Racial differences in survival post cerebral infarction among the elderly

Delays in presentation and mortality among Black patients with mechanical thrombectomy after large-vessel stroke at a US hospital

OBJECTIVE

The incidence and severity of stroke are disproportionately greater among Black patients. In this study, the authors sought to examine clinical outcomes among Black versus White patients after mechanical thrombectomy for stroke at a single US institution.

METHODS

All patients who underwent mechanical thrombectomy at a single center from January 1, 2014, through March 31, 2020, were retrospectively analyzed. Patients were grouped based on race, and demographic characteristics, preexisting conditions, clinical presentation, treatment, and stroke outcomes were compared. The association of race with mortality was analyzed in multivariable logistic regression analysis adjusted for potential confounders.

RESULTS

In total, 401 patients (233 males) with a reported race of Black (n = 28) or White (n = 373) underwent mechanical thrombectomy during the study period. Tobacco use was more prevalent among Black patients (43% vs 24%, p = 0.04), but there were no significant differences between the groups with respect to insurance, coronary artery disease, diabetes, illicit drug use, hypertension, or hyperlipidemia. The mean time from stroke onset to hospital presentation was significantly greater among Black patients (604.6 vs 333.4 minutes) (p = 0.007). There were no differences in fluoroscopy time, procedural success (Thrombolysis in Cerebral Infarction grade 2b or 3), hospital length of stay, or prevalence of hemicraniectomy. In multivariable analysis, Black race was strongly associated with higher mortality (32.1% vs 14.5%, p = 0.01). The disparity in mortality rates resolved after adjusting for the average time from stroke onset to presentation (p = 0.14).

CONCLUSIONS

Black race was associated with an increased risk of death after mechanical thrombectomy for stroke. The increased risk may be associated with access-related factors, including delayed presentation to stroke centers.

Racial/Ethnic and Geographic Variations In Long-Term Survival Among Medicare Beneficiaries After Acute Ischemic Stroke

INTRODUCTION

Little information is available about racial/ethnic and geographic variations in long-term survival among older patients (≥65) after acute ischemic stroke (AIS).

METHODS

We examined data on 1,019,267 Medicare fee-for-service (FFS) beneficiaries aged 66 or older, hospitalized with a primary diagnosis of AIS from 2008 through 2012. Survival was defined as the time from the date of AIS to date of death, or an end of follow-up date of December 31, 2017. We used Cox proportional hazard models to estimate 5-year survival after AIS, adjusted for age, sex, race and Hispanic ethnicity, poverty level, Charlson Comorbidity Index, and state.

RESULTS

Among 1,019,267 Medicare FFS beneficiaries hospitalized with AIS from 2008 through 2012, we documented 701,718 deaths (68.8%) during a median of 4 years of follow-up with 4.08 million person-years. The overall adjusted 5-year survival was 44%. Non-Hispanic Black men had the lowest 5-year survival, and 5-year survival varied significantly by state, from the highest at 49.1% (North Dakota) to the lowest at 40.5% (Hawaii). The ranges between the highest and lowest 5-year survival rates across states also varied significantly by racial/ethnic groups, with percentage point differences of 9.6 among non-Hispanic White, 11.3 among non-Hispanic Black, 17.7 among Hispanic, and 28.5 among other racial/ethnic beneficiaries.

CONCLUSION

We identified significant racial/ethnic and geographic variations in 5-year survival rates after AIS among 2008-2012 Medicare FFS beneficiaries. Further study is needed to understand the reasons for these variations and develop prevention strategies to improve survival and racial disparities in survival after AIS.

A Targeted Self-Management Approach for Reducing Stroke Risk Factors in African American Men Who Have Had a Stroke or Transient Ischemic Attack

PURPOSE

This study compared a novel self-management (TargetEd MAnageMent Intervention [TEAM]) versus treatment as usual (TAU) to reduce stroke risk in African American (AA) men.

DESIGN

Six-month prospective randomized controlled trial with outcomes evaluated at baseline, 3 months, and 6 months.

SETTING

Academic health center.

PARTICIPANTS

Thirty-eight (age < 65) AA men who had a stroke or transient ischemic attack and a Barthel index score of >60 were randomly assigned to TEAM (n = 19) or TAU (n = 19).

INTERVENTION

Self-management training, delivered in 1 individual and 4 group sessions (over 3 months).

MEASURES

Blood pressure, glycosylated hemoglobin (HbA1c), lipids, medication adherence, weight, and standardized measures of health behaviors (diet, exercise, smoking, substances), depression, and quality of life. Qualitative assessments evaluated the perspectives of TEAM participants.

ANALYSIS

T tests for paired differences and nonparametric tests. Thematic content qualitative analysis.

RESULTS

Mean age was 52.1 (standard deviation [SD] = 7.4) and mean body mass index was 31.4 (SD = 7.4). Compared to TAU, TEAM participants had significantly lower mean systolic blood pressure by 24 weeks, and there was also improvement in HbA1c and high-density lipoprotein cholesterol ( P = .03). Other biomarker and health behaviors were similar between groups. Qualitative results suggested improved awareness of risk factors as well as positive effects of group support.

Dialogues in Diversity: An Invited Series of Papers, Advance Directives, DNRs, and End-of-Life Care for African Americans

The article utilizes a meta-analysis of the existing empirical research and theory on health care directives to provide some insights into the documented pattern of African Americans to use advance directives less than Whites. A number of relevant factors are highlighted and examined. In addition the article attempts to provide some insights into African American family life and traditional values regarding the care of the elderly and end-of-life care. The African American tradition of employing a family-centered decision making process during family crisis, as well as a significant cultural mistrust of institutionalized care is also explored. The article also attempts to offer some practical suggestions for clinical care givers working with African Americans to enhance culturally sensitive care giving and the utilization of advanced directives among African Americans at the end-of-life.

Using focus groups to inform the development of stroke recovery and prevention programs for younger African-American (AA) men

OBJECTIVE

To assess perceived facilitators and recommendations for stroke recovery and prevention among younger African-American (AA) men (age < 65 years) in order to inform the development and pilot testing of an intervention for this high-risk group.

METHODS

Focus group methodology was used to collect data from 10 community-dwelling AA stroke survivors and seven of their care partners (CPs) (N = 17). Thematic analysis of session transcripts and the constant comparative method were used to generate themes.

RESULTS

Participants cited facilitators to post-stroke care and recovery as Family Support, Stress Reduction, and Dietary Changes. Specific person-level recommendations for AA men included following established stroke guidelines, use of complementary and alternative medicine, and never give up recovery efforts. Community-level recommendations included making a list of community resources available, providing support and education to care partners, using videos that feature AA men to deliver information and use AA men stroke survivors to help disseminate the information. Provider and health system recommendations included consolidation of medical bills, improving provider communication skills, and making providers aware of needs specific to AA men and their families.

CONCLUSIONS

While AA men and their CPs acknowledged and welcomed learning more about the American Health Association Stroke Prevention Guidelines, it is clear that they desired approaches that addressed their specific needs and preferences as young AA men who sometimes felt de-valued by their community and care providers. Specific person, community and care-system level approaches that are of perceived value to AA men offer potential to improve health outcomes and reduce health disparities.

Stroke recovery and prevention barriers among young african-american men: potential avenues to reduce health disparities

BACKGROUND

African Americans (AAs) who experience a first time stroke are younger and have double the stroke rate and more poststroke complications than other Americans.

OBJECTIVE

To assess perceived poststroke care barriers among younger AA men and their care partners (CPs) in order to inform the development of acceptable and effective improvements in poststroke care for this high-risk group.

METHODS

Ten community-dwelling AA stroke survivors and 7 of their CPs participated in focus groups and advisory board meetings. Survivors had stroke or transient ischemic attack within 1 year and a Barthel Index score ≯60. In focus groups, using a semi-structured interview guide, survivors and CPs identified self-perceived barriers and facilitators to poststroke care. Thematic analysis of session transcripts and the constant comparative method were used to generate themes.

RESULTS

Survivor age ranged from 34 to 64 years. Mean Barthel score was 95.5. CPs, all AA women, ranged in age from 49 to 61 years. Five CPs were wives, 1 was a fiancée, and 1 was a niece. Participants cited multiple personal, social, and societal stroke recovery challenges. Although hypertension and smoking risks were acknowledged, stress, depression, posttraumatic stress disorder, anger/frustration, personal identity change, and difficulty communicating unique needs as AA men were more frequently noted. Facilitators included family support, stress reduction, and dietary changes.

CONCLUSIONS

Younger AA men and their CPs perceive multiple poststroke care barriers. Biological risk reduction education may not capture all salient aspects of health management for AA stroke survivors. Leveraging family and community strengths, addressing psychological health, and directly engaging patients with health care teams may improve care management.

Preventing recurrence of thromboembolic events through coordinated treatment in the District of Columbia

RATIONALE

PROTECT DC examines whether stroke navigators can improve cardiovascular risk factors in urban underserved individuals newly hospitalized for stroke or ischemic attack. Within one-year of hospital discharge, up to one-third of patients no longer adhere to secondary prevention behaviors. Adherence rates are lower in minority-underserved groups, contributing to health disparities. In-hospital programs increase use of stroke prevention therapies but may not be as successful in underserved individuals. In these groups, low literacy, limited healthcare access, and sparse community resources may reduce adherence. Lay community health workers (navigators) improve adherence in other illnesses through education and assisting in overcoming barriers to achieving desired health behaviors and obtaining needed healthcare services.

AIMS AND DESIGN

PROTECT DC is a Phase II, single-blind, randomized, controlled trial comparing in-hospital education plus stroke navigators to usual care. Atherogenic ischemic stroke and transient ischemic attack survivors are recruited from Washington, DC hospitals. Navigators meet with participants during the index hospitalization, perform home visits, and meet by phone. They focus on stroke education, medication compliance, and overcoming practical barriers to adherence. The interventions are driven by the theories of reasoned action and planned behavior.

STUDY OUTCOMES

The primary dependent measure is a summary score of four objective measures of stroke risk factor control: systolic blood pressure, low-density lipoprotein, hemoglobin Hb A1C, and antiplatelet agent pill counts. Secondary outcomes include stroke knowledge, exercise, dietary modification, and smoking cessation.

CONCLUSION

PROTECT DC will determine whether a Phase III trial of stroke navigation for urban underserved individuals to improve adherence to secondary stroke prevention behaviors is warranted.

Association between health education needs and stroke caregiver injury

OBJECTIVE

Many stroke caregivers are inadequately informed about stroke and its sequelae and have little preparation for the physical demands of moving, lifting, and handling often required. Our objectives are to examine the association between health education needs and physical injury sustained as a result of activities related to the caregiving role.

METHOD

A total of 276 caregivers of veterans who suffered an acute stroke event were surveyed about their information needs and injury status.We used multivariate logistic regression analysis to calculate adjusted and unadjusted odds ratios for injury status.

RESULTS

Results indicate that in the adjusted model, caregivers who had increased educational needs were almost twice as likely (OR: 1.80; 95% CI: 1.74-1.94) to have incurred an injury related to caregiving activities.

CONCLUSIONS

Health education interventions that provide stroke caregivers with educational materials may help reduce caregiver injuries.

Is there a sex or race difference in stroke mortality?

OBJECTIVES

We sought to confirm previous studies for the presence and direction of sex and race difference in stroke mortality.

METHODS

Administrative data for 40,450 Medicare beneficiaries who were hospitalized in 1994 to 1996 with acute stroke were used in regression analyses to study sex and race differences in 1-year all-cause mortality among patients with different types of stroke and cause-specific mortality in patients with all types of stroke combined. Hazard ratios were adjusted for age, sex or race, state, year of index stroke, past stroke, subsequent stroke, and fatal coexisting conditions excluding cerebrovascular diseases.

RESULTS

Men with ischemic cerebral infarction, nonspecific stroke, or all types of stroke combined were at 21% to 35% higher risk of all-cause mortality than women, but there was no sex difference among patients with subarachnoid or intracerebral hemorrhage. Nonwhite patients with ischemic cerebral infarction had 11% higher all-cause mortality than white patients, but there were no race differences after adjustments for fatal coexisting conditions. Compared with women, mortality was higher in men with all types of stroke regardless of the cause of death. There was higher risk of death caused by cerebrovascular diseases in white patients with all types of stroke combined, but the risk of death caused by cardiovascular diseases other than ischemic heart disease was higher in nonwhite patients.

CONCLUSIONS

There was no sex or race difference in all-cause mortality in patients with hemorrhagic stroke and higher risk in men with ischemic and nonspecific stroke. Relatively higher risk of mortality caused by cerebrovascular diseases was found in men and white patients.

Stroke mortality and race: does access to care influence outcomes?

BACKGROUND

Stroke is the third leading cause of death in the United States. We investigated racial differences in death after hospital discharge for ischemic stroke in a large cohort of Veterans Health Affairs (VHA) stroke patients. We hypothesized that having access to VA care would ameliorate the excess stroke mortality rates in African-Americans (AA) reported in non-VA studies.

METHODS

Hospital administrative data were used to identify all patients discharged from any VA hospital between October 1990 and September 1997 with a primary discharge diagnosis of ischemic stroke (ICD-9-CM codes 434 and 436). We obtained demographic data and clinical data recorded during the index hospitalization and after discharge, including deaths, from VA clinical and administrative databases. The Charlson comorbidity index was constructed for each patient from the index admission's discharge diagnoses. Patients were followed through 1998.

RESULTS

Of 55,094 VHA stroke patients discharged after ischemic strokes, 34,579 (63%) were white and 11,530 (21%) were AA. Charlson index was similar between the groups. One-year mortality rate was significantly higher for whites: Adjusting for demographic and clinical differences, being white remained predictive of higher mortality rates (multivariable hazard ratio, 1.06; 95% CI, 1.02 to 1.10). From Kaplan-Meier estimates, the probability that whites would survive for 1 year was 0.86 compared with 0.87 for AA.

CONCLUSIONS

Despite having similar severity of illness and adjusting for other clinical differences, mortality rate was marginally lower in AA after being discharged from VA hospitals after ischemic strokes. This is contrary to prior reports from non-VA hospitals and suggests the possibility of access to care playing a role in stroke deaths.

Ethnic Disparities in Stroke

BACKGROUND AND PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.