Racial/Ethnic Disparities in Mortality Among Medicare Beneficiaries in the FL - PR CR eSD Study

Background

Racial/ethnic disparities in acute stroke care may impact stroke outcomes. We compared outcomes by race/ethnicity among elderly Medicare beneficiaries in hospitals participating in the FL‐PR CReSD (Florida–Puerto Rico Collaboration to Reduce Stroke Disparities) registry with those in hospitals not participating in any quality improvement programs (non‐QI) in Florida and Puerto Rico (PR).

Methods and Results

The population included fee‐for‐service Medicare beneficiaries age 65+ in Florida and PR, discharged with primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD‐9‐CM], codes 433, 434, 436) in 2010–2013. We used mixed logistic models to assess racial/ethnic differences in outcomes (in‐hospital, 30‐day, and 1‐year mortality, and 30‐day readmission) for CReSD and non‐QI hospitals, adjusted for demographic and clinical characteristics. The study included 62 CReSD hospitals (N=44 013, 84% white, 9% black, 4% Florida Hispanic, 1% PR Hispanic) and 113 non‐QI hospitals (N=14 422, 78% white, 7% black, 5% Florida Hispanic, 8% PR Hispanic). For patients treated at CReSD hospitals, there were no differences in risk‐adjusted in‐hospital mortality by race/ethnicity; blacks had lower 30‐day mortality versus whites (odds ratio, 0.86; 95% confidence interval, 0.77–0.97), but higher 30‐day readmission (hazard ratio, 1.09; 1.00–1.18) and 1‐year mortality (odds ratio, 1.13; 1.04–1.23); Florida Hispanics had lower 30‐day readmission (hazard ratio, 0.87; 0.78–0.98). PR Hispanic and black stroke patients treated at non‐QI hospitals had higher risk‐adjusted in‐hospital, 30‐day and 1‐year mortality, but similar 30‐day readmission versus whites treated in non‐QI hospitals.

Conclusions

Disparities in outcomes were less common in CReSD than non‐QI hospitals, suggesting the benefits of quality improvement programs, particularly those focusing on racial/ethnic disparities.

Race-Ethnic Disparities in 30-Day Readmission After Stroke Among Medicare Beneficiaries in the Florida Stroke Registry

OBJECTIVE

To examine racial/ethnic disparities in 30-day all-cause readmission after stroke.

METHODS

Thirty-day all-cause readmission was compared by race/ethnicity among Medicare fee-for-service beneficiaries discharged for ischemic stroke from hospitals in the Florida Stroke Registry from 2010 to 2013. We fit a Cox proportional hazards model that censored for death and adjusted for age, sex, length of stay, discharge home, and comorbidities to assess racial/ethnic differences in readmission.

RESULTS

Among 16,952 stroke patients (54% women, 75% white, 8% black, and 15% Hispanic), 30-day all-cause readmission was 15% (17.2% for blacks, 16.7% for Hispanics, 14.4% for whites, and 14.7% for others; P = .003). There was a median of 11 days between discharge and first readmission. In adjusted analyses, there was no significant difference in readmission for blacks (hazard ratio 1.15, 95% confidence interval 0.99-1.33), Hispanics (1.00, .90-1.13), and those of other race/ethnicity (.91, .71-1.16) compared with whites. Nearly 1 in 4 readmissions were attributable to acute cerebrovascular events: 16.6% ischemic stroke or transient ischemic attack, 1.5% hemorrhagic stroke, and 5.2% cerebral artery interventions. Interventions were more common among whites and those of other race than blacks and Hispanics (P = .029). Readmission due to pneumonia or urinary tract infection was 8.2%.

CONCLUSIONS

Readmissions attributable to acute cerebrovascular events were common and generally occurred within 2 weeks of hospital discharge. Racial/ethnic disparities were present in readmissions for arterial interventions. Our results underscore the importance of postdischarge transitional care and the need for better secondary prevention strategies after ischemic stroke, particularly among minority populations.

Patterns and Outcomes of Endovascular Therapy in Mild Stroke

Background and Purpose- We aimed to evaluate the current practice patterns, safety and outcomes of patients who receive endovascular therapy (EVT) having mild neurological symptoms. Methods- From Jan 2010 to Jan 2018, 127,794 ischemic stroke patients were enrolled in the Florida-Puerto Rico Stroke Registry. Patients presenting within 24 hours of symptoms who received EVT were classified into mild (National Institutes of Health Stroke Scale [NIHSS] ≤5) or moderate/severe (NIHSS>5) categories. Differences in clinical characteristics and outcomes were evaluated using multivariable logistic regression. Results- Among 4110 EVT patients (median age, 73 [interquartile range=20] years; 50% women), 446 (11%) had NIHSS ≤5. Compared with NIHSS >5, those with NIHSS ≤5 arrived later to the hospital (median, 138 versus 101 minutes), were less likely to receive intravenous alteplase (30% versus 43%), had a longer door-to-puncture time (median, 167 versus 115 minutes) and more likely treated in South Florida (64% versus 53%). In multivariable analysis younger age, private insurance (versus Medicare), history of hypertension, prior independent ambulation and hospital size were independent characteristics associated with NIHSS ≤5. Among EVT patients with NIHSS ≤5, 76% were discharged home/rehabilitation and 64% were able to ambulate independently at discharge as compared with 53% and 32% of patients with NIHSS >5. Symptomatic intracerebral hemorrhage occurred in 4% of mild stroke EVT patients and 6.4% in those with NIHSS >5. Conclusions- Despite lack of evidence-based recommendations, 11% of patients receiving EVT in clinical practice have mild neurological presentations. Individual, hospital and geographic disparities are observed among endovascularly treated patients based on the severity of clinical symptoms. Our data suggest safety and overall favorable outcomes for EVT patients with mild stroke.

Abstract TP23: Safety and Outcome of Endovascular Therapy in Patients With Minor Stroke: Florida Puerto Rico Collaboration to Reduce Stroke Disparities Study

Background: Patients with minor ischemic stroke were largely excluded from the randomized trials of endovascular therapy (EVT) in stroke. In the Florida-Puerto Rico Registry we sought to determine the utilization of EVT in this population.

Methods: From January 2010 to March 2017, 57,750 acute ischemic stroke patients within 24 hours of symptom onset were prospectively included from 88 sites in four Florida regions (south, west central, north and panhandle, east central) and Puerto Rico. Differences between minor (NIHSS ≤ 5) and moderate/severe (NIHSS>5) stroke patients who received EVT were evaluated using multivariable logistic regression with generalized estimating equations.

Results: Among 2,845 EVT patients (50% women, mean age ±SD 71±14 years), 347 (12%) had NIHSS ≤ 5. As compared to NIHSS>5, minor stroke patients were younger (mean age 67 vs. 71, p<0.01), more men (58% vs. 49%, p=0.01) more privately insured (47% vs. 35%, p<0.01), having more HTN (69% vs. 63%, p=0.03) and prior strokes (25% vs. 20%, p=0.02) but less atrial fibrillation (25% vs. 38%, p<0.01). Minor stroke EVT patients arrived later to the hospital (median 128 vs. 102 min, p=0.02) and during working hours (51% vs. 46%,p=0.09). They were less likely to receive IV tPA (29% vs. 42%, p<0.01), had a longer door to puncture time (median 192 vs. 128 min, p<0.01). In multivariable analysis, young age (OR=1.02, 95%CI 1.01-1.03), early arrival (OR=1.64, 95% CI 1.15-2.33) and FL regions (south vs. west central) (OR=2.67, 95% CI 1.07-6.62) were independently associated with EVT in minor stroke. Symptomatic ICH occurred in 4.6% of minor stroke EVT patients and 6.4% in those with NIHSS>5. Majority of minor stroke patients who received EVT were discharged home or to rehab (75%) while 53% of those with NIHSS>5.

Conclusions: More than 1 in 10 cases that received EVT had mild neurological symptoms. Many factors including hospital expertise and time of presentation affect the use of this treatment. Further study of EVT in minor stroke is warranted.

Stroke Hospital Characteristics in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study

OBJECTIVES

Although disparities in stroke care and outcomes have been well documented nationally, state-based registries to monitor acute stroke care in Florida (FL) and Puerto Rico (PR) have not been established. The FL-PR Collaboration to Reduce Stroke Disparities (CReSD) was developed to evaluate race-ethnicity and regional disparities in stroke care performance. The objective of this study was to assess and compare hospital characteristics within a large quality improvement registry to identify characteristics associated with better outcomes for acute ischemic stroke care.

METHODS

Trained personnel from 78 FL-PR CReSD hospitals (69 FL, 9 PR) completed a 50-item survey assessing institutional characteristics across seven domains: acute stroke care resource availability, emergency medical services integration, stroke center certification, data collection and use, quality improvement processes, FL-PR CReSD recruitment incentives, and hospital infrastructure.

RESULTS

The rate of survey completion was 100%. Differences were observed both within FL and between FL and PR. Years participating in Get With The Guidelines-Stroke (8.9 ± 2.6 years FL vs 4.8 ± 2.4 years PR, P < 0.0001) and proportion of hospitals with any stroke center certification (94.2% FL vs 11.1% PR, P < 0.0001) showed the largest variations. Smaller hospital size, fewer years in Get With The Guidelines-Stroke, and lack of stroke center designation and acute stroke care practice implementation may contribute to poorer outcomes.

CONCLUSIONS

Results from our survey indicated variability in hospital- and system-level characteristics in stroke care across hospitals in Florida and Puerto Rico. Identification of these variations, which may explain potential disparities, can help clinicians understand gaps in stroke care and outcomes and targeted interventions to reduce identified disparities can be implemented.

Disparities and Trends in Door-to-Needle Time: The FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities)

BACKGROUND AND PURPOSE

In the United States, about half of acute ischemic stroke patients treated with tPA (tissue-type plasminogen activator) receive treatment within 60 minutes of hospital arrival. We aimed to determine the proportion of patients receiving tPA within 60 minutes (door-to-needle time [DTNT] ≤60) and 45 minutes (DTNT ≤45) of hospital arrival by race/ethnicity and sex and to identify temporal trends in DTNT ≤60 and DTNT ≤45.

METHODS

Among 65 654 acute ischemic stroke admissions in the National Institute of Neurological Disorders and Stroke-funded FL-PR CReSD study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) from 2010 to 2015, we included 6181 intravenous tPA-treated cases (9.4%). Generalized estimating equations were used to determine predictors of DTNT ≤60 and DTNT ≤45.

RESULTS

DTNT ≤60 was achieved in 42% and DTNT ≤45 in 18% of cases. After adjustment, women less likely received DTNT ≤60 (odds ratio, 0.81; 95% confidence interval, 0.72-0.92) and DTNT ≤45 (odds ratio, 0.73; 95% confidence interval, 0.57-0.93). Compared with Whites, Blacks less likely had DTNT ≤45 during off hours (odds ratio, 0.68; 95% confidence interval, 0.47-0.98). Achievement of DTNT ≤60 and DTNT ≤45 was highest in South Florida (50%, 23%) and lowest in West Central Florida (28%, 11%).

CONCLUSIONS

In the FL-PR CReSD, achievement of DTNT ≤60 and DTNT ≤45 remains low. Compared with Whites, Blacks less likely receive tPA treatment within 45 minutes during off hours. Treatment within 60 and 45 minutes is lower in women compared with men and lowest in West Central Florida compared with other Florida regions and Puerto Rico. Further research is needed to identify reasons for delayed thrombolytic treatment in women and Blacks and factors contributing to regional disparities in DTNT.

Racial-Ethnic Disparities in Acute Stroke Care in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study

BACKGROUND

Racial-ethnic disparities in acute stroke care can contribute to inequality in stroke outcomes. We examined race-ethnic disparities in acute stroke performance metrics in a voluntary stroke registry among Florida and Puerto Rico Get With the Guidelines-Stroke hospitals.

METHODS AND RESULTS

Seventy-five sites in the Florida Puerto Rico Stroke Registry (66 Florida and 9 Puerto Rico) recorded 58 864 ischemic stroke cases (2010-2014). Logistic regression models examined racial-ethnic differences in acute stroke performance measures and defect-free care (intravenous tissue plasminogen activator treatment, in-hospital antithrombotic therapy, deep vein thrombosis prophylaxis, discharge antithrombotic therapy, appropriate anticoagulation therapy, statin use, smoking cessation counseling) and temporal trends. Among ischemic stroke cases, 63% were non-Hispanic white (NHW), 18% were non-Hispanic black (NHB), 14% were Hispanic living in Florida, and 6% were Hispanic living in Puerto Rico. NHW patients were the oldest, followed by Hispanics, and NHBs. Defect-free care was greatest among NHBs (81%), followed by NHWs (79%) and Florida Hispanics (79%), then Puerto Rico Hispanics (57%) (P<0.0001). Puerto Rico Hispanics were less likely than Florida whites to meet any stroke care performance metric other than anticoagulation. Defect-free care improved for all groups during 2010-2014, but the disparity in Puerto Rico persisted (2010: NHWs=63%, NHBs=65%, Florida Hispanics=59%, Puerto Rico Hispanics=31%; 2014: NHWs=93%, NHBs=94%, Florida Hispanics=94%, Puerto Rico Hispanics=63%).

CONCLUSIONS

Racial-ethnic/geographic disparities were observed for acute stroke care performance metrics. Adoption of a quality improvement program improved stroke care from 2010 to 2014 in Puerto Rico and all Florida racial-ethnic groups. However, stroke care quality delivered in Puerto Rico is lower than in Florida. Sustained support of evidence-based acute stroke quality improvement programs is required to improve stroke care and minimize racial-ethnic disparities, particularly in resource-strained Puerto Rico.

Abstract TP2: Disparities in Delivery of Endovascular Therapy: Who Gets it and Where? The Florida Puerto Rico Collaboration to Reduce Stroke Disparities Study

Background and Purpose: Endovascular thrombectomy improves functional outcome in select ischemic stroke patients. In the NINDS-funded CReSD Registry we sought to determine the clinical, hospital and regional characteristics associated with use of this therapy in patients presenting with acute ischemic stroke.

Methods: Ischemic stroke patients within 24 hours of onset were prospectively included from 82 sites in Florida and Puerto Rico from January 2010 to April 2016. Independent predictors of endovascular therapy were evaluated using multivariable logistic regression with generalized estimating equations.

Results: Among 58,204 patients with acute ischemic stroke (50% male, 65% white, 15% black, 20% Hispanic, mean age±SD 71±14 yrs), 2105 (3.6%) received endovascular thrombectomy (50.9% men, 62.3% white, 13.7% black, 24% Hispanic, mean age±SD 70±15yrs) with (35.2%) or without intravenous thrombolysis. Patients who received endovascular therapy had a significantly lower risk of vascular risk factors except for Afib (33.7% vs 19.0%), more severe strokes (median NIHSS 15 vs. 5) and were more likely to arrive quickly (126 min vs. 210 min), via EMS (70.4% vs. 59.6%) or as a transfer from another hospital (20.8% vs 5.8%,) during working hours (47.7% vs. 45.6%), to large hospitals (≥ 680 beds) (48.3% vs 28.8%), and treated in South Florida (47.3% vs. 35.9%) as compared to those not receiving this treatment. In multivariable analysis; age (OR 0.97, 95% CI 0.96- 0.98), Blacks (OR 0.68, 95% CI 0.56-2.28) vs. White, off-hour presentation (OR 0.76, 95% CI 0.66- 0.96), to regions other than South Florida (North OR 0.40, 95% CI 0.17-0.93, Panhandle OR 0.12, 95% CI 0.04-0.36) remained independently associated with lower use of endovascular therapy. In contrast, Hispanics (OR 1.28, 95% CI 1.03- 1.69) vs. White and presenting to large hospital (OR 4.92, 95% CI 1.05- to 22.6) were associated with higher use of endovascular treatment.

Conclusions: There are significant race, regional and hospital disparities in delivery of endovascular care. Efforts should me made to improve access to endovascular treatment in patients presenting across the region to all stroke centers.

Abstract WMP90: Race/Ethnic Disparities in Short and Long Term Mortality Among Medicare Beneficiaries in Florida and Puerto Rico: Data from the Florida Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study - the NINDS Stroke Prevention Intervention Research Program

Background: Race/ethnic disparities in acute stroke care may impact stroke outcomes. We compared short- and long-term mortality by race/ethnicity among Medicare beneficiaries in Get With The Guidelines (GWTG) hospitals participating in the NINDS-funded prospective Florida Puerto Rico Collaboration to Reduce Stroke Disparities Registry (GWTG/CReSD), GWTG hospitals not in the Registry (GWTG/non-CReSD), and non-GWTG hospitals not in the Registry (non-GWTG/non-CReSD).

Methods: The population included Medicare beneficiaries age 65+ in FL and PR, hospitalized from 2010-2013 with ischemic stroke (ICD-9 433, 434, 436; N=105,205, mean age=80 years, 54% women). We used mixed logistic models adjusted for demographic and clinical characteristics to assess race/ethnic differences in in-hospital, 30-day, and 1-year mortality, stratifying by hospital type (GWTG/CReSD, GWTG/non-CReSD, non-GWTG/non-CReSD).

Results: In the 62 GWTG/CReSD hospitals (N=44013, 84% non-Hispanic White (NHW), 9% NH-Black (NHB), 4% FL-Hispanic (FLH), 1% PR-Hispanic (PRH)), NHB had lower 30-day mortality vs NHW (10% vs 12%; OR 0.86, 95% CI 0.77-0.97), but higher 1-year mortality (22% vs 20%; OR 1.13, 95% CI 1.04-1.23); there were no race/ethnic disparities for in-hospital mortality (NHB=6%, NHW=5%, FLH=7%, PRH=12%). However, in 74 GWTG/non-CReSD hospitals (N=46770, 88% NHW, 8% NHB, 2% FLH, 0% PRH), FLH (5%) and NHB (4%) had higher in-hospital mortality vs NHW (3%). For 113 non-GWTG/non-CReSD hospitals (N=14422, 78% NHW, 7% NHB, 5% FLH, 8% PRH), in-hospital mortality was higher for PRH (17%) and NHB (8%) vs NHW (5%). In-hospital and 1-year mortality were lower in CReSD and in GWTG/non-CReSD vs in non-GWTG/non-CReSD hospitals.

Conclusions: FL and PR Medicare beneficiaries treated for stroke in GWTG hospitals (both GWTG/CReSD and GWTG/non-CReSD) had lower mortality vs those treated in non-GWTG hospitals; however, there were less race/ethnic disparities in in-hospital mortality for stroke patients treated at GWTG/CReSD hospitals, which are focused on reducing disparities in acute stroke care. Findings underscore the benefits of quality improvement programs, particularly those focusing on race/ethnic disparities.

Abstract TMP81: Regional, Race-Ethnic and Sex Disparities in Lifestyle Interventions: Data from the Florida Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study - the NINDS Stroke Prevention Intervention Research Program

Background: As key components of the AHA Life’s Simple 7 campaign, lifestyle modifications play an integral role in the prevention of vascular disease. Little is known about the prevalence of lifestyle modification counseling in patients with acute ischemic stroke (AIS). We sought to investigate disparities in the delivery of lifestyle interventions to AIS patients in the large NINDS-funded FL-PR CReSD Registry of Get With The Guidelines-Stroke (GWTG-S) data.

Methods: GWTG-S collects data on the provision of several lifestyle interventions including counseling on exercise/weight loss, Therapeutic Lifestyle Changes (TLC) diet, diabetes (DM) education and antihypertensive (low sodium) diet. 80,598 AIS cases were prospectively included from 82 sites (69 FL; 13 PR) from 2010-2016. Multilevel logistic regression models adjusted for age, race, and aphasia were used to evaluate differences in the provision of lifestyle interventions as indicated for patients prior to hospital discharge.

Results: Among AIS cases, 51% were men, 62% non-Hispanic White (NHW), 18% NH-Black (NHB), 13% FL-Hispanic (FLH), and 6% PR-Hispanic (PRH). Mean age was 71±14 years. The highest mean BMI was in PRH (29±7 kg/m 2 ), with the lowest in NHW (27±6 kg/m 2 ) and FLH (28±6 kg/m 2 ). Despite this, PRH were less likely to receive exercise/weight loss counseling compared to NHW (OR 0.43, 95% CI 0.20-0.90) and FLH (OR 0.46, 95% CI 0.22-0.97). PRH also had lower odds of receiving TLC diet counseling compared to NHW and FLH (OR 0.32, 95% CI 0.15-0.68). Though NHB presented with higher rates of DM compared to NHW (38% vs. 25%), they were less likely to receive DM education (OR 0.95, 95% CI 0.91-0.99). Women were less likely to receive TLC diet counseling (OR 0.94, 95% CI 0.90-0.98) and DM education (OR 0.94, CI 0.92-0.97) compared to men. Despite higher HTN frequency in women and NHB (67% and 69%), both were less likely to receive low sodium diet recommendations as compared to men (OR 0.94, 95% CI 0.92-0.97) and NHW (OR 0.95, 95% CI 0.91-0.99).

Conclusion: Overall, disparities were identified in the provision of several lifestyle interventions in AIS patients. These interventions can benefit all and providers should continue counseling patients regarding modifiable risk factors to prevent future stroke.

Abstract 89: Differences in Acute Stroke Care in Primary and Comprehensive Stroke Centers in Florida: An Analysis of the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study- the NINDS Stroke Prevention Intervention Research Program

Introduction: Primary stroke center (PSC) and comprehensive stroke center (CSC) designation in Florida aims to improve delivery of care and outcomes for stroke patients. In line with the goals of the NINDS funded Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study, we sought to compare ischemic stroke performance metrics by stroke center designation in participating Florida hospitals.

Methods: We analyzed 74,623 cases with acute ischemic stroke from 26 CSC and 40 PSC from January 2010-April 2016. We described patient demographics, comorbidities and Get With The Guidelines-Stroke performance metrics of defect free care (compliance with 7 pre-defined performance core measures), door to CT time (DTCT) ≤25 mins and door to needle time (DTN) ≤60 mins.

Results: Compared with PSC patients, CSC patients were younger (70 ± 15 vs. 71 ± 14 years, p<.0001), more likely male (51% vs. 50%, p=.0008), more likely Hispanic (17% vs. 10%, p<.0001) and Black (21% vs. 17%, p<.0001), had more severe strokes (NIHSS median 5 (IQR 2-12) vs. 4 (IQR 1-9); NIHSS ≥16, 12% vs. 9%, p <.0001), were more likely to have atrial fibrillation (19% vs. 17%, p<.0001), and were more likely to arrive by EMS (55% vs. 46%, p<.0001). CSC cases were more likely to have faster DTCT (44 vs. 48 mins, p=.0124 ; < 25 mins 33% vs. 31%, p<.0001). More patients in CSC received thrombolysis (12% vs. 9%, p<.0001), with faster DTN (59 vs. 71 min, p <.0001; ≤60 minutes 53% vs. 37%, p <.0001). Patients in CSC had greater rates of defect free care (85% vs. 82.4%, p<.0001). Blacks had longer median DTCT than Whites and Hispanics in both CSC (56 mins Blacks vs. 41 mins Whites and Hispanics) and PSC (60 mins Blacks, 44 mins Whites, 57 mins Hispanics). Blacks in CSC had longer median DTN (63 mins) than Whites (60 mins) and Hispanics (53 mins). Hispanics had longer median DTN (73 mins) in PSC than Blacks (70 mins) and Whites (70 mins).

Conclusion: Patients treated in CSC, compared with those treated in PSC, received better defect-free care and had lower DTCT and DTN times. Race-ethnic disparities in performance metrics are still evident in both CSC and PSC. Identification of these disparities is important to design interventions to reduce disparities and improve stroke quality of care for all.

Sex Disparities in Ischemic Stroke Care: FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities)

BACKGROUND AND PURPOSE

Sex-specific disparities in stroke care including thrombolytic therapy and early hospital admission are reported. In a large registry of Florida and Puerto Rico hospitals participating in the Get With The Guidelines-Stroke program, we sought to determine sex-specific differences in ischemic stroke performance metrics and overall thrombolytic treatment.

METHODS

Around 51 317 (49% women) patients were included from 73 sites from 2010 to 2014. Multivariable logistic regression with generalized estimating equations evaluated sex-specific differences in the prespecified Get With The Guidelines-Stroke metrics for defect-free care in ischemic stroke, adjusting for age, race-ethnicity, insurance status, hospital characteristics, individual risk factors, and the presenting stroke severity.

RESULTS

As compared with men, women were older (73±15 versus 69±14 years; P<0.0001), more hypertensive (67% versus 63%, P<0.0001), and had more atrial fibrillation (19% versus 16%; P<0.0001). Defect-free care was slightly lower in women than in men (odds ratio, 0.96; 95% confidence interval, 0.93-1.00). Temporal trends in defect-free care improved substantially and similarly for men and women, with a 29% absolute improvement in women (P<0.0001) and 28% in men (P<0.0001), with P value of 0.13 for time-by-sex interaction. Women were less likely to receive thrombolysis (odds ratio, 0.92; 95% confidence interval, 0.86-0.99; P=0.02) and less likely to have a door-to-needle time <1 hour (odds ratio, 0.83; 95% confidence interval, 0.71-0.97; P=0.02) as compared with men.

CONCLUSIONS

Women received comparable stroke care to men in this registry as measured by prespecified Get With The Guidelines metrics. However, women less likely received thrombolysis and had door-to-needle time <1 hour, an observation that calls for the implementation of interventions to reduce sex disparity in these measures.

Abstract TMP67: Sex Disparities in Atrial Fibrillation as a Predictor of Poor Discharge Disposition After Ischemic Stroke Hospitalization: The Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study

Background: It is unknown whether atrial fibrillation (AF) is responsible for increased morbidity and disability seen in women with ischemic stroke. We sought to determine whether patients with ischemic stroke and AF had poorer outcomes than ischemic stroke patients without AF and whether this effect is more pronounced among women.

Methods: We analyzed data from the FL-PR CReSD Study, a large quality improvement registry of Florida (N=66) and Puerto Rico (N=9) hospitals based on the Get With The Guidelines-Stroke (GWTG-S) program. Discharge disposition was utilized as a surrogate marker for morbidity and disability, with discharge to home or rehabilitation in comparison to other discharge dispositions (skilled nursing facility, hospice or died). Multilevel generalized linear models were used to evaluate AF and sex disparities in discharge disposition adjusted for demographics, risk factors (hypertension, diabetes, heart failure, previous stroke/TIA), and NIHSS and CHADS2 scores.

Results: We examined a total of 55,945 ischemic stroke patients, of whom 11,797 (21%) had AF at discharge. AF patients were older than non-AF patients (79.0±10.9 years vs. 68.7±14.4 years), had higher proportion of women (54% vs. 49%) and more severe strokes (mean NIHSS 10±9 vs. 7±7). Among AF patients, women were older (81±10 vs. 76±11 years) and had greater NIHSS (11±9 vs. 9±8) and CHADS2 scores (3.9±0.9 vs. 3.7±1.0) than men. Overall, AF patients were less likely discharged to home or rehabilitation than those without AF (54% vs. 71%, OR 0.93, 95% CI 0.89-0.98). There was a significant effect modification between AF and discharge disposition by sex. In stratified analyses by sex, AF was associated with less discharged to home or rehabilitation among women (OR 0.85, 95% CI 0.79-0.91), but not among men (OR 1.04, 95% CI 0.96-1.11).

Conclusion: Women with AF were less likely discharged to home or rehabilitation facility after ischemic stroke. Baseline differences in age, stroke severity, risk factors, and comorbidities between men and women had little impact on the poorer outcome and discharge disposition after ischemic stroke in women. Further studies are warranted to identify the causes of sex-specific differences in stroke outcomes for patients with AF.

Abstract WP285: Sex Disparities in Stroke Care in Puerto Rico Hospitals Participating in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study

Background: Sex is a contributing factor to inequalities in stroke care. In line with the aims of the FL-PR CReSD Study to assess Get With The Guidelines-Stroke (GWTG-S) quality improvement data, we sought to compare stroke performance metrics by sex among 9 GWTG-S participating Puerto Rico hospitals from 2010-2014.

Methods: Age and NIHSS-adjusted hierarchical generalized linear models, stratified by sex, were evaluated for the following GWTG-S performance metrics: IV tPA treatment, early antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy for atrial fibrillation (AF) at discharge, statin medication at discharge, smoking cessation counseling, defect-free care (compliance with all performance measures), in addition to CT scan ≤25 minutes and door-to-IV tPA administration ≤60 minutes of hospital arrival.

Results: Among 3,277 acute ischemic stroke cases, 48% were women. As compared to men, women were older (72±14 vs. 68±13 years, P<0.0001) with higher NIHSS scores (10±8.5 vs. 9±7.7, P=0.005). Women were less likely to receive IV tPA ≤ 4.5 hours among eligible patients arriving ≤ 3.5 hours (OR 0.71, 95% CI 0.51-0.98, P=0.04), early antithrombotic therapy (OR 0.86, 95% CI 0.75-0.97, P=0.02), DVT prophylaxis (OR 0.93, 95% CI 0.88-0.99, P=0.03), statin medication at discharge (OR 0.85, 95% CI 0.78-0.93, P=0.0001), and anticoagulation for AF at discharge (OR 0.67, 95% CI 0.49-0.92, P=0.01) despite having higher rates of AF at admission (11% vs. 7%, P=0.001). Rates of IV tPA for patients arriving ≤ 2 hours, antithrombotic therapy at discharge, and smoking cessation counseling showed no sex differences. While women were less likely to have a CT scan ≤ 25 minutes of hospital arrival compared to men (OR 0.83, 95% CI 0.74-0.93, P=0.002), no difference was found in door-to-IV tPA administration ≤ 60 minutes. Although an overall temporal improvement in defect-free care was observed from 2010-2014 (31% to 63%, P<.0001), women were less likely to receive this measure than men (OR 0.91, 95% CI 0.85-0.97, P=0.007).

Conclusions: Overall, stroke care remains lower for Puerto Rican women than men. Continued adoption of the GWTG-S quality improvement program may help reduce sex disparities in quality of care across the island.

Abstract TP315: Predictors of Thrombolysis Administration in Patients with Minor Stroke or TIA in the Florida Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study

Background: Minor stroke/TIA is the most common cause for thrombolysis exclusion in patients acutely presenting to the hospital. Thrombolysis administration in this subgroup is highly variable amongst different clinicians and institutions. We aim to study the predictors of thrombolysis in patients with mild ischemic stroke in the FL-PR CReSD Study.

Methods: 73,712 patients with ischemic stroke/TIA were prospectively enrolled from January 2010 to April 2015. We included 7,746 patients who had persistent neurological symptoms with NIHSS score ≤5 and arrived within 4 hours of symptom onset. Multilevel logistic regression analysis was used to identify independent predictors of thrombolysis in the subgroup of patients without contraindications to thrombolysis

Results: 6,826 patients (25% final diagnosis TIA, 75% minor stroke) were included (mean age=70±14 years), 52.7% male, 70.3% white, 13% black, 16.7% Hispanic, median NIHSS=2 (IQR=1,4). Patients who received thrombolysis (N=1281, 18.7%) were younger (67 vs. 70.7 years, P<0.001), had less vascular risk factors (HTN, DM, dyslipidemia), lower risk of prior vascular disease (MI, PVD, previous stroke) and had a higher presenting median NIHSS score (4 vs. 2, P<0.0001). In the multivariable analysis, younger age (OR 1.02, 95% CI 1.02-1.03, P<0.0001), white or Hispanic vs. black (OR 1.2, 95% CI 1.04-1.37, P=0.0097), early hospital arrival (unit change in 30 min.) (OR 1.26, 95% CI 1.21-1.31, P<0.0001), arrival by EMS (OR 1.28, 95% CI 1.08-1.49, P<0.0001), higher NIHSS score (OR 1.96, 95% CI 1.87-2.06, P<0.0001), altered level of consciousness (OR 1.43, 95% CI 1.11-1.85, P=0.0062) and aphasia at presentation (OR 1.34, 95% CI 1.13-1.58, P=0.0008) were independent predictors of thrombolysis administration.

Conclusion: Minor acutely presenting stroke patients were more likely to receive thrombolysis if they were young, white or Hispanic, and arrived early to the hospital with more severe neurological presentation specifically aphasia and altered level of consciousness. Identification of predictors of thrombolysis utilization is important in the design of educational programs and randomized trials to increase the use of thrombolysis for minor stroke.

Abstract W P283: Race-Ethnic Stroke Disparities in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study - The NINDS Stroke Prevention Intervention Research Program

Background: Race-ethnic disparities in stroke care can contribute to inequality in stroke outcomes. We sought to determine the disparities in stroke performance metrics by race-ethnicity in a voluntary stroke registry of Florida and Puerto Rico Get With The Guidelines-Stroke (GWTG-S) data.

Methods: Sixty-three sites who had enrolled in the FL-PR Stroke Registry (54 FL; 9 PR) recorded 38,684 ischemic stroke cases from 2010 to 2013. Generalized linear regression models were used to evaluate race-ethnic differences in 7 pre-defined acute stroke performance measures and defect-free care (IV tPA treatment, in-hospital antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy, statin medication at discharge, and smoking cessation counseling), adjusting for age and region (FL vs. PR).

Results: Of acute ischemic stroke cases, 63% were non-Hispanic White (NHW), 18% NH-Black (NHB), and 17% Hispanic. The mean age was 71±14 years. NHW were older (73±14), followed by Hispanics (70±14), and NHB (63±14); p<0.0001. Defect-free care was better among NHB (78%) and NHW (76%) than in Hispanics (68%), p<0.0001. Defect-free care improved over time and the race-ethnic disparity decreased (2010: NHW 61%, NHB 64%, Hispanic 46%, p<0.0001; 2013: 91%, 91%, 86%, p=0.47 respectively). NHW were most likely to receive IV tPA treatment (arrived by 2 hours and treated by 3 hours; 88%) and early antithrombotic treatment (96%). Hispanics were least likely to receive DVT prophylaxis (76%), anticoagulation (92%), statins (89%), and smoking cessation counseling (93%).

Conclusions: Race-ethnic disparities in acute stroke care are evident yet decreasing, coinciding with improvements in quality of care over time in Florida and Puerto Rico hospitals participating in GWTG-S. Special stroke quality improvement programs to target areas where performance is less than expected and minimize race-ethnic disparities are necessary to improve stroke care for all Americans.

Abstract T P262: Lower Thrombolysis Rates in Women with Acute Ischemic Stroke in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study - The NINDS Stroke Prevention Intervention Research Program

Background: Higher prevalence of stroke in women and sex-specific disparities in stroke care are reported. We sought to determine sex-specific differences in stroke performance metrics in a large quality improvement registry of Florida and Puerto Rico based on Get With The Guidelines-Stroke (GWTG-S).

Methods: 38,684 (49% women) acute ischemic stroke patients were included from 63 sites (54 FL; 9 PR) from 2010 to 2013. Logistic regression was used to evaluate sex-specific differences in defect-free care (IV tPA therapy, in-hospital antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy, statin medication at discharge, smoking cessation counseling) adjusting for age and race-ethnicity.

Results: As compared to men, women were older (73±15 vs. 69±14 years; p<0.0001), less likely Hispanic (17% vs. 18%; p=0.0001), with lower age- and race-ethnic-adjusted rates of hypertension (34% vs. 37%; p=0.0009) and smoking (13% vs. 21%; p<0.0001), but higher rates of atrial fibrillation (18% vs. 16%; p=0.02). Overall, 9% of patients received thrombolysis. Women were less likely to receive thrombolysis (OR 0.92, 95% CI 0.86-0.99) and less likely to have door-to-needle time <1 hour (OR 0.84, 95% CI 0.73-0.97). Overall, defect-free care was 75% in women and 76% in men (lower early antithrombotic therapy [OR 0.86, 95% CI 0.77-0.96], less antithrombotic at discharge [OR 0.87, 95% CI 0.77-0.99], less statin therapy at discharge [OR 0.81, 95% CI 0.74-0.88] and less smoking cessation counseling [OR 0.74, 95% CI 0.56-0.98]). Defect- free care improved over the study period; it was significantly lower in women vs. men in 2010 (58.2% vs. 60.7%, p=0.005), but similar in 2013 (90.2% vs 90.0%; p=0.64).

Conclusions: Women eligible to receive IV tPA for acute ischemic stroke were less likely to be treated and received less defect-free care compared to men, but these measures improved over time. These findings suggest that the adoption of GWTG-S quality improvement program helps reduce sex disparities in quality of care for acute ischemic stroke patients.

Abstract T P261: Stroke Care Improvement Trends in Puerto Rico Hospitals Participating in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study - the NINDS Stroke Prevention Intervention Research Program

Background: Racial and ethnic disparities in stroke care are known to contribute to inequality in stroke outcomes. The goal of the FL-PR CReSD Study is to assess and evaluate Get With The Guidelines-Stroke (GWTG-S) quality improvement data collected among Florida and Puerto Rico hospitals to evaluate for race-ethnic, sex, and regional disparities in stroke performance metrics. We sought to analyze the temporal trends in stroke performance metrics among the 9 hospitals located in Puerto Rico from 2010 to 2013.

Methods: Age-adjusted temporal trends were evaluated in the following GWTG-S pre-defined performance measures (IV tPA treatment within 3 hours among eligible patients arriving in 2 hours, in-hospital antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy, statin medication at discharge, and smoking cessation counseling) and defect-free care (compliance with all 7 performance measures).

Results: The mean age of 3,094 registered stroke cases was 69.5 ± 14.0 years, 50% were men, and 2,184 (71%) were diagnosed as ischemic strokes. Defect-free care occurred in 60% of ischemic stroke patients. Lower performance metrics were found for IV tPA treatment (78%), DVT prophylaxis (64%), and statin medication at discharge (83%). An additional IV tPA measure of treatment by 4.5 hours when arriving by 3.5 hours was observed in 65% of patients. The performance metrics that significantly improved over time from 2010 to 2013 included: IV tPA treatment within 3 hours (64% to 87%, p=0.04), DVT prophylaxis (33% to 87%, p<0.0001), statin medication at discharge (78% to 87%, p=0.01), and defect-free care (37% to 79%, p<0.0001).

Conclusions: In only four years, Puerto Rico hospitals participating in GWTG-S showed significant improvement across all pre-defined acute stroke performance measures. Wider implementation of quality improvement programs like GWTG-S among the 3.7 million inhabitants of Puerto Rico could further improve acute stroke care.

Activity of sulfate-reducing bacteria in human periodontal pocket

Samples of subgingival dental tissues were examined for the presence of sulfate-reducing bacteria (SRB). Using enrichment cultures, SRBs were detected in 9 of 17 individuals. A pure culture of SRB was obtained from one sample collected from a patient with type IV periodontal disease. The characterization of this isolate showed that it belongs to the genus Desulfovibrio. The isolate used pyruvate, lactate, glucose, fructose, and ethanol as the sole source of carbon. However, the isolate was unable to use acetate and methanol as a carbon source, indicating it as an incomplete oxidizer unable to carry out the terminal oxidation of substrates. Apart from using sulfate as electron acceptor, the isolate also used thiosulfate and nitrate as an electron acceptor. It has the ability to use a variety of nitrogen sources, including ammonium chloride, nitrate, and glutamate. The optimum growth temperature of the isolate was 37 degrees C and the optimum pH for growth was 6.8. The SRB isolate contained the electron carrier desulfoviridin. The numbers of SRB in the mouth are assumed to be limited by sulfate. Potential sources of sulfate in the subgingival area include free sulfate in pocket fluid and glycosaminoglycans and sulfur-containing amino acids from periodontal tissues.

Alu insertion polymorphisms and the genetic structure of human populations from the Caucasus

An analysis of 8 Alu insertion loci (ACE, TPA25, PV92, APO, FXIIIB, D1, A25, B65) has been carried out in six populations from the Caucasus, including Indo-European-speaking Armenians; Altaic-speaking Azerbaijanians; North Caucasian-speaking Cherkessians, Darginians, and Ingushians; and South Caucasian (Kartvelian)-speaking Georgians. The Caucasus populations exhibit low levels of within-population variation and high levels of between-population differentiation, with the average Fst value for the Caucasus of 0.113, which is almost as large as the Fst value of 0.157 for worldwide populations. Maximum likelihood tree and principal coordinate analyses both group the Caucasus populations with European populations. Neither geographic nor linguistic relationships appear to explain the genetic relationships of Caucasus populations. Instead, it appears as if they have been small and relatively isolated, and hence genetic drift has been the dominant influence on the genetic structure of Caucasus populations.

Long DOP-PCR of rare archival anthropological samples

The application of molecular DNA technologies to anthropological questions has meant that rare or archival samples of human remains, including blood, hair, and bone, can now be used as a source of material for genetic analysis. Often, these samples are irreplaceable, and/or yield very small quantities of DNA, so methods for preamplifying as much of the whole genome as possible would greatly enhance their usefulness. DOP-PCR (degenerate oligonucleotide-primed polymerase chain reaction) is an amplification method that uses a degenerate primer and very low initial annealing temperatures to amplify the whole genome. We adapted a published DOP-PCR protocol to long PCR enzyme and amplification conditions. The effectiveness of these modifications was tested by PCR amplification of DOP-PCR products at a mixture of genomic targets including 66 different microsatellites, 11 Alu insertion polymorphisms, and variable-length segments of the human lipoprotein lipase gene (LPL). The selected microsatellite markers were chosen to represent every chromosome, with expected product sizes ranging from 150 base pairs to 8,000 base pairs in length, while the 22 Alu insertion polymorphisms were selected to reveal biases in the recovery of alleles of different sizes. To determine nucleotide sequence variation, 2 kilobases (kb) of the LPL gene in 30 Mongolian individuals were sequenced. All gene-specific targets from DOP-PCR product template were amplified. No unexpected polymorphisms in the sequence results attributable to the DOP-PCR step were found, and 93% to 95% of Alu genotypes that have been amplified from total genomic DNA were replicated. The incorrect typings were all due to the preferential amplification of the shorter of two possible alleles in individuals heterozygous for an Alu insertion and were all correctly typed on subsequent reamplification of the gene-specific PCR products. This method of whole-genome amplification promises to be an efficient way to maximize the genetic use of rare anthropological samples.

Reading between the LINEs: human genomic variation induced by LINE-1 retrotransposition

The insertion of mobile elements into the genome represents a new class of genetic markers for the study of human evolution. Long interspersed elements (LINEs) have amplified to a copy number of about 100,000 over the last 100 million years of mammalian evolution and comprise approximately 15% of the human genome. The majority of LINE-1 (L1) elements within the human genome are 5' truncated copies of a few active L1 elements that are capable of retrotransposition. Some of the young L1 elements have inserted into the human genome so recently that populations are polymorphic for the presence of an L1 element at a particular chromosomal location. L1 insertion polymorphisms offer several advantages over other types of polymorphisms for human evolution studies. First, they are typed by rapid, simple, polymerase chain reaction (PCR)-based assays. Second, they are stable polymorphisms that rarely undergo deletion. Third, the presence of an L1 element represents identity by descent, because the probability is negligible that two different young L1 repeats would integrate independently between the exact same two nucleotides. Fourth, the ancestral state of L1 insertion polymorphisms is known to be the absence of the L1 element, which can be used to root plots/trees of population relationships. Here we report the development of a PCR-based display for the direct identification of dimorphic L1 elements from the human genome. We have also developed PCR-based assays for the characterization of six polymorphic L1 elements within the human genome. PCR analysis of human/rodent hybrid cell line DNA samples showed that the polymorphic L1 elements were located on several different chromosomes. Phylogenetic analysis of nonhuman primate DNA samples showed that all of the recently integrated "young" L1 elements were restricted to the human genome and absent from the genomes of nonhuman primates. Analysis of a diverse array of human populations showed that the allele frequencies and level of heterozygosity for each of the L1 elements was variable. Polymorphic L1 elements represent a new source of identical-by-descent variation for the study of human evolution. [The sequence data described in this paper have been submitted to the GenBank data library under accession nos. AF242435-AF242451.]