The Effect of Structural Racism on Urban Hospital Stroke Care Access

Compared with White patients, older Black patients in the United States on Medicare in urban hospitals experience disparities in stroke care access and outcomes, according to study findings published in the Journal of the American Heart Association.

Investigators explored the relationship between structural racism (practices, policies, and laws that restrict access to resources and services based on race), urban hospitals, and delivery of stroke care in the US. In the study, stroke care specifically referred to intravenous thrombolysis (tissue plasminogen activator [tPA]) and endovascular thrombectomy (ET).

The investigators conducted a retrospective study from January 2016 through December 2019 that included deidentified inpatient data of Medicare beneficiaries aged at least 65 years admitted to urban and non-urban hospitals with incident acute ischemic stroke.

Almost 1 million patients (N=951,914) were included in analysis, divided into large metropolitan areas (LMAs; ≥1 million residents; n=472,388), small metropolitan areas (<1 million residents; n=383,609), micropolitan areas (n=71,843), and non-urban areas (n=24,074). A county-level composite structural racism score (includes measures of income, education, employment, housing, and segregation) was incorporated in the analysis.

In non-urban hospitals vs LMAs, there was lower intensive care unit capacity (27.5% vs 88.6%), lower stroke certification (5.3% vs 38.4%), and lower rates of tPA (1.6% vs 12.3%) and ET (<1% vs 3.8%). LMAs had higher levels of racial segregation and income inequality vs non-urban areas. The investigators noted the composite structural racism score was associated with increased odds of ET (odds ratio [OR], 4.15; 95% CI, 2.98-5.79) and receipt of tPA (OR, 1.47; 95% CI, 1.33-1.63). The composite structural racism scores were 0.58 for LMAs, 0.97 for small metropolitan areas, 0.88 for micropolitan areas, and 0.77 for non-urban areas, with no statistical significance in the differences between them (P =.21).

Black patients, compared with White patients, in urban areas were less likely to receive ET (OR, 0.63; 95% CI, 0.60-0.66; 37% lower odds of receiving ET) and tPA (OR, 0.70; 95% CI, 0.68-0.72; 30% lower odds of receiving tPA) despite greater access overall to stroke care in urban areas.

Study limitations include no granularity of data offering individual patient clinical details that might affect ET and tPA administration, and possible incorporation of patients with a recurrent event.

“Despite greater access to stroke care in urban areas, a persistent racial disparity remained, with Black patients less likely to receive intravenous thrombolysis and endovascular thrombectomy compared with White patients,” the investigators concluded. “We found persistent disparities in stroke care access and outcomes, influenced by structural racism and rural–urban differences.”

This article originally appeared on The Cardiology Advisor