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Ospel JM, Diprose WK, Ganesh A, Martins S, Nguyen T, Psychogios M, Mansour O, Al-Ajlan F, Yang P, Pandian J, Gopinathan A, Sandset EC, Kennedy J, Volders D, Fahed R, Tjoumakaris S, Bhogal P, Kurz M, Yavagal D, Inoa V, Hill MD, Goyal M. Challenges to Widespread Implementation of Stroke Thrombectomy. Stroke 2024; 55:2173-2183. [PMID: 38979609 DOI: 10.1161/strokeaha.124.045889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Endovascular treatment (EVT) for acute ischemic stroke is one of the most efficacious and effective treatments in medicine, yet globally, its implementation remains limited. Patterns of EVT underutilization exist in virtually any health care system and range from a complete lack of access to selective undertreatment of certain patient subgroups. In this review, we outline different patterns of EVT underutilization and possible causes. We discuss common challenges and bottlenecks that are encountered by physicians, patients, and other stakeholders when trying to establish and expand EVT services in different scenarios and possible pathways to overcome these challenges. Lastly, we discuss the importance of implementation research studies, strategic partnerships, and advocacy efforts to mitigate EVT underutilization.
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Affiliation(s)
- Johanna Maria Ospel
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - William K Diprose
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Sheila Martins
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil (S.M.)
| | - Thanh Nguyen
- Departments of Radiology and Neurology, Boston Medical Center, MA (T.N.)
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, Switzerland (M.P.)
| | - Ossama Mansour
- Alexandria Faculty of Medicine, Department of Neurology, Alexandria University, Egypt (O.M.)
| | - Fahad Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia (F.A.-A.)
| | - Pengfei Yang
- Department of Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (P.Y.)
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College and Hospital, Vellore, India (J.P.)
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore (A. Gopinathan)
| | | | - James Kennedy
- Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom (J.K.)
| | - David Volders
- Department of Radiology, Dalhousie University, Halifax, Canada (D.V.)
| | - Robert Fahed
- Division Neurology, Department of Medicine, The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada (R.F.)
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA (S.T.)
| | - Pervinder Bhogal
- Department of Neuroradiology, The Royal London Hospital, Barts NHS Trust, United Kingdom (P.B.)
| | - Martin Kurz
- Department of Neurology, Stavanger University Hospital, Norway (M.K.)
| | - Dileep Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, FL (D.Y.)
| | - Violiza Inoa
- Department of Neurology, University of Tennessee Health Science Center, Memphis (V.I.)
| | - Michael D Hill
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
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Kiefer L, Daniel D, Polineni S, Dhamoon M. Racial disparities in access to, and outcomes of, acute ischaemic stroke treatments in the USA. Stroke Vasc Neurol 2024:svn-2023-003051. [PMID: 38777349 DOI: 10.1136/svn-2023-003051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Racism contributes to higher comorbid risk factors and barriers to preventive measures for black Americans. Advancements in systems of care, tissue plasminogen activator (tPA) availability and endovascular thrombectomy (ET) have impacted practice and outcomes while outpacing contemporary investigation into acute ischaemic stroke (AIS) care disparities. We examined whether recent data suggest ongoing disparity in AIS interventions and outcomes, and if hospital characteristics affect disparities. METHODS We examined 2016-2019 fee-for-service Medicare inpatient data. We ran unadjusted logistic regression models to calculate ORs and 95% CI for two interventions (tPA and ET) and four outcomes (inpatient mortality, 30-day mortality, discharge home and outpatient visit within 30 days), with the main predictor black versus white race, additionally adjusting for demographics, hospital characteristics, stroke severity and comorbidities. RESULTS 805 181 AIS admissions were analysed (12.4% black, 87.6% white). Compared with white patients, black patients had reduced odds of receiving tPA (OR 0.71, 95% CI 0.69 to 0.74, p<0.0001) and ET (0.69, 95% CI 0.65 to 0.72, p<0.0001). After tPA, black patients had reduced odds of 30-day mortality (0.77, 95% CI 0.72 to 0.82, p<0.0001), discharge home (0.72, 95% CI 0.68 to 0.77, p<0.0001) and outpatient visit within 30 days (0.89, 95% CI 0.84 to 0.95, p=0.0002). After ET, black patients had reduced odds of 30-day mortality (0.71, 95% CI 0.63 to 0.79, p<0.0001) and discharge home (0.75, 95% CI 0.64 to 0.88, p=0.0005). Adjusted models showed little difference in the magnitude, direction or significance of the main effects. CONCLUSIONS Black patients were less likely to receive AIS treatments, and if treated had lower likelihood of 30-day mortality, discharge home and outpatient visits. Despite advancements in practice and therapies, racial disparities remain in the modern era of AIS care and are consistent with inequalities previously identified over the last 20 years. The impact of hospital attributes on AIS care disparities warrants further investigation.
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Affiliation(s)
- Luke Kiefer
- Department of Neurology, Icahn School of Medicine, New York, New York, USA
| | - David Daniel
- Department of Neurology, Icahn School of Medicine, New York, New York, USA
| | - Sai Polineni
- Department of Neurology, Icahn School of Medicine, New York, New York, USA
| | - Mandip Dhamoon
- Department of Neurology, Icahn School of Medicine, New York, New York, USA
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Denny MC, Rosendale N, Gonzales NR, Leslie‐Mazwi TM, Middleton S. Addressing Disparities in Acute Stroke Management and Prognosis. J Am Heart Assoc 2024; 13:e031313. [PMID: 38529656 PMCID: PMC11179759 DOI: 10.1161/jaha.123.031313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/03/2024] [Indexed: 03/27/2024]
Abstract
There are now abundant data demonstrating disparities in acute stroke management and prognosis; however, interventions to reduce these disparities remain limited. This special report aims to provide a critical review of the current landscape of disparities in acute stroke care and highlight opportunities to use implementation science to reduce disparities throughout the early care continuum. In the prehospital setting, stroke symptom recognition campaigns that have been successful in reducing prehospital delays used a multilevel approach to education, including mass media, culturally tailored community education, and professional education. The mobile stroke unit is an organizational intervention that has the potential to provide more equitable access to timely thrombolysis and thrombectomy treatments. In the hospital setting, interventions to address implicit biases among health care providers in acute stroke care decision-making are urgently needed as part of a multifaceted approach to advance stroke equity. Implementing stroke systems of care interventions, such as evidence-based stroke care protocols at designated stroke centers, can have a broader public health impact and may help reduce geographic, racial, and ethnic disparities in stroke care, although further research is needed. The long-term impact of disparities in acute stroke care cannot be underestimated. The consistent trend of longer time to treatment for Black and Hispanic people experiencing stroke has direct implications on long-term disability and independence after stroke. A learning health system model may help expedite the translation of evidence-based interventions into clinical practice to reduce disparities in stroke care.
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Affiliation(s)
- M. Carter Denny
- Department of NeurologyGeorgetown University School of MedicineWashingtonDCUSA
- Department of Neurology, MedStar HealthWashingtonDCUSA
| | - Nicole Rosendale
- Department of NeurologyUniversity of California San FranciscoSan FranciscoCAUSA
- Weill Institute for Neurosciences, University of California San FranciscoSan FranciscoCAUSA
| | - Nicole R. Gonzales
- Department of NeurologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
| | | | - Sandy Middleton
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne and Australian Catholic UniversityDarlinghurstAustralia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic UniversityDarlinghurstAustralia
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Faigle R. Racial and Ethnic Disparities in Stroke Reperfusion Therapy in the USA. Neurotherapeutics 2023; 20:624-632. [PMID: 37219714 PMCID: PMC10275817 DOI: 10.1007/s13311-023-01388-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 05/24/2023] Open
Abstract
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.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA.
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Lekoubou A, Tankam C, Bishu KG, Ovbiagele B. Decompressive hemicraniectomy for stroke by race/ethnicity in the United States. eNeurologicalSci 2022; 29:100421. [PMID: 36176317 PMCID: PMC9513722 DOI: 10.1016/j.ensci.2022.100421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/13/2022] [Accepted: 08/24/2022] [Indexed: 11/24/2022] Open
Abstract
Objective Racial and ethnic differences in the performance of indicated neurosurgical procedures have been reported. However, it is not clear whether there are racial or ethnic differences in the performance of decompressive hemicraniectomy (DHC) for acute ischemic stroke. This study evaluated the rate, trends, and independent association of race and ethnicity with DHC among hospitalized ischemic stroke patients in the United States. Materials and methods We used the International Classification of Diseases, Clinical Modification (ICD-9-CM) to identify adult patients (18-year-old and older) with a primary discharge diagnosis of ischemic stroke, excluding those with a posterior circulation ischemic stroke in the Nationwide Inpatient Sample between 2006 and 2014. We computed the rate and trends of DHC. We then applied a multivariable logistic regression model to evaluate the independent association of race with DHC. Results A total 715,649 patients had anterior ischemic stroke, including 1514 who underwent DHC (2.1 per 1000). The rate of DHC increased overall from 1 per 1000 in 2006 to 3 per 1000 in 2014. Similar upward trends were noted among Non-Hispanic Whites, Non-Hispanic Blacks, and Hispanics. Hispanics with anterior ischemic stroke were 1.28 times more likely than non-Hispanic Whites to have DHC but no difference was observed between Non-Hispanic Blacks and Non-Hispanic Whites. Conclusions In this nationally representative sample of patients with anterior ischemic strokes, being of Hispanic ethnicity was independently associated with a higher frequency of receiving DHC compared to being Non-Hispanic White. Future studies should confirm this difference and explore the underlying reasons for it. Between 2006 and 2014, The rate of decompressive hemicraniectomy (DHC) increased from 1 per 1000 to 3 per 1000. The rate of DHC increased across all races/ethnicities. DHC was performed less frequently in Whites compared with other races each year. Hispanics with anterior ischemic stroke were 1.28 times more likely than non-Hispanic Whites to have DHC. No difference in the rate of DHC was observed between Blacks and Non-Hispanic Whites.
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Affiliation(s)
- Alain Lekoubou
- Department of Neurology, Penn State University, Hershey, PA, USA
| | - Cyril Tankam
- Penn State College of Medicine, Hershey, PA, USA
| | - Kinfe G Bishu
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, USA
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