Introduction: Healthcare disparities exist between demographic groups with stroke. We examined whether patients of particular ethnicity or income levels experienced reduced access to or delays in receiving stroke care.

Methods: All admissions in the Nationwide Inpatient Sample (NIS) database from 2002 to 2008 for ischemic stroke were studied. We used statistical models to determine whether median income or race were associated with intravenous thrombolysis treatment, in-hospital mortality, discharge disposition, hospital charges and length of stay in high- or low-volume hospitals.

Results: There were 477,474 patients with ischemic stroke: 10,781 (2.3%) received intravenous thrombolysis, and 380,400 (79.7%) were treated in high-volume hospitals. Race (p<0.0001) and median income (p<0.001) were significant predictors of receiving IV thrombolysis, with minorities and low-income patients less likely to receive IV thrombolysis. Median income was a predictor of access to high-volume hospitals (p<0.0001) with wealthier patients more likely to be treated in high-volume hospitals which had lower mortality (p=0.0002). Patients in high-volume hospitals were 1.84 times more likely to receive IV thrombolysis (p<0.0001).

Conclusions: African-Americans, Hispanics and low median income patients are less likely to receive IV thrombolysis for ischemic stroke. Low median income patients are less likely to be treated at high-volume hospitals. High-volume hospitals have lower mortality and higher likelihood of treating with IV thrombolysis. There is evidence for an influence of socioeconomic status and racial disparity in the treatment of ischemic stroke.

Patient Care: Make the medical community aware of the disparity in acute ischemic stroke treatment so that we can educate those patients at highest risk, as well as those who take care of stroke patients.

Learning Objectives: By the conclusion of this session, participants should be able to be aware that there is a socioeconomic disparity in stroke treatment in the United States, and to focus on narrowing this disparity.

References: 1. Zweifler RM, McClure LA, Howard VJ, Cushman M, Hovater MK, et al. Racial and Geographic Differences in Prevalence, Awareness, Treatment and Control of Dyslipidemia: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Neuroepidemiology. 2011;37:39-44. 2. Cruz-Flores S, Rabinstein A, Biller J, Elkind MS, Griffith P, Gorelick PB, et al. American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Epidemiology and Prevention; Council on Quality of Care and Outcomes Research. Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:2091-116. 3. Lacy CR, Suh DC, Bueno M, Kostis JB. Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.). Stroke. 2001;32:63– 69. 4. Saposnik G, Jeerakathil T, Selchen D, Baibergenova A, Hachinski V, Kapral MK; Socioeconomic status, hospital volume, and stroke fatality in Canada. Stroke Outcome Research Canada Working Group. Stroke. 2008;39:3360-6. 5. Saposnik G, Baibergenova A, O'Donnell M, Hill MD, Kapral MK, Hachinski V; Stroke Outcome Research Canada (SORCan) Working Group. Hospital volume and stroke outcome: does it matter? Neurology. 2007;69:1142-51. 6. Marler JR, Tilley BC, Lu M, Brott TG, Lyden PC, Grotta JC, et al. National Institute of Neurological Disorders and Stroke: Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology. 2000;55:1649-55. 7. Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009;40:2945-8. 8. Wahlgren N, Ahmed N, Dávalos A, Hacke W, Millán M, Muir K, et al. Thrombolysis with alteplase 3-4.5 h after acute ischaemic stroke (SITS-ISTR): an observational study. Lancet. 2008;372:1303-9. 9. Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, et al. Executive summary: heart disease and stroke statistics--2010 update: a report from the American Heart Association. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2010;121:948-54. 10. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8-27. 11. Pearson TA, Lewis C. Rural epidemiology: insights from a rural population laboratory. Am J Epidemiol. 1998;148:949-957. 12. Eberhardt MS, Pamuk ER. The importance of place of residence: examining health in rural and nonrural areas. Am J Public Health. 2004;94:1682-1686. 13. Murray CJ, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, Iandiorio TJ, Ezzati M. Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Med. 2006;3:3260. 14. Levine DA, Neidecker MV, Kiefe CI, Karve S, Williams LS, Allison JJ. Racial/ethnic disparities in access to physician care and medications among US stroke survivors. Neurology. 2011;76:53-61. 15. Reiner-Deitemyer V, Teuschl Y, Matz K, Reiter M, Eckhardt R, Seyfang L, et al. Austrian Stroke Unit Registry Collaborators. Helicopter transport of stroke patients and its influence on thrombolysis rates: data from the Austrian Stroke Unit Registry. Stroke. 2011;42:1295-300. 16. Liao Y, Greenlund KJ, Croft JB, Keenan NL, Giles WH. Factors explaining excess stroke prevalence in the US Stroke Belt. Stroke. 2009;40:3336-41. 17. Cesaroni G, Agabiti N, Forastiere F, Perucci CA Socioeconomic differences in stroke incidence and prognosis under a universal healthcare system. Stroke. 2009;40:2812-9. 18. Gropen T, Magdon-Ismail Z, Day D, Melluzzo S, Schwamm LH; NECC Advisory Group. Regional implementation of the stroke systems of care model: recommendations of the northeast cerebrovascular consortium. Stroke. 2009;40:1793-802. 19. Kapral MK, Wang H, Mamdani M, Tu JV. Effect of socioeconomic status on treatment and mortality after stroke. Stroke. 2002;33:268-73. 20. Hsia AW, Edwards DF, Morgenstern LB, Wing JJ, Brown NC, Coles R, et al. Racial disparities in tissue plasminogen activator treatment rate for stroke: a population-based study. Stroke. 2011;42:2217-21. 21. Johnston SC, Fung LH, Gillum LA, Smith WS, Brass LM, Lichtman JH, et al. Utilization of intravenous tissue-type plasminogen activator for ischemic stroke at academic medical centers: the influence of ethnicity. Stroke. 2001;32: 1061-8. 22. Leira EC, Hess DC, Torner JC, Adams HP Jr Rural-urban differences in acute stroke management practices: a modifiable disparity. Arch Neurol. 2008;65:887-91. 23. Karve SJ, Balkrishnan R, Mohammad YM, Levine DA. Racial/ethnic disparities in emergency department waiting time for stroke patients in the United States. J Stroke Cerebrovasc Dis. 2011;20:30–40. 24. Howard G, Anderson RT, Russell G, Howard VJ, Burke GL. Race, socioeconomic status, and cause-specific mortality. Ann Epidemiol. 2000;10:214 –223. 25. Trimble B, Morgenstern LB. Stroke in minorities. Neurol Clin. 2008; 26:1177–1190.