Inequalities in Acute Ischemic Stroke Treatment Utilization and Outcomes

Introduction: Advances in acute ischemic stroke care led to significant improvements in treatment outcomes. However, access to stroke treatments in the United States is unequally distributed throughout the population. It is unclear how these treatments are distributed, especially for endovascular stroke therapy (EST), and if there are inequalities in outcomes and usage. Thus, we aim to study the trends and predictors of the outcome of stroke treatments using the National Inpatient Sample (NIS) database.

Methods: This is a retrospective study conducted from 2010 to 2019 using the NIS. Patients were divided into those who received recombinant tissue plasminogen activator (rt-PA), EST, and both rt-PA+EST. Demographic, socioeconomic, and hospital data were obtained and analysis was performed comparing differences in disposition, mortality, and length of stay.

Results: There was significant inequality of utilization for EST for Black race controlling for income with Black patients needing to be three quartiles higher in income for the same utilization of EST as lowest quartile White patients (p < 0.001). For predictors of mortality, older age, self-pay insurance, Hispanic race (only EST), and higher comorbidities were predictive (p < 0.05). For the length of stay, older age, higher comorbidities, all minority races other than Native American were predictive of longer length of stay (p < 0.05). For home discharge, Black race (all treatments), Asian race (rt_PA and rt_PA with EST), and increasing comorbidities (EST and rt_PA with EST) were predictive of fewer home discharges (p < 0.05).

Conclusion : Despite optimistic trends in stroke treatment outcomes, there are significant inequities that are visible across region, income status, and race. Efforts should be focused on the reduction of inequality of utilization and outcomes potentially with programs that improve awareness of stroke and access to treatments for the population at risk.