Inaugural Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving Symposium

Addressing disparities in the global epidemiology of stroke

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.

Attributable Costs of Stroke in Ontario, Canada and Their Variation by Stroke Type and Social Determinants of Health

BACKGROUND

Estimates of attributable costs of stroke are scarce, as most prior studies do not account for the baseline health care costs in people at risk of stroke. We estimated the attributable costs of stroke in a universal health care setting and their variation across stroke types and several social determinants of health.

METHODS

We undertook a population-based administrative database-derived matched retrospective cohort study in Ontario, Canada. Community-dwelling adults aged ≥40 years with a stroke between 2003 and 2018 were matched (1:1) on demographics and comorbidities with controls without stroke. Using a difference-in-differences approach, we estimated the mean 1-year direct health care costs attributable to stroke from a public health care payer perspective, accounting for censoring with a weighted available sample estimator. We described health sector-specific costs and reported variation across stroke type and social determinants of health.

RESULTS

The mean 1-year attributable costs of stroke were Canadian dollars 33 522 (95% CI, $33 231-$33 813), with higher costs for intracerebral hemorrhage ($40 244; $39 193-$41 294) than ischemic stroke ($32 547; $32 252-$32 843). Most of these costs were incurred in acute care hospitals ($15 693) and rehabilitation facilities ($7215). Compared with all patients with stroke, the mean attributable costs were higher among immigrants ($40 554; $39 316-$41 793), those aged <65 years ($35 175; $34 533-$35 818), and those residing in low-income neighborhoods ($34 687; $34 054-$35 320) and lower among rural residents ($29 047; $28 362-$29 731).

CONCLUSIONS

Our findings of high attributable costs of stroke, especially in immigrants, younger patients, and residents of low-income neighborhoods, can be used to evaluate potential health care cost savings associated with different primary stroke prevention strategies.

Perceived Interpersonal Racism and Incident Stroke Among US Black Women

Importance

Black individuals in the US experience stroke and stroke-related mortality at younger ages and more frequently than other racial groups. Studies examining the prospective association of interpersonal racism with stroke are lacking.

Objective

To examine the association of perceived interpersonal racism with incident stroke among US Black women.

Design, Setting, and Participants

The Black Women's Health Study, a prospective cohort study of 59 000 Black women from across the US, assessed the longitudinal association between perceived interpersonal racism and stroke incidence. Stroke-free participants were followed up from 1997 until onset of stroke, death, loss to follow-up, or the end of the study period (December 31, 2019). Cox models were used to estimate hazard ratios (HRs) and 95% CIs, adjusting for major confounders, including education, neighborhood socioeconomic environment, and cardiometabolic factors. Data analysis was performed from March 2021 until December 2022.

Exposure

On a questionnaire completed in 1997, participants reported experiences of racism in everyday life and when dealing with situations that involved employment, housing, and interactions with police.

Main Outcomes and Measures

Strokes were identified through self-report on biennial questionnaires, medical records adjudication, and linkage with the National Death Index.

Results

In 1997, 48 375 Black women (mean [SD] age, 41 [10] years) provided information on perceived interpersonal racism and were free of cardiovascular disease and cancer. During the 22 years of follow-up, 1664 incident stroke cases were identified; among them, 550 were definite cases confirmed by neurologist review and/or National Death Index linkage. Multivariable HRs for reported experiences of racism in all 3 domains of employment, housing, and interactions with police vs no such experiences were 1.38 (95% CI, 1.14-1.67), a 38% increase, for all incident cases and 1.37 (95% CI, 1.00-1.88) for definite cases. For comparisons of women in the highest quartile of everyday interpersonal racism score vs women in the lowest quartile, multivariable HRs were 1.14 (95% CI, 0.97-1.35) for analyses that included all incident stroke and 1.09 (95% CI, 0.83-1.45) for analyses that included definite cases only.

Conclusions and Relevance

In this study, Black women who reported experiences of interpersonal racism in situations involving employment, housing, and interactions with police appeared to have an increased risk of stroke, even after accounting for demographic and vascular risk factors, suggesting that the high burden of racism experienced by Black US women may contribute to racial disparities in stroke incidence.

Use of Community-Engaged Research Approaches in Clinical Interventions for Neurologic Disorders in the United States: A Scoping Review and Future Directions for Improving Health Equity Research

BACKGROUND AND OBJECTIVES

Evidence suggests a significant prevalence of race and ethnic disparities in the United States among people with neurologic conditions including stroke, Alzheimer disease and related dementia (ADRD), Parkinson disease (PD), epilepsy, spinal cord injury (SCI), and traumatic brain injury (TBI). Recent neurologic research has begun the paradigm shift from observational health disparities research to intervention research in an effort to narrow the disparities gap. There is an evidence base that suggests that community engagement is a necessary component of health equity. While the increase in disparities focused neurologic interventions is encouraging, it remains unclear whether and how community-engaged practices are integrated into intervention design and implementation. The purpose of this scoping review was to identify and synthesize intervention studies that have actively engaged with the community in the design and implementation of interventions to reduce disparities in neurologic conditions and to describe the common community engagement processes used.

METHODS

Two databases, PubMed and CINAHL, were searched to identify eligible empirical studies within the United States whose focus was on neurologic interventions addressing disparities and using community engagement practices.

RESULTS

We identified 392 disparity-focused interventions in stroke, ADRD, PD, epilepsy, SCI, and TBI, of which 53 studies incorporated community engagement practices: 32 stroke studies, 15 ADRD, 2 epilepsy studies, 2 PD studies, 1 SCI study, and 1 TBI study. Most of the interventions were designed as randomized controlled trials and were programmatic in nature. The interventions used a variety of community engagement practices: community partners (42%), culturally tailored materials and mobile health (40%), community health workers (32%), faith-based organizations and local businesses (28%), focus groups/health need assessments (25%), community advisory boards (19%), personnel recruited from the community/champions (19%), and caregiver/social support (15%).

DISCUSSION

Our scoping review reports that the proportion of neurologic intervention studies incorporating community engagement practices is limited and that the practices used within those studies are varied. The major practices used included collaboration with community partners and utilization of culturally tailored materials. We also found inconsistent reporting and dissemination of results from studies that implemented community engagement measures in their interventions. Future directions include involving the community in research early and continuously, building curricula that address challenges to community engagement, prioritizing the inclusion of community engagement reporting in peer-reviewed journals, and prioritizing and incentivizing research of subpopulations that experience disparities in neurologic conditions.

Trends in Disparities in Advanced Neuroimaging Utilization in Acute Stroke: A Population-Based Study

BACKGROUND

Our primary objective was to evaluate if disparities in race, sex, age, and socioeconomic status (SES) exist in utilization of advanced neuroimaging in year 2015 in a population-based study. Our secondary objective was to identify the disparity trends and overall imaging utilization as compared with years 2005 and 2010.

METHODS

This was a retrospective, population-based study that utilized the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study) data. Patients with stroke and transient ischemic attack were identified in the years 2005, 2010, and 2015 in a metropolitan population of 1.3 million. The proportion of imaging use within 2 days of stroke/transient ischemic attack onset or hospital admission date was computed. SES determined by the percentage below the poverty level within a given respondent's US census tract of residence was dichotomized. Multivariable logistic regression was used to determine the odds of advanced neuroimaging use (computed tomography angiogram/magnetic resonance imaging/magnetic resonance angiogram) for age, race, gender, and SES.

RESULTS

There was a total of 10 526 stroke/transient ischemic attack events in the combined study year periods of 2005, 2010, and 2015. The utilization of advanced imaging progressively increased (48% in 2005, 63% in 2010, and 75% in 2015 [P<0.001]). In the combined study year multivariable model, advanced imaging was associated with age and SES. Younger patients (≤55 years) were more likely to have advanced imaging compared with older patients (adjusted odds ratio, 1.85 [95% CI, 1.62-2.12]; P<0.01), and low SES patients were less likely to have advanced imaging compared with high SES (adjusted odds ratio, 0.83 [95% CI, 0.75-0.93]; P<0.01). A significant interaction was found between age and race. Stratified by age, the adjusted odds of advanced imaging were higher for Black patients compared with White patients among older patients (>55 years; adjusted odds ratio, 1.34 [95% CI, 1.15-1.57]; P<0.01), but no racial differences among the young.

CONCLUSIONS

Racial, age, and SES-related disparities exist in the utilization of advanced neuroimaging for patients with acute stroke. There was no evidence of a change in trend of these disparities between the study periods.

Kenton Award Lecture-Stroke Disparities Research: Learning From the Past, Planning for the Future

Inequities in stroke care and outcomes have been documented both within and among countries based on factors, such as race, geography, and socioeconomic status. Research can help us to identify, understand, and address inequities, and this article offers considerations for scientists working in this area. These include designing research aimed at identifying the underlying causes of inequities, recognizing the importance of the social determinants of health, considering interventions that go beyond the individual patient and provider to include policies and systems, acknowledging the role of structural racism, performing community-engaged participatory research, considering intersecting social identities, learning from cross-national comparisons, maintaining the data sources needed for inequities research, using terminology that advances health equity, and improving diversity across the research enterprise.

Telerehabilitation for Stroke is Here to Stay. But at What Cost?

The use of telerehabilitation after stroke has necessarily increased in the last 2 years because of the COVID-19 pandemic, and many rehabilitation teams rapidly adapted to offering their services remotely. Evidence supporting the efficacy of telerehabilitation is still scarce with few randomized controlled trials, although current systematic reviews suggest that telerehabilitation does not lead to inferior outcomes when compared to face-to-face treatment. Increasing experience of telerehabilitation however has highlighted some of the pitfalls that need to be solved before we see widespread pragmatic adoption of new practices. We must ensure that offering services using digital technologies does not exclude those who need our services. We must acknowledge that our interactions online differ, both in the way we relate to each other and in the content of clinical consultations. Furthermore, we need to consider how to support staff who may be feeling disconnected and fatigued after spending hours providing remote therapies. Telerehabilitation is likely here to stay and has potential to help deliver rehabilitation to the many people who could benefit, but there are obstacles, challenges and trade-offs to be considered and overcome.

Community Engagement: Lessons Learned From the AAASPS and SDBA

Community engagement is a means to help overcome challenges to the delivery of health care and preventative services. On the occasion of the 2021 International Stroke Conference Edgar J. Kenton III Lecture, I review community engagement strategies utilized in the AAASPS trial (African-American Antiplatelet Stroke Prevention Study) and SDBA (Studies of Dementia in the Black Aged) observational studies that I directed. The main community engagement strategies included use of home visits (bringing the study to the community), engagement of churches, community advisors, community physicians, other healthcare providers, major Black community organizations, and utilization of diversity training. Community engagement strategies were a major component of AAASPS and SDBA that helped to ensure successful recruitment and retention of an underrepresented community in clinical trial and observational studies. Lessons learned from these studies largely carried out in the 1980s and 1990s helped to dispel myths that Blacks could not be recruited into large-scale clinical trials, emphasized the importance of studying underrepresented groups with adequate statistical power to test primary study hypotheses, and provided foundational recruitment and retention methods for future consideration.

The 2021 William Feinberg Award Lecture Seeking Glocal Solutions to Cerebrovascular Health Inequities

Global and local (“glocal”) disparities in stroke incidence, prevalence, care, and mortality are persistent, pervasive, and progressive. In particular, the disproportionate burden of stroke in people of African ancestry compared to most other racial/ethnic groups around the world has been long standing, is expected to worsen, and so far, has defied solution, largely because conventional risk factors likely account for less than half of the Black versus White disparity in stroke outcomes. While hypotheses such as a differential impact or inadequate evaluation of traditional risk factors by race have been suggested as potentially key factors contributing to lingering racial/ethnic stroke disparities, relatively understudied novel risk factors such as psychosocial stress, environmental pollution, and inflammation; and influences of the social determinants of health are gaining the most attention (and momentum). Moreover, it is increasingly recognized that while there is a lot still to understand, there needs to be a major shift from incessantly studying the problem, to developing interventions to resolve it. Resolution will likely require targeting multilevel factors, considering contemporaneous cross-national and cross-continental data collection, creating scalable care delivery models, jointly addressing care quality and community drivers of stroke occurrence, incorporating policy makers in planning/dissemination of successful interventions, and investing in robust transdisciplinary research training programs that address the interrelated issues of health equity and workforce diversity, and regional capacity building. To this end, our international multidisciplinary team has been involved in conducting several epidemiological studies and clinical trials in the area of stroke disparities, as well as executing career enhancing research training programs in the United States and Africa. This award lecture paper shares some of the lessons we have learnt from previous studies, presents objectives/design of ongoing initiatives, and discusses plans for the future.

HEADS-UP: Understanding and Problem-Solving: Seeking Hands-Down Solutions to Major Inequities in Stroke

There are substantial and longstanding inequities in stroke incidence, prevalence, care, and outcomes. The Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving (HEADS-UP) symposium is an annual multidisciplinary scientific and educational forum targeting major inequities in cerebrovascular disease, with the ultimate objective of helping to bridge major inequities in stroke, and promptly translating scientific results into routine clinical practice, for the benefit of vulnerable and underserved populations. HEADS-UP is a collaborative undertaking by the National Institute of Neurological Disorders and Stroke and the American Stroke Association and is held the day before the annual International Stroke Conference. In 2020, the HEADS-UP focused on the topic of racial/ethnic disparities in stroke and comprised invited lectures on determinants of racial/ethnic inequities in stroke as well as emerging interventions or promising strategies designed to overcome these inequities. Competitively selected travel award scholarships were given to 19 early stage investigators who presented posters at professor moderated sessions; engaged in several career development activities aimed imparting grant writing skills, knowledge about climbing the academic ladder, and striving for work-life balance; and participated in networking events. This Health Equity edition of Focused Updates will feature an overview of the HEADS-UP 2020 symposium proceedings and articles covering the key scientific content of the major lectures delivered during the symposium including the presentation by the award-winning plenary speaker. Starting in 2021, HEADS-UP will expand to include 5 major inequities in stroke (racial/ethnic, sex, geographic, socioeconomic, and global) and seeks to be a viable avenue to meet the health equity goals of the American Heart Association/American Stroke Association, National Institutes of Neurological Disorders and Stroke, and World Stroke Organization.