Blacks hospitalized with the most common type of stroke are less likely than white or Hispanic patients to receive evidence-based stroke care, according to a new study in Circulation: Journal of the American Heart Association.
But this disparity in care improved over time at hospitals participating in the American Heart Association/American Stroke Association's Get With The Guidelines®-Stroke quality improvement program, researchers said.
"Previous reports that have identified variances in the quality of care and outcomes among different racial and ethnic groups have been limited in size, have not looked at trends over time and have had inconsistent findings," said Lee H. Schwamm, M.D., lead author of the study and director of the TeleStroke and Acute Stroke Services at Massachusetts General Hospital in Boston, Mass. "But it's critical to recognize and understand the reasons for these differences in treatment patterns and outcomes so we can develop the strategies needed to eliminate them."
Schwamm and colleagues analyzed in-hospital deaths and examined how frequently 397,257 black, white and Hispanic ischemic stroke patients (average age 71) received seven evidence-based stroke care measures at 1,181 hospitals participating in the Get With The Guidelines-Stroke program between 2003 to 2008.
After adjusting for patient and hospital characteristics, the researchers found that Hispanic patients received care similar to their white counterparts on most of the seven measures. Black patients, however, were less likely than white or Hispanic patients to receive most of the quality measures:
- Blacks were 16 percent less likely than whites to receive the clot-busting drug tissue plasminogen activator (tPA) and to receive anticoagulants for atrial fibrillation.
- Blacks were 12 percent less likely than whites to receive deep vein thrombosis prevention and to be discharged with anti-clotting medications.
- Blacks were 3 percent less likely than whites to receive early anti-clotting medications.
- Blacks were 9 percent less likely than whites to receive cholesterol-lowering therapy.
- Blacks were 15 percent less likely than whites and Hispanics were 18 percent less likely than whites to receive smoking cessation counseling.
- Overall, blacks were 10 percent less likely than whites to receive "defect free care," which is defined as the proportion of patients who receive all of the interventions for which they are eligible.
"An interesting finding is that, despite being less likely to receive the interventions, black patients were less likely to die in the hospital than whites or Hispanics," said Schwamm, chair of the Get With The Guidelines National Steering Committee. "We suspect that's because black patients are more likely to have stroke at younger ages and present with less severe strokes than the other groups."
Researchers also found racial and ethnic differences in stroke-related outcomes at discharge:
- Black (47.9 percent) and Hispanic (52.6 percent) patients were more likely to be discharged to home compared to white patients (44.0 percent), who were more likely to be discharged to a skilled nursing facility compared to black and Hispanic patients.
- Black (4.37 percent) and Hispanic (4.90 percent) patients were less likely than white patients (6.06 percent) to die in the hospital.
- Black (6.60 days) and Hispanic (6.34 days) patients had longer hospital stays than whites (5.49 days).
During the study, Get With The Guidelines-Stroke hospitals significantly improved the quality of stroke care for patients in all three groups, Schwamm said.
"These findings tell us that a focused, systematic quality improvement intervention, such as this, can improve care, regardless of race and ethnicity," he said. "What remains is to identify the causes of these differences in care among ethnic groups so we can develop strategies to eliminate that small but persistent disparity."
Limitations of the study are that participation in Get With The Guidelines-Stroke is voluntary and hospitals that participate are more likely to be larger teaching institutions with a strong interest in stroke care and quality improvement, Schwamm said. So the findings may not represent care at all U.S. hospitals.
Furthermore, reliable information about stroke severity is not always captured in patients' records; so the authors said they're cautious in their conclusions that relate to in-patient death.
Co-authors are Mathew J. Reeves, Ph.D.; Wenqin Pan, Ph.D.; Eric E. Smith, M.D., M.P.H.; Michael R. Frankel, M.D.; DaiWai Olson, Ph.D., R.N.; Xin Zhao, M.S.; Eric Peterson, M.D., M.P.H.; and Gregg C. Fonarow, M.D. Author disclosures are on the manuscript.
Get With The Guidelines-Stroke is supported in part by unrestricted educational grants from Pfizer, Inc. and the Merck-Schering Plough Partnership.
- Lee H. Schwamm, Mathew J. Reeves, Wenqin Pan, Eric E. Smith, Michael R. Frankel, DaiWai Olson, Xin Zhao, Eric Peterson, and Gregg C. Fonarow. Race/Ethnicity, Quality of Care, and Outcomes in Ischemic Stroke. Circulation: Journal of the American Heart Association, 2010; DOI: 10.1161/CIRCULATIONAHA.109.881490
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