Racial Disparities in Stroke Recovery Persistence in the Post-Acute Stroke Recovery Phase: Evidence from the Health and Retirement Study

Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke

Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.

Racial disparities in functional outcomes following mechanical thrombectomy in a cohort of patients with ischemic stroke

BACKGROUND

Non-Hispanic Black (NHB) patients experience increased prevalence of stroke risk factors and stroke incidence compared with non-Hispanic White (NHW) patients. However, little is known about >90-day post-stroke functional outcomes following mechanical thrombectomy.

OBJECTIVE

To describe patient characteristics, evaluate stroke risk factors, and analyze the adjusted impact of race on long-term functional outcomes to better identify and limit sources of disparity in post-stroke care.

METHODS

We retrospectively reviewed 326 patients with ischemic stroke who underwent thrombectomy at two centers between 2019 and 2022. Race was self-reported as NHB, NHW, or non-Hispanic Other. Stroke risk factors, insurance status, procedural parameters, and post-stroke functional outcomes were collected. Good outcomes were defined as modified Rankin Scale score ≤2 and/or discharge disposition to home/self-care. To assess the impact of race on outcomes at 3-, 6-, and 12-months' follow-up, we performed univariate and multivariate logistic regression.

RESULTS

Patients self-identified as NHB (42%), NHW (53%), or Other (5%). 177 (54.3%) patients were female; the median (IQR) age was 67.5 (59-77) years. The median (IQR) National Institutes of Health Stroke Scale score was 15 (10-20). On univariate analysis, NHB patients were more likely to have poor short- and long-term functional outcomes, which persisted on multivariate analysis as significant at 3 and 6 months but not at 12 months (3 months: OR=2.115, P=0.04; 6 months: OR=2.423, P=0.048; 12 months: OR=2.187, P=0.15). NHB patients were also more likely to be discharged to rehabilitation or hospice/death than NHW patients after adjusting for confounders (OR=1.940, P=0.04).

CONCLUSIONS

NHB patients undergoing thrombectomy for ischemic stroke experience worse 3- and 6-month functional outcomes than NHW patients after adjusting for confounders. Interestingly, this disparity was not detected at 12 months. Future research should focus on identifying social determinants in the short-term post-stroke recovery period to improve parity in stroke care.

Association of Race, Ethnicity, and Gender to Disparities in Functional Recovery and Social Health After Major Lower Limb Amputation: A Cross-sectional Pilot Study

OBJECTIVE

To assess if evidence of disparities exists in functional recovery and social health post-lower limb amputation.

DESIGN

Race-ethnicity, gender, and income-based group comparisons of functioning and social health in a convenience sample of lower limb prosthetic users.

SETTING

Prosthetic clinics in 4 states.

PARTICIPANTS

A geographically diverse cohort of 56 English and Spanish speaking community-dwelling individuals with dysvascular lower limb amputation, between 18-80 years old.

INTERVENTIONS

None.

MAIN OUTCOMES MEASURES

Primary outcomes included 2 physical performance measures, the Timed Up and Go test and 2-minute walk test, and thirdly, the Prosthetic Limb Users Survey of Mobility. The PROMIS Ability to Participate in Social Roles and Activities survey measured social health.

RESULTS

Of the study participants, 45% identified as persons of color, and 39% were women (mean ± SD age, 61.6 (9.8) years). People identifying as non-Hispanic White men exhibited better physical performance than men of color, White women, and women of color by -7.86 (95% CI, -16.26 to 0.53, P=.07), -10.34 (95% CI, -19.23 to -1.45, P=.02), and -11.63 (95% CI, -21.61 to -1.66, P=.02) seconds, respectively, on the TUG, and by 22.6 (95% CI, -2.31 to 47.50, P=.09), 38.92 (95% CI, 12.53 to 65.30, P<.01), 47.53 (95% CI, 17.93 to 77.13, P<.01) meters, respectively, on the 2-minute walk test. Income level explained 14% and 11% of the variance in perceived mobility and social health measures, respectively.

CONCLUSIONS

Study results suggest that sociodemographic factors of race-ethnicity, gender, and income level are associated with functioning and social health post-lower limb amputation. The clinical effect of this new knowledge lies in what it offers to health care practitioners who treat this patient population, in recognizing potential barriers to optimal recovery and quality of life. More work is required to assess lived experiences after amputation and provide better understanding of amputation-related health disparities.

Community-Based Culturally Tailored Education Programs for Black Communities with Cardiovascular Disease, Diabetes, Hypertension, and Stroke: Systematic Review Findings

BACKGROUND

Community-based culturally tailored education (CBCTE) programs for chronic diseases may reduce health disparities; however, a synthesis across chronic diseases is lacking. We explored (1) the characteristics and outcomes of CBCTE programs and (2) which strategies for culturally appropriate interventions have been used in CBCTE programs, and how they have been implemented.

METHODS

A systematic review was conducted by searching three databases to identify empirical full-text literature on CBCTE programs for Black communities with cardiovascular disease, hypertension, diabetes, or stroke. Studies were screened in duplicate, then data regarding study characteristics, participants, intervention, and outcomes were extracted and analyzed. Cultural tailoring strategies within programs were categorized using Kreuter and colleagues' framework.

RESULTS

Of the 74 studies, most were conducted in the USA (97%) and delivered in one site (53%; e.g., church/home). CBCTE programs targeted diabetes (65%), hypertension (30%), diabetes and hypertension (1%), cardiovascular disease (3%), and stroke (1%). Reported program benefits included physiological, medication-related, physical activity, and literacy. Cultural tailoring strategies included peripheral (targeted Black communities), constituent-involving (e.g., community informed), evidential (e.g., integrated community resources), linguistic (e.g., delivered in community's dialect/accent), and sociocultural (e.g., integrated community members' religious practices).

CONCLUSIONS

CBCTE programs may have beneficial outcomes, but a small sample size limited several. The strategies identified can be adopted by programs seeking to culturally tailor. Future interventions should clearly describe community members' roles/involvement and deliver programs in multiple locations to broaden reach.

TRIAL REGISTRATION

PROSPERO CRD42021245772.

Racial Disparities in Utilization of Emergency Medical Services and Related Impact on Poststroke Disability

BACKGROUND

Prompt seeking of emergency medical services (EMS) assistance at stroke onset is critical to minimize poststroke disability.

OBJECTIVE

The aim was to study how racial differences in EMS decision-relevant factors and EMS use impact stroke care and disability outcomes.

DESIGN

A prospective observational study.

PARTICIPANTS

A total of 1168 acute ischemic stroke patients discharged from April 2016 to October 2017 at a safety net hospital were included; 108 patients were surveyed before discharge.

MEASURES

(1) Prehospital delay: EMS use, timely hospital arrival; (2) Stroke care: alteplase receipt and inpatient rehab; (3) Outcomes: Functional improvement at discharge (admission minus discharge scores on National Institutes of Health Stroke Scale), 90-day modified Rankin Scale; (4) EMS decision-relevant factors: Stroke symptom knowledge, source of knowledge, unfavorable past EMS/care experiences, and financial barriers to EMS use.

RESULTS

Despite more Black patients using EMS than Whites/Asians (56% vs. 48%, P =0.003), their timely hospital arrival was 30% less likely. Adjusted for stroke severity, receipt of alteplase, and inpatient rehab were similar, but Black patients fared worse on functional improvement at discharge (among severe strokes, 2.4 National Institutes of Health Stroke Scale points less improvement, P <0.01), and on functional normalcy at 90 days (modified Rankin Scale score 0-1 being 60% less likely across severity categories) ( P <0.01). Fewer Black patients knew any stroke symptoms before the stroke (72% vs. 87%, P =0.03), and fewer learned about stroke from providers ( P =0.01). Financial barriers and provider mistrust were similar.

CONCLUSIONS

Black patients had less knowledge of stroke symptoms, more care-seeking delay, and poorer outcomes. Including stroke education as a standard of chronic disease care may mitigate stroke outcome disparities.

Toward more diverse, inclusive, and equitable neuromodulation

Racial and ethnic disparities exist for many nervous system disorders that are intervention targets for neuromodulation investigators. Yet, to date, there has been both a lack of racial and ethnic diversity and a lack of emphasis on diversity in neuromodulation research. In this paper, we suggest three potential reasons for the lack of racial and ethnic diversity in neuromodulation research: 1) the lack of diversity in the neuromodulation workforce, 2) incompatibility between the technologies employed and phenotypic traits (e.g., hair texture) commonly present in minoritized populations, and 3) minoritized populations' reluctance to participate in clinical trials. We argue that increasing diversity in the neuromodulation workforce, in conjunction with mutual collaboration between current neuromodulation researchers and underrepresented communities in neuromodulation, can aid in removing barriers to diversity, equity, and inclusion in neuromodulation research. This is important, because greater diversity, equity, and inclusion in neuromodulation research brings with it the development of novel, yet safe and effective, treatment approaches for brain disorders and enhances the rigor and generalizability of discoveries in the field.

Stroke in women between 2006 and 2018: Demographic, socioeconomic, and age disparities

BACKGROUND

Black Americans have a higher prevalence of stroke and stroke-related deaths than any other racial group. Racial disparities in stroke outcomes are even wider among women than men. Conventional studies have cited differences in lifestyle (i.e. smoking, alcohol consumption, etc.) and vascular risk factors between races as the source of these disparities. However, these studies fail to account for the higher prevalence of minoritized populations at the lower end of the socioeconomic distribution.

OBJECTIVES

This study explores differences in stroke risk factors across age and socioeconomic cohorts to determine whether comorbidities can sufficiently explain disparities at all ages and income levels.

DESIGN

Using the 2006-2018 National Health Interview Survey data, statistical analysis evaluated differences in risk factors among a full sample cohort (aged 18-85 years; n = 131,091) and a "young" subsample cohort (aged 18-59 years; n = 6183) of women.

METHODS

Logistics and unconditional quantile regression models assessed the relationship between stroke and comorbid, demographic, and behavioral characteristics across socioeconomic classes.

RESULTS

Results suggest that Black women had a 1.415-fold (confidence interval = 1.259, 1.591) higher likelihood of stroke compared with White women after controlling for age, behavior, and comorbidities. Racial disparities were not statistically significant at the higher income ranges for either the full (odds ratio = 1.404, p = 0.3114) or young samples (odds ratio = 1.576, p = 0.7718). However, Blacks had significantly higher odds of stroke in the lower quartiles (lower odds ratio: 1.329, p = 0.0242; lower middle odds ratio: 1.233, p = 0.0486; and upper middle odds ratio: 1.994, p = 0.0005). Disparities were larger among young women (odds ratio = 1.449, confidence interval = 1.211, 1.734).

CONCLUSION

While comorbidities were highly associated with stroke prevalence in all socioeconomic cohorts, Blacks only had higher relative odds in the lower income classes. Lack of biological or behavioral explanations for these findings suggests that unobserved or uncontrolled factors such as systemic racism, prejudicial institutions, or differential treatment may contribute to this.

Racial Variation in the Association Between Domains of Depressive Symptomatology and Functional Recovery in Stroke Survivors

OBJECTIVE

The purpose of the study was to investigate the relationships between various domains of depressive symptomatology and functional recovery in Black and White stroke survivors.

METHODS

Black (n = 181) and White (n = 797) stroke survivors from the Stroke Recovery in Underserved Population database were included. Four domains of depressive symptomatology (depressed affect, positive affect, somatic symptoms, interpersonal difficulties) were measured by the Center for Epidemiologic Studies Depression Scale at discharge; functional recovery was measured by the Functional Independence Measure at discharge and 3-month follow-up. Multivariable linear regression analyses examined the relation between race and functional recovery, and the association between depressive symptomatology and functional recovery by race.

RESULTS

Three-month functional recovery was greater among White stroke survivors than Black survivors. Affective symptoms of depression predicted poorer functional recovery of White survivors; whereas somatic symptoms predicted poorer functional recovery of Black survivors.

CONCLUSIONS

Domains of depressive symptomatology were differentially associated with poorer functional recovery in Black and White stroke survivors. Psychosocial interventions aimed at alleviating depressive symptomatology have the potential to improve functional recovery in Black and White stroke survivors and should be addressed in planning rehabilitation post-stroke.

Effect of Hispanic Status in Mechanical Thrombectomy Outcomes After Ischemic Stroke: Insights From STAR

Background and Purpose

Epidemiological studies have shown racial and ethnic minorities to have higher stroke risk and worse outcomes than non-Hispanic Whites. In this cohort study, we analyzed the STAR (Stroke Thrombectomy and Aneurysm Registry) database, a multi-institutional database of patients who underwent mechanical thrombectomy for acute large vessel occlusion stroke to determine the relationship between mechanical thrombectomy outcomes and race.

Methods

Patients who underwent mechanical thrombectomy between January 2017 and May 2020 were analyzed. Data included baseline characteristics, vascular risk factors, complications, and long-term outcomes. Functional outcomes were assessed with respect to Hispanic status delineated as non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic patients. Multivariate analysis was performed to identify variables associated with unfavorable outcome or modified Rankin Scale ≥3 at 90 days.

Results

Records of 2115 patients from the registry were analyzed. Median age of Hispanic patients undergoing mechanical thrombectomy was 60 years (72–84), compared with 63 years (54–74) for NHB, and 71 years (60–80) for NHW patients (P<0.001). Hispanic patients had a higher incidence of diabetes (41%; P<0.001) and hypertension (82%; P<0.001) compared with NHW and NHB patients. Median procedure time was shorter in Hispanics (36 minutes) compared to NHB (39 minutes) and NHW (44 minutes) patients (P<0.001). In multivariate analysis, Hispanic patients were less likely to have favorable outcome (odds ratio, 0.502 [95% CI, 0.263–0.959]), controlling for other significant predictors (age, admission National Institutes Health Stroke Scale, onset to groin time, number of attempts, procedure time).

Conclusions

Hispanic patients are less likely to have favorable outcome at 90 days following mechanical thrombectomy compared to NHW or NHB patients. Further prospective studies are required to validate our findings.

Heterogeneity among women with stroke: health, demographic and healthcare utilization differentials

BACKGROUND

Although age specific stroke rates are higher in men, women have a higher lifetime risk and are more likely to die from a stroke. Despite this increased severity, most studies focus on male/female differences in stroke onset, patterns of care and stroke-related outcomes. Given that stroke presents differently in men and women, mixed sex studies fail to fully capture heterogeneity among women with stroke and the subsequent impact on their outcomes. This study examined the sociodemographic characteristics, factors related to stroke incidence and post-stroke functional status between young (< 60) and old (≥ 60) women with stroke.

METHODS

Using 5 years of data from the National Health Interview Survey (NHIS), a nationally representative sample of US adults, cohorts of young and old women with stroke were identified. A set of demographic/lifestyle, health services utilization and health status characteristics were used evaluate within gender heterogeneity in three ways. First, disparities in population characteristics were assessed using Chi-Square and t tests. Second, young and old women with stroke were matched with women without stroke in their respective cohorts to determine differences in factors related to stroke incidence. Finally, the determinants of post-stroke functional limitation for the two cohorts were determined.

RESULTS

Young women with stroke were more likely to be Black, smoke regularly and frequently consume alcohol than older women. Young women were also less likely to engage with their health provider regularly or receive preventative health screenings. Diabetes, high blood pressure, high cholesterol and high BMI were correlated with an increased relative likelihood of stroke among older women. In contrast, family size, smoking frequency, alcohol consumption and sleep were correlated with an increased prevalence of stroke among young women. Although factors correlated with stroke varied between young and old women, health status and receipt of healthcare were the most significant determinants of post-stroke functional status for both cohorts.

CONCLUSIONS

Health related characteristics were the primary correlates of stroke in older women, whereas post-stroke lifestyle and behaviors are the most significant correlates for younger stroke survivors. These findings suggest that while receipt of health services is essential for preventing stroke in both young and old women, providers should stress the importance of post-stoke lifestyle and behaviors to younger women at risk of stroke using approaches that may be different from older stroke women.