist throughout childhood is unclear. Methods: Using the National Inpatient Sample database, we analyzed all children with CCHD ≤ 18 years hospitalized from 2005-2018. Primary outcome was a composite of incident stroke (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) and all-cause mortality within strata of ages and years and over the 14-year period of observation. Chi-square tests and multivariable regression were used to assess differences in outcomes. Trends were analyzed adjusting for sex, insurance, and hospital features. Results: A total of 59,438 children with CCHD were hospitalized during the study period: 58% were White (W), 15% Black (B), and 27% Hispanic (H). Overall rate of stroke or death was 4.7% in White children, 6.6% in Black, and 5.6% in Hispanic. Disparities were most pronounced in infancy (Figure; relative differences (RD) compared to White children: 27% (B) and 20% (H), P=0.000) and in early childhood (Figure; RD: 42% (B) and 9% (H), P=0.002). Black and Hispanic children with CCHD had higher rates of stroke and death from 2005-2009 (Figure; RD compared to White children: 24% (B), 22% (H); P = 0.001) and in 2015-2018 (Figure; RD: 21% (B), 18% (H); P = 0.000). These disparities did not change significantly over time in crude or adjusted models (P=0.07, P=0.06). Conclusion: Racial and ethnic disparities in stroke and death among children with CCHD persist after the neonatal period with only modest change in these differences in recent years. Further work identifying the mediators of these disparities is necessary to improve outcomes in this vulnerable pediatric population.

Stroke Disparities: From Observations to Actions: Inaugural Edward J. Kenton Lecture 2020.

Numerous epidemiological studies have demonstrated stroke disparities across race and ethnic groups. The goal of the NOMAS (Northern Manhattan Study) was to evaluate race and ethnic differences in stroke within a community with 3 different race-ethnic groups. Starting as a population-based incidence and case-control study, the study evolved into a cohort study. Results from NOMAS have demonstrated differences in stroke incidence, subtypes, risk factors, and outcomes. Disparities in ideal cardiovascular health can help explain many differences in stroke incidence and call for tailored risk factor modification through innovative portals to shift more diverse subjects to ideal cardiovascular health. The results of NOMAS and multiple other studies have provided foundational data to support interventions. Conceptual models to address health disparities have called for moving from detecting disparities in disease incidence, to determining the underlying causes of disparities and developing interventions, and then to testing interventions in human populations. Further actions to address race and ethnic stroke disparities are needed including innovative risk factor interventions, stroke awareness campaigns, quality improvement programs, workforce diversification, and accelerating policy changes.

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 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.

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.

Abstract WP224: Impact of Stroke Risk Factors on Ethnic Stroke Disparities Among Midlife Mexican Americans and Non-hispanic Whites

Introduction: Overall ischemic stroke (IS) incidence has declined in the US, but has remained stable among midlife (age 45-59) adults and is higher in midlife Mexican Americans (MAs). We examined the contribution of stroke risk factors to ethnic differences in IS rates among midlife MAs and non-Hispanic Whites (NHWs) in a population-based study. Methods: Incident IS (N=823) counts and corresponding risk factors were identified from the BASIC Project, Nueces County, Texas (2000-2010). US Census data (2000) for Nueces County was used to estimate the population at-risk for stroke, and the Texas Behavioral Risk Factor Surveillance System for Public Health Region 11(2000-2010) was used to estimate prevalence of risk factors in the stroke free population. Poisson regressions were run combining stroke 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 (diabetes, hypertension, coronary heart disease, high cholesterol, education &lt; high school, no health insurance, current smoking, BMI&gt;30), and extended to include an interaction term between ethnicity and risk factor. Results: The crude ethnic IS rate ratio (RR) comparing MAs with NHWs was 2.13 (95% CI: 1.84-2.47). The ethnic RR was lower in models that adjusted for diabetes (RR:1.54; 95% CI: 1.31-1.78), hypertension (RR: 1.92; 95% CI: 1.65-2.22), and education &lt; high school (RR: 2.02; 95% CI: 1.72-2.38) compared to the crude association. Ethnicity significantly modified associations between diabetes, smoking, health insurance, education and IS rates. Associations between diabetes and IS rates was greater among MAs (RR: 6.82, 95% CI: 5.76-8.07) compared with NHWs (RR: 4.40, 95% CI: 3.33-5.81), while smoking associations were greater in NHWs (MA RR: 2.61, 95% CI: 2.20-3.10; NHW RR: 3.49, 95% CI: 2.73-4.46). Socioeconomic variables increased IS risk in NHWs but were insignificant or protective in MAs. Conclusion: Traditional stroke risk factors may contribute to midlife ethnic stroke disparities; particularly diabetes, given its high prevalence and stronger association with IS among midlife MAs as compared with NHWs.

Abstract W P149: Ethnic Disparities In Stroke Related In-Hospital Mortality In Patients With Atrial Fibrillation

Background: Improved strategies are needed to stratify the risk of stroke in atrial fibrillation. While stroke-related mortality is higher in African Americans, it is unclear whether stroke related mortality in patients with atrial fibrillation differs among different ethnicities. We aim to study race/gender disparities in stroke related in-hospital mortality in patients with atrial fibrillation. Method: Data were obtained from the California State Inpatient Database between 2008-2011, using appropriate ICD-9 codes. Frequencies and descriptive analysis adjusting for influence of comorbidities and confounders were utilized. Age and ICD-9 codes for hypertension, diabetes, congestive heart failure and prior stroke were used to calculate the CHADS2 score of patients with atrial fibrillation. A multivariate Cox regression model was used to further explore the relationship. The primary outcome was in-hospital mortality. We hypothesized that higher CHADS2 scores increase the risk of stroke among African Americans due to increased disease burden. Results: Between 2008 and 2011, 18,089 patients with atrial fibrillation had a stroke, 70% were Whites, 5% African Americans, 15% Hispanics and 10% Asians. 57% were females, and 66% of the population were 75 years of age and older. After adjusting for baseline demographics, there was no significant difference in the the odds of in-hospital stroke mortality, with Whites taken as reference (African Americans OR 0.93, 95% CI 0.83-1.05; Hispanics OR 1.02, 95% CI 0.94-1.10; Asians OR 1.07, 95% CI 0.98-1.17). There was no significant difference in the odds of in-hospital stroke mortality between males and females (Males OR 0.97, 95% CI 0.92-1.02). Conclusion: Our results indicate that in a large, statewide database, the in-hospital stroke mortality among the different races with stroke during hospitalization was not significantly different as compared to Whites.

Prevalence of pre-stroke sleep apnea risk and short or long sleep duration in a bi-ethnic stroke population

BackgroundThe ethnic disparity in ischemic stroke between Mexican Americans (MAs) and non-Hispanic whites (NHWs) may be partly attributable to disparities in sleep and its disorders. We therefore assessed whether pre-stroke sleep apnea symptoms (SA risk) and pre-stroke sleep duration differed between MAs and NHWs. MethodsMA and NHW ischemic stroke survivors in the Brain Attack Surveillance in Corpus Christi (BASIC) project reported sleep duration and SA symptoms on the validated Berlin questionnaire, both with respect to their pre-stroke baseline. Log binomial and linear regression models were used to test the unadjusted and adjusted (demographics and vascular risk factors) associations of high-risk Berlin scores and sleep duration with ethnicity. ResultsAmong 862 subjects, 549 (63.7%) were MA and 514 (59.6%) had a high risk of pre-stroke SA. The MA and NHW subjects showed no ethnic difference, after adjustment for potential confounders, in pre-stroke SA risk (risk ratio (95% confidence interval (CI)): 1.06 (0.93, 1.20)) or in pre-stroke sleep duration (on average MAs slept 2.0 fewer minutes than NHWs, 95% CI: −18.8, 14.9 min). ConclusionsPre-stroke SA symptoms are highly prevalent, but ethnic differences in SA risk and sleep duration appear unlikely to explain ethnic stroke disparities.

The Affordable Care Act and stroke.

The Patient Protection and Affordable Care Act (ACA) was enacted on March 23, 2010, and has important implications for stroke care. The ACA is a comprehensive reform, although the signature component is the expansion of health insurance primarily by expanding Medicaid eligibility and by providing subsidies for consumers to purchase private insurance in online marketplaces called exchanges. Although many ACA provisions went into effect with its passage or have been phased in during the past several years, the Medicaid expansion and insurance exchanges went into effect more recently in January 2014. In this article, we begin by describing the working-age stroke population. We then discuss the health insurance provisions of the ACA, which largely target the working-age stroke population, and implications for racial/ethnic and geographic disparities. We then focus on how the ACA may affect stroke prevention, treatment, and postacute care (PAC). We conclude by discussing how health system reform under the ACA could affect patients with stroke. Working-age Americans, those aged 19 to 64 years, are experiencing stable or increasing stroke incidence even as overall stroke incidence is decreasing over time.1,2 Although racial and ethnic stroke disparities are present overall, the largest disparities are found among working-age Americans.1,2 To provide national estimates of stroke hospitalizations and insurance status among the working-age population, we used data from the Nationwide Inpatient Sample, a nationally representative sample of hospitalizations (for detailed methods, see online-only Data Supplement). In 2010, ≈230 000 or 37% of all stroke hospitalizations were among patients aged <65 years. Of the working-age stroke hospitalizations, 20% were among patients who had Medicaid and 14% were among uninsured. Disparities in stroke hospitalizations and insurance status, particularly among blacks, are striking. First, hospitalizations among the working age are more frequent in blacks (26.5%) than would be …

Abstract 2279: Ethnic Comparisons in Pre-Stroke Awareness and Treatment of Hypertension in Stroke Subjects: Modification by SES and Acculturation

Background and Objectives: Mexican Americans (MAs) have higher stroke incidence rates than non-Hispanic whites (NHWs). Ethnic differences in the pre-stroke treatment of risk factors could potentially explain this disparity and may be exacerbated by low socio-economic status or less acculturation. We assessed pre-stroke awareness and treatment of hypertension by ethnicity, education and English proficiency in a population-based stroke surveillance project. Methods: Among 1,111 stroke subjects aged ≥45 years in the Brain Attack Surveillance in Corpus Christi (BASIC) project from 01/2000-06/2006, we examined pre-stroke hypertension prevalence (medical record documentation of hypertension diagnosis) at the time of the index stroke by ethnicity (MA vs. NHW). Among those with prevalent hypertension, we measured awareness (self-report of hypertension) and treatment (self-report of anti-hypertensive medication use). We first compared awareness and treatment of hypertension by ethnicity overall. We then compared ethnic differences in awareness and treatment of hypertension using 2 approaches: 1) after stratification by education (&lt;high school vs. ≥high school); and 2) after dichotomizing MAs by self-reported language fluency. Limited English proficiency (EP) was defined as Spanish only (less accultured) and EP was defined as English only/bilingual (more accultured).We adjusted associations for age, gender, education, diabetes, coronary artery disease, and previous stroke using logistic regression. Results: MAs (mean age 68.3 ± 12.1 years; n=566) were more likely than NHWs (mean age 74.4 ± 11.7 years; n=545) to report &lt;high school education (71% vs. 23%; P&lt;0.001). Thirty-two percent of MAs reported limited EP. Hypertension prevalence was 74% in both MAs and NHWs. There was a trend toward MAs having greater awareness than NHWs (89% vs. 85%; P=0.15) but similar treatment (89-90%) of hypertension. Among high school graduates, we found non-significant trends toward greater awareness but less treatment of hypertension in MAs compared with NHWs ( Figure 1 ). Compared with MAs with EP, NHWs and MAs with limited EP had less awareness of hypertension but similar treatment ( Figure 2 ). After adjustment for socio-demographics and co-morbidities, differences in hypertension awareness were no longer significant (NHWs: aOR, 0.96; 95%CI, 0.52-1.79; MAs with limited EP: aOR, 0.57; 95%CI, 0.27-1.19; MAs with EP: referent). Conclusion: We found little evidence that differences in pre-stroke awareness and treatment of hypertension may explain ethnic disparities in stroke.

Racial-Ethnic Disparities in Stroke Care: The American Experience

Our goal is to describe the effect of race and ethnicity on stroke epidemiology, personal beliefs, access to care, response to treatment, and participation in clinical research. In addition, we seek to determine the state of knowledge on the main factors that may explain disparities in stroke care, with the goal of identifying gaps in knowledge to guide future research. The intended audience includes physicians, nurses, other healthcare professionals, and policy makers. Members of the writing group were appointed by the American Heart Association Stroke Council Scientific Statement Oversight Committee and represent different areas of expertise in relation to racial-ethnic disparities in stroke care. The writing group reviewed the relevant literature, with an emphasis on reports published since 1972. The statement was approved by the writing group; the statement underwent peer review, then was approved by the American Heart Association Science Advisory and Coordinating Committee. There are limitations in the definitions of racial and ethnic categories currently in use. For the purpose of this statement, we used the racial categories defined by the US federal government: white, black or African American, Asian, American Indian/Alaskan Native, and Native Hawaiian/other Pacific Islander. There are 2 ethnic categories: people of Hispanic/Latino origin or not of Hispanic/Latino origin. There are differences in the distribution of the burden of risk factors, stroke incidence and prevalence, and stroke mortality among different racial and ethnic groups. In addition, there are disparities in stroke care between minority groups compared with whites. These disparities include lack of awareness of stroke symptoms and signs and lack of knowledge about the need for urgent treatment and the causal role of risk factors. There are also differences in attitudes, beliefs, and compliance among minorities compared with whites. Differences in socioeconomic status and insurance coverage, mistrust of the healthcare system, the relatively limited number of providers who are members of minority groups, and system limitations may contribute to disparities in access to or quality of care, which in turn might result in different rates of stroke morbidity and mortality. Cultural and language barriers probably also contribute to some of these disparities. Minorities use emergency medical services systems less, are often delayed in arriving at the emergency department, have longer waiting times in the emergency department, and are less likely to receive thrombolysis for acute ischemic stroke. Although unmeasured factors may play a role in these delays, the presence of bias in the delivery of care cannot be excluded. Minorities have equal access to rehabilitation services, although they experience longer stays and have poorer functional status than whites. Minorities are inadequately treated with both primary and secondary stroke prevention strategies compared with whites. Sparse data exist on racial-ethnic disparities in access to surgical care after intracerebral hemorrhage and subarachnoid hemorrhage. Participation of minorities in clinical research is limited. Barriers to participation in clinical research include beliefs, lack of trust, and limited awareness. Race is a contentious topic in biomedical research because race is not proven to be a surrogate for genetic constitution. There are limitations in the current definitions of race and ethnicity. Nevertheless, racial and ethnic disparities in stroke exist and include differences in the biological determinants of disease and disparities throughout the continuum of care, including access to and quality of care. Access to and participation in research is also limited among minority groups. Acknowledging the presence of disparities and understanding the factors that contribute to them are necessary first steps. More research is required to understand these differences and find solutions.

Ethnic Disparities in Stroke and Hypertension Among Women: The BASIC Project

Little data exist on stroke burden in Mexican-American (MA) women. The objective of this study was to characterize the burden of stroke in MA and non-Hispanic white (NHW) women and to compare this burden across ethnic groups. Cases of ischemic stroke and intracerebral hemorrhage among women (January 2000-December 2006) were identified as part of the Brain Attack Surveillance in Corpus Christi (BASIC) Project, a stroke surveillance study in a biethnic Texas community. Cumulative incidence of stroke among women was compared by ethnicity and age. Logistic regression was used to compare risk factors and age-adjusted use of antihypertensives between MA and NHW female stroke cases. MA women had elevated stroke risk compared with NHW women at younger ages (ages 45-59: relative risk (RR) = 2.00 (95% confidence interval (CI): 1.54-2.58); ages 60-74: RR = 1.57 (95% CI: 1.31-1.87); ages > or =75: RR = 1.13 (95% CI: 0.98-1.29)). Stroke severity and stroke type did not differ between ethnic groups. MA female stroke cases were more likely to have hypertension (odds ratio (OR) = 1.41 (95% CI: 1.11-1.80)), diabetes (OR = 3.54 (95% CI: 2.82-4.45)), and the presence of both risk factors (OR = 3.31 (95% CI: 2.61-4.21)) compared with NHW female stroke cases and were more likely to report use of antihypertensives (OR = 1.51 (95% CI: 1.10-2.06)). There was a trend toward greater hypertension awareness among MA female stroke cases (OR = 1.37 (95% CI: 0.98-1.91)). MA women have increased risk of stroke at younger ages compared with NHW women. Reasons for this ethnic disparity, including an increased prevalence of hypertension and diabetes, should be explored.

Addressing racial and ethnic disparities in stroke

Stroke is pricey.1 In addition to its devastating medical and social consequences it has enormous financial costs, which unfavorably impact the individual stroke survivor, their family, and society. According to the American Heart Association, estimated direct and indirect costs for stroke in 2006 will reach $58 billion.2 While knowledge of the huge and increasing economic burden of stroke is not new, further delineation of the sociodemographic implications of the problem could help health policy decision-makers prioritize resources and implement comprehensive steps of action to mitigate the rising financial tide due to stroke. The article by Brown et al. in this issue of Neurology explores the impact of racial and ethnic disparities on future economic consequences attributable to stroke.3 Utilizing United States census estimates of race-ethnic populations, and extracting stroke epidemiology data from representative multiethnic stroke surveillance cohort studies, they developed a conservative model of projected direct and indirect costs …

Ethnic Disparities in Stroke

Evidence for ethnic disparities in stroke incidence, severity, and mortality has continued to mount in recent years. However, the picture for disparities in acute management and rehabilitation remains more ambiguous. The objective of this report is to summarize current evidence from stroke epidemiology and studies focusing on disparities in stroke care and disability, suggesting courses for action. A comprehensive search of current literature on ethnic/racial variation in stroke incidence, mortality, and severity, as well as acute and postacute patient care was performed. Recent evidence unambiguously reaffirms a greater burden of disease in stroke, greater mortality, and greater severity of strokes for blacks. Evidence for disparities in acute and postacute care is less conclusive, as is the evidence for disparities among other ethnic groups. Evidence for health disparities in stroke care across settings, regions, and the continuum of care varies considerably. Minority ethnic groups have higher rates or more severe stroke, but variations in prognosis for clinical outcomes other than mortality remain less certain. There is considerable need for more studies that take into account regional ethnic variations in treatment and outcomes, and for better documentation of stroke outcomes among groups in addition to blacks. Dealing with ethnic disparities in stroke will be served by sustained attention to quality improvement in high-impact areas in stroke care, complemented by initiatives that promote cultural competence.

Racism and tPA Use in African-Americans

To the Editor: The investigation of Johnston et al1 into the influence of ethnicity on thrombolysis raises the spectre of racism in health service provision. However, as shown in the case of cardiac catheterization after myocardial infarction, racism is not always the reason for differences in treatment.2 Although the authors used a simple dichotomous definition of stroke severity in their regression analysis, they did not account for stroke subtype (or National Institutes of Health Stroke Scale [NIHSS] score). The proportion of ischemic stroke due to small-vessel disease in African-Americans is 52% compared with 25% in whites.3 Lacunar strokes tend to be less severe (maximum NIHSS of 10) and have a better prognosis than cortical ischemic strokes.4 The authors’ Table 2 demonstrates that despite American Heart Association guidelines, physicians are reluctant to give tPA to patients with …