Disparities in Inter-hospital Helicopter Transportation for Hispanics by Geographic Region: A Threat to Fairness in the Era of Thrombectomy

Racial and Ethnic Disparities in Stroke Reperfusion Therapy in the USA

Racial and ethnic inequities in stroke care are ubiquitous. Acute reperfusion therapies, i.e., IV thrombolysis (IVT) and mechanical thrombectomy (MT), are central to acute stroke care and are highly efficacious at preventing death and disability after stroke. Disparities in the use of IVT and MT in the USA are pervasive and contribute to worse outcomes among racial and ethnic minority individuals with ischemic stroke. A meticulous understanding of disparities and underlying root causes is necessary in order to develop targeted mitigation strategies with lasting effects. This review details racial and ethnic disparities in the use of IVT and MT after stroke and highlights inequities in the underlying process measures as well as the contributing root causes. Furthermore, this review spotlights the systemic and structural inequities that contribute to race-based differences in the use of IVT and MT, including geographic and regional differences and differences based on neighborhood, zip code, and hospital type. In addition, recent promising trends suggesting improvements in racial and ethnic IVT and MT disparities and potential approaches for future solutions to achieve equity in stroke care are briefly discussed.

A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks

Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism.

CONTEXT

Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers.

METHODS

To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research.

FINDINGS

The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity.

CONCLUSIONS

The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.

Disparities in Care Among Gunshot Victims: A Nationwide Analysis

INTRODUCTION

Given the well-known healthcare disparities most pronounced in racial and ethnic minorities, trauma healthcare in underrepresented patients should be examined, as in-hospital bias may influence the care rendered to patients. This study seeks to examine racial differences in outcomes and resource utilization among victims of gunshot wounds in the United States.

METHODS

This is a retrospective review of the National Trauma Data Bank (NTDB) conducted from 2007 to 2017. The NTDB was queried for patients who suffered a gunshot wound not related to accidental injury or suicide. Patients were stratified according to race. The primary outcome for this study was mortality. Secondary outcomes included racial differences in resource utilization including air transport and discharge to rehabilitation centers. Univariate and multivariate analyses were used to compare differences in outcomes between the groups.

RESULTS

A total of 250,675 patients were included in the analysis. After regression analysis, Black patients were noted to have greater odds of death compared to White patients (odds ratio [OR] 1.14, confidence interval [CI] 1.037-1.244; P = 0.006) and decreased odds of admission to the intensive care unit (ICU) (OR 0.76, CI 0.732-0.794; P < 0.001). Hispanic patients were significantly less likely to be discharged to rehabilitation centers (Hispanic: 0.78, CI 0.715-0.856; P < 0.001). Black patients had the shortest time to death (median time in minutes: White 49 interquartile range [IQR] [9-437] versus Black 24 IQR [7-205] versus Hispanic 39 IQR [8-379] versus Asian 60 [9-753], P < 0.001).

CONCLUSIONS

As society carefully examines major institutions for implicit bias, healthcare should not be exempt. Greater mortality among Black patients, along with differences in other important outcome measures, demonstrate disparities that encourage further analysis of causes and solutions to these issues.

Racial and ethnic disparities in interhospital transfer for complex emergency general surgical disease across the United States

BACKGROUND

Differential access to specialty surgical care can drive health care disparities, and interhospital transfer (IHT) is one mechanism through which access barriers can be realized for vulnerable populations. The association between race/ethnicity and IHT for patients presenting with complex emergency general surgery (EGS) disease is understudied.

METHODS

Using the 2019 Nationwide Emergency Department Sample, we identified patients 18 years and older with 1 of 13 complex EGS diseases based on International Classification of Diseases, Tenth Revision , diagnosis codes. The primary outcome was IHT. A series of weighted logistic regression models was created to determine the association of race/ethnicity with the primary outcome while controlling for patient and hospital characteristics.

RESULTS

Of 387,610 weighted patient encounters from 989 hospitals, 59,395 patients (15.3%) underwent IHT. Compared with non-Hispanic White patients, rates of IHT were significantly lower for non-Hispanic Black (15% vs. 17%; unadjusted odds ratio (uOR) [95% confidence interval (CI)], 0.58 [0.49-0.68]; p < 0.001), Hispanic/Latinx (HL) (9.0% vs. 17%; uOR [95% CI], 0.48 [0.43-0.54]; p < 0.001), Asian/Pacific Islander (Asian/PI) (11% vs. 17%; uOR [95% CI], 0.84 [0.78-0.91]; p < 0.001), and other race/ethnicity (12% vs. 17%; uOR [95% CI], 0.68 [0.57-0.81]; p < 0.001) patients. In multivariable models, the adjusted odds of IHT remained significantly lower for HL (adjusted odds ratio [95% CI], 0.76 [0.72-0.83]; p < 0.001) and Asian/PI patients (adjusted odds ratio [95% CI], 0.73 [0.62-0.86]; p < 0.001) but not for non-Hispanic Black and other race/ethnicity patients ( p > 0.05).

CONCLUSION

In a nationally representative sample of emergency departments across the United States, patients of minority race/ethnicity presenting with complex EGS disease were less likely to undergo IHT when compared with non-Hispanic White patients. Disparities persisted for HL and Asian/PI patients when controlling for comorbid conditions, hospital and residential geography, neighborhood socioeconomic status, and insurance; these patients may face unique barriers in accessing surgical care.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Association Between Hyperacute Blood Pressure Variability and Hematoma Expansion After Intracerebral Hemorrhage: Secondary Analysis of the FAST-MAG Database

BACKGROUND

Blood pressure variability (BPV) has emerged as a significant factor associated with clinical outcomes after intracerebral hemorrhage (ICH). Although hematoma expansion (HE) is associated with clinical outcomes, the relationship between BPV that encompasses prehospital data and HE is unknown. We hypothesized that BPV was positively associated with HE.

METHODS

We analyzed 268 patients with primary ICH enrolled in the National Institutes of Health-funded Field Administration of Stroke Therapy-Magnesium (FAST-MAG) study who received head computed tomography or magnetic resonance imaging on arrival to the emergency department (ED) and repeat imaging within 6-48 h. BPV was calculated by standard deviation (SD) and coefficient of variation (CV) from prehospital data as well as systolic blood pressure (SBP) measurements taken on ED arrival, 15 min post antihypertensive infusion start, 1 h post maintenance infusion start, and 4 h after ED arrival. HE was defined by hematoma volume expansion increase > 6 mL or by 33%. Univariate logistic regression was used for presence of HE in quintiles of SD and CV of SBP for demographics and clinical characteristics.

RESULTS

Of the 268 patients analyzed from the FAST-MAG study, 116 (43%) had HE. Proportions of patients with HE were not statistically significant in the higher quintiles of the SD and CV of SBP for either the hyperacute or the acute period. Presence of HE was significantly more common in patients on anticoagulation.

CONCLUSIONS

Higher BPV was not found to be associated with occurrence of HE in the hyperacute or the acute period of spontaneous ICH. Further study is needed to determine the relationship.

The relationship between stroke system organization and disparities in access to stroke center care in California

Background

There are significant racial and ethnic disparities in receipt of reperfusion interventions for acute ischemic stroke. Our objective was to determine whether there are disparities in access to stroke center care by race or ethnicity that help explain differences in reperfusion therapy and to understand whether interhospital patient transfer plays a role in improving access.

Methods

Using statewide administrating data including all emergency department and hospital discharges in California from 2010 to 2017, we identified all acute ischemic stroke patients. Primary outcomes of interest included presentation to primary or comprehensive stroke center (PSC or CSC), interhospital transfer, discharge from PSC or CSC, and discharge from CSC alone. We used hierarchical logistic regression modeling to identify the relationship between patient- and hospital-level characteristics and outcomes of interest.

Results

Of 336,247 ischemic stroke patients, 55.4% were non-Hispanic White, 19.6% Hispanic, 10.6% non-Hispanic Asian/Pacific Islander, and 10.3% non-Hispanic Black. There was no difference in initial presentation to stroke center hospitals between groups. However, adjusted odds of reperfusion intervention, interhospital transfer and discharge from CSC did vary by race and ethnicity. Adjusted odds of interhospital transfer were lower among Hispanic (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98) and non-Hispanic Asian/Pacific Islander patients (OR 0.84, 95% CI 0.79 to 0.90) and odds of discharge from a CSC were lower for Hispanic (OR 0.91, 95% CI 0.85 to 0.97) and non-Hispanic Black patients (OR 0.74, 95% CI 0.67 to 0.81).

Conclusions

There are racial and ethnic disparities in reperfusion intervention receipt among stroke patients in California. Stroke system of care design, hospital resources, and transfer patterns may contribute to this disparity.

Mechanical Thrombectomy Access for All? Challenges in Increasing Endovascular Treatment for Acute Ischemic Stroke in the United States

Mechanical thrombectomy (MT) is the most effective treatment for selected patients with an acute ischemic stroke due to emergent large vessel occlusions (LVOs). There is an urgent need to identify and address challenges in access to MT to maximize the numbers of patients who can benefit from this treatment. Barriers in access to MT include delays in evaluation and accurate diagnosis of LVO leading to inappropriate triage, logistical delays related to availability of facilities and trained interventionalists, and financial hurdles that affect treatment reimbursement. Collection of regional data related to these barriers is critical to better understand current access gaps and a measurable access score to thrombectomy could be useful to plan local public health intervention.

Measuring More than Mortality: A scoping review of air ambulance outcome measures in a combined Institutes of Medicine and Donabedian quality framework

INTRODUCTION

Measuring the performance of air ambulance services are complex and dynamic due to the variability and interconnectedness of emergency systems. The aim of this study is to review the range and nature of air ambulance outcome measures published in peer review articles and construct a quality framework based on the results. A scoping review of the literature was conducted to identify outcome measures that evaluate the quality of air ambulance services. Combined frameworks from the Institutes of Medicine (IOM) and Dr. Avedia Donabedian were used to create a dashboard structure for a framework of air ambulance outcome measures.

METHODS

A literature search strategy was undertaken, following PRISMA-ScR guidelines and included eight databases over the period 2001-2019. Qualitative content analysis was conducted in 4-phases: 1) table summary of selected article outcome measures, 2) content analysis themes, codes of outcome measures and independent variables 3) narrative description of main themes 4) visual dashboard diagram of service priorities and quality strategies, based on the findings.

RESULTS

Thirty-four articles were screened by full text and eighteen met the selection criteria. Twenty codes emerged and were grouped to form eight consistent outcome themes; asset/ team type, access to definitive interventions, prehospital factors, mortality, morbidity, responsiveness of service, accessibility of service and patient disposition.

CONCLUSIONS

A quality framework consisting of eight outcome measures was created, it also identified seven gaps which ordinarily require performance evaluation; patient comfort and satisfaction reporting, cultural awareness training, safety alarms in place to identify volume stress, optimal coordination of resources, cost of service analysis, comprehensive patient journey time and an adaptive referral system analysis. The measures in the framework provide a broad perspective of air ambulance performance we believe will help decision-making and planning to improve patients experience and outcomes.

Racial/Ethnic Disparities in Interhospital Transfer for Conditions With a Mortality Benefit to Transfer Among Patients With Medicare

IMPORTANCE

Interhospital transfer (IHT) of patients is a common occurrence in modern health care. Racial/ethnic disparities are prevalent throughout US health care, but their presence in IHT is not well characterized.

OBJECTIVE

To determine if there are racial/ethnic disparities in IHT for medical diagnoses for which IHT is associated with a mortality benefit.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis used 2013 data from the Center for Medicare & Medicaid Services 100% Master Beneficiary Summary and Inpatient Claims merged with 2013 American Hospital Association data. Individuals with Medicare aged 65 years or older continuously enrolled in Medicare Part A and B with an inpatient hospitalization claim in 2013 for primary diagnosis of acute myocardial infarction, stroke, sepsis, or respiratory diseases were included. Data analysis occurred from November 2019 through July 2020.

EXPOSURES

Race/ethnicity.

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was IHT. For the primary analysis, a series of logistic regression models were created to estimate the adjusted odds of IHT for Black and Hispanic patients compared with White patients, controlling for patient clinical and demographic variables and incorporating hospital fixed effects. In secondary analyses, subgroup analyses were conducted by diagnosis, hospital teaching status, and hospitalization to hospitals in the top decile of Black and Hispanic patient proportion.

RESULTS

Among 899 557 patients, 734 958 patients were White (81.7%), 84 544 patients were Black (9.4%), and 47 588 patients were Hispanic (5.3%); there were 418 683 men (46.5%), and 306 215 patients (34.0%) were older than 84 years. The mean (SD) age was 76.8 (7.5) years. Among all patients, 20 171 White patients (2.7%), 1913 Black patients (2.3%), and 1062 Hispanic patients (2.2%) underwent IHT. After controlling for patient variables and hospital fixed effects, Black patients had a persistently lower odds of IHT (adjusted odds ratio, 0.87; 95% CI, 0.81-0.92; P < .001), while Hispanic patients had higher odds of IHT (adjusted odds ratio, 1.14; 95% CI, 1.05-1.24; P = .002) compared with White patients.

CONCLUSIONS AND RELEVANCE

This national evaluation of IHT among patients hospitalized with diagnoses previously found to have mortality benefit with transfer found that, compared with White patients, Black patients had persistently lower adjusted odds of transfer after accounting for patient and hospital characteristics and measured across various hospital settings. Meanwhile, Hispanic patients had higher adjusted odds of transfer. This research highlights the need for the development of strategies to mitigate disparate transfer practices by patient race/ethnicity.

A Neurodisparity Index of Nationwide Access to Neurological Health Care in Northern Ireland

Nationwide disparities in managing neurological patients have rarely been reported. We compared neurological health care between the population who reside in a Health and Social Care Trust with a tertiary neuroscience center and those living in the four non-tertiary center Trusts in Northern Ireland. Using the tertiary center Trust population as reference, neurodisparity indices (NDIs) defined as the number of treated patients resident in each Trust per 100,000 residents compared to the same ratio in the tertiary center Trust for a fixed time period. NDIs were calculated for four neurological pathways—intravenous thrombolysis (iv-tPA) and mechanical thrombectomy (MT) for acute ischemic stroke (AIS), disease modifying treatment (DMT) in multiple sclerosis (MS) and admissions to a tertiary neurology ward. Neurological management was recorded in 3,026 patients. Patients resident in the tertiary center Trust were more likely to receive AIS treatments (iv-tPA and MT) and access to the neurology ward (p < 0.001) than patients residing in other Trusts. DMT use for patients with MS was higher in two non-tertiary center Trusts than in the tertiary center Trust. There was a geographical gradient for MT for AIS patients and ward admissions. Averaged NDIs for non-tertiary center Trusts were: 0.48 (95%CI 0.32–0.71) for patient admissions to the tertiary neurology ward, 0.50 (95%CI 0.38–0.66) for MT in AIS patients, 0.78 (95%CI 0.67–0.92) for iv-tPA in AIS patients, and 1.11 (95%CI 0.99–1.26) for DMT use in MS patients. There are important neurodisparities in Northern Ireland, particularly for MT and tertiary ward admissions. Neurologists and health service planners should be aware that geography and time-dependent management of neurological patients worsen neurodisparities.

Identifying Racial/Ethnic Disparities in Interhospital Transfer: an Observational Study

BACKGROUND

Interhospital transfer (IHT) is often performed to provide patients with specialized care. Racial/ethnic disparities in IHT have been suggested but are not well-characterized.

OBJECTIVE

To evaluate the association between race/ethnicity and IHT.

DESIGN

Cross-sectional analysis of 2016 National Inpatient Sample data.

PATIENTS

Patients aged ≥ 18 years old with common medical diagnoses at transfer, including acute myocardial infarction, congestive heart failure, arrhythmia, stroke, sepsis, pneumonia, and gastrointestinal bleed.

MAIN MEASURES

We performed a series of logistic regression models to estimate adjusted odds of transfer by race/ethnicity controlling for patient demographics, clinical variables, and hospital characteristics and to identify potential mediators. In secondary analyses, we estimated adjusted odds of transfer among patients at community hospitals (those more likely to transfer patients) and performed subgroup analyses by region and primary medical diagnosis.

KEY RESULTS

Of 5,774,175 weighted hospital admissions, 199,015 (4.5%) underwent IHT, including 4.7% of White patients, compared with 3.9% of Black patients and 3.8% of Hispanic patients. Black (OR 0.83, 95% CI 0.78-0.89) and Hispanic (OR 0.81, 95% CI 0.75-0.87) patients had lower crude odds of transfer compared with White patients, but this became non-significant after adjusting for hospital-level characteristics. In secondary analyses among patients hospitalized at community hospitals, Hispanic patients had lower adjusted odds of transfer (aOR 0.89, 95% CI 0.79-0.98). Disparities in IHT by race/ethnicity varied by region and medical diagnosis.

CONCLUSIONS

Black and Hispanic patients had lower odds of IHT, largely explained by a higher likelihood of being hospitalized at urban teaching hospitals. Racial/ethnic disparities in transfer were demonstrated at community hospitals, in certain geographic regions and among patients with specific diseases.

The impact of helicopter emergency medical service on acute ischemic stroke patients: A systematic review

BACKGROUND

Helicopter emergency medical services (HEMS) is commonly elected transport for acute ischemic stroke (AIS) known as a time-critical illness.

AIM

To conduct a systematic review in order to explore the HEMS impact on healthcare status, process and outcome measures for AIS patients.

METHODS

A systematic search was conducted of PubMed, Medline, CINAHL, Cochrane Library and Google Scholar. The gray literature and reference lists of included articles were also searched. Thirty studies met inclusion criteria.

RESULTS

Using Donabedian's framework, two studies focused on the impact on healthcare structure, twenty-three explored the impact on process measures, and five focused on clinical outcomes. HEMS structure implications could not be assessed due to insufficient studies. HEMS showed no significant outcome benefit compared to ground emergency medical services (EMS) and the impact on process measures was ambiguous.

CONCLUSIONS

HEMS necessity varied considerably between studies. More robust studies are needed for detection of the most suitable use of HEMS in AIS.