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, early research shows.
“The findings should serve as an eye-opener that social determinants of health seem to be playing a role in who receives thrombolytic therapy, said study investigator Chanaka Kahathuduwa, MD, PhD, resident physician, Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock.
The findings were released ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology.
Contributor to Poor Outcomes
Social determinants of health are important contributors to poor stroke-related outcomes, the investigators noted. They pointed out that previous research has yielded conflicting results as to the cause.
Whereas some studies suggest poor social determinants of health drive increased stroke incidence, others raise the question of whether there are disparities in acute stroke care.
To investigate, the researchers used a publicly available database and diagnostic and procedure codes to identify patients presenting at emergency departments in Texas from 2016 to 2019 with ischemic stroke who did and did not receive thrombolytic therapy.
“We focused on Texas, which has a very large area but few places where people have easy access to health care, which is a problem,” said study co-investigator Chathurika Dhanasekara, MD, PhD, research assistant professor in the Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center.
The study included 63,983 stroke patients, of whom 51.6% were female, 66.6% were White, and 17.7% were Black. Of these, 7198 (11.2%) received thrombolytic therapy; such therapies include the tissue plasminogen activators (tPAs) alteplase and tenecteplace.
Researchers collected information on social determinants of health such as age, race, gender, insurance type, and residence based on zip codes. They computed risk ratios (RRs) of administering thrombolysis on the basis of these variables.
Results showed that Black patients were less likely than their White counterparts to receive thrombolysis (RR, 0.90; 95% CI, 0.85-0.96). In addition, patients older than 65 years were less likely those aged 18-45 years to receive thrombolysis (RR, 0.47; 95% CI, 0.44-0.51), and rural residents were less likely than urban dwellers to receive the intervention (RR, 0.60; 95% CI, 0.55-0.65).
It makes some sense, the researchers said, that rural stroke patients would be less likely to get thrombolysis because there’s a limited time window — within 4.5 hours — during which this therapy can be given, and such patients may live a long distance from a hospital.
Two other groups less likely to receive thrombolysis were Hispanic persons versus non-Hispanic persons (RR, 0.93; 95% CI, 0.87-0.98) and Medicare/Medicaid/Veterans Administration patients (RR, 0.77; 95% CI, 0.73-0.81) or uninsured patients (RR, 0.90; 95% CI, 0.94-0.87) vs those with private insurance.
Interestingly, male patients were less likely than female patients to receive thrombolysis (RR, 0.95; 95% CI, 0.90-0.99).
Surprising Findings
With the exception of the discrepancy in thrombolysis rates between rural versus urban dwellers, the study’s findings were surprising, said Dr. Kahathuduwa.
Researchers divided participants into quartiles, from least to most disadvantaged, based on the Social Vulnerability Index (SVI), created by the Centers for Disease Control and Prevention to determine social vulnerability or factors that can negatively affect a community’s health.
Among the 7930 individuals in the least disadvantaged group, 1037 received thrombolysis. In comparison, among the 7966 persons in the most disadvantaged group, 964 received thrombolysis.
After adjusting for age, sex, and education, investigators found that patients in the first quartile based on SVI were more likely to be associated with thrombolysis vs those in the second and third quartiles (RR, 1.13; 95% CI, 1.04-1.22).
The researchers also examined the impact of comorbidities using the Charlson Comorbidity Index. Patients with diabetes, hypertension, and high cholesterol in addition to signs of stroke would rouse a higher degree of suspicion and be more likely to be treated with tPA or tenecteplase, said Dr. Kahathuduwa.
“But even when we controlled for those comorbidities, the relationships we identified between health disparities and the likelihood of receiving thrombolysis remained the same,” said Dr. Kahathuduwa.
It’s not clear from this study what factors contribute to the disparities in stroke treatment. “All we know is these relationships exist,” said Dr. Kahathuduwa. “We should use this as a foundation to understand what’s really going on at the grassroots level.”
However, he added, it’s possible that accessibility plays a role. He noted that Lubbock has the only Level 1 stroke center in west Texas; most stroke centers in the state are concentrated in cities in east and central Texas.
The investigators are embarking on further research to assess the impact of determinants of health on receipt of endovascular therapy and the role of stroke severity.
“In an ideal world, all patients who need thrombolytic therapy would get thrombolytic therapy within the recommended time window because the benefits are very clear,” said Dr. Kahathuduwa.
The findings may not be generalizable because they come from a single database. “Our findings need to be validated in another independent dataset before we can confidently determine what’s going on,” said Dr. Kahathuduwa.
A limitation of the study was that it is unknown how many of the participants were seen at the hospital within the recommended time frame and would thus be eligible to receive the treatment.
Commenting on the research, Martinson Arnan, MD , a vascular neurologist at Bronson Neuroscience Center, Kalamazoo, Michigan, said the study’s “exploratory finding” is important and “illuminates the potential impact of social determinants of health on disparities in acute stroke treatment.”
Neurologists consistently emphasize the principle that “time is brain” — that timely restoration of blood flow is crucial for minimizing morbidity associated with ischemic stroke. This study offers a potential opportunity to investigate how social determinants of health may affect stroke care, said Dr. Arnan.
However, he added, further research is needed “to understand whether the differences in outcomes observed here are influenced by levels of health education, concordance between patients and their treating providers, or other issues related to access barriers.”
The investigators and Dr. Arnan report no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
, early research shows.
“The findings should serve as an eye-opener that social determinants of health seem to be playing a role in who receives thrombolytic therapy, said study investigator Chanaka Kahathuduwa, MD, PhD, resident physician, Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock.
The findings were released ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology.
Contributor to Poor Outcomes
Social determinants of health are important contributors to poor stroke-related outcomes, the investigators noted. They pointed out that previous research has yielded conflicting results as to the cause.
Whereas some studies suggest poor social determinants of health drive increased stroke incidence, others raise the question of whether there are disparities in acute stroke care.
To investigate, the researchers used a publicly available database and diagnostic and procedure codes to identify patients presenting at emergency departments in Texas from 2016 to 2019 with ischemic stroke who did and did not receive thrombolytic therapy.
“We focused on Texas, which has a very large area but few places where people have easy access to health care, which is a problem,” said study co-investigator Chathurika Dhanasekara, MD, PhD, research assistant professor in the Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center.
The study included 63,983 stroke patients, of whom 51.6% were female, 66.6% were White, and 17.7% were Black. Of these, 7198 (11.2%) received thrombolytic therapy; such therapies include the tissue plasminogen activators (tPAs) alteplase and tenecteplace.
Researchers collected information on social determinants of health such as age, race, gender, insurance type, and residence based on zip codes. They computed risk ratios (RRs) of administering thrombolysis on the basis of these variables.
Results showed that Black patients were less likely than their White counterparts to receive thrombolysis (RR, 0.90; 95% CI, 0.85-0.96). In addition, patients older than 65 years were less likely those aged 18-45 years to receive thrombolysis (RR, 0.47; 95% CI, 0.44-0.51), and rural residents were less likely than urban dwellers to receive the intervention (RR, 0.60; 95% CI, 0.55-0.65).
It makes some sense, the researchers said, that rural stroke patients would be less likely to get thrombolysis because there’s a limited time window — within 4.5 hours — during which this therapy can be given, and such patients may live a long distance from a hospital.
Two other groups less likely to receive thrombolysis were Hispanic persons versus non-Hispanic persons (RR, 0.93; 95% CI, 0.87-0.98) and Medicare/Medicaid/Veterans Administration patients (RR, 0.77; 95% CI, 0.73-0.81) or uninsured patients (RR, 0.90; 95% CI, 0.94-0.87) vs those with private insurance.
Interestingly, male patients were less likely than female patients to receive thrombolysis (RR, 0.95; 95% CI, 0.90-0.99).
Surprising Findings
With the exception of the discrepancy in thrombolysis rates between rural versus urban dwellers, the study’s findings were surprising, said Dr. Kahathuduwa.
Researchers divided participants into quartiles, from least to most disadvantaged, based on the Social Vulnerability Index (SVI), created by the Centers for Disease Control and Prevention to determine social vulnerability or factors that can negatively affect a community’s health.
Among the 7930 individuals in the least disadvantaged group, 1037 received thrombolysis. In comparison, among the 7966 persons in the most disadvantaged group, 964 received thrombolysis.
After adjusting for age, sex, and education, investigators found that patients in the first quartile based on SVI were more likely to be associated with thrombolysis vs those in the second and third quartiles (RR, 1.13; 95% CI, 1.04-1.22).
The researchers also examined the impact of comorbidities using the Charlson Comorbidity Index. Patients with diabetes, hypertension, and high cholesterol in addition to signs of stroke would rouse a higher degree of suspicion and be more likely to be treated with tPA or tenecteplase, said Dr. Kahathuduwa.
“But even when we controlled for those comorbidities, the relationships we identified between health disparities and the likelihood of receiving thrombolysis remained the same,” said Dr. Kahathuduwa.
It’s not clear from this study what factors contribute to the disparities in stroke treatment. “All we know is these relationships exist,” said Dr. Kahathuduwa. “We should use this as a foundation to understand what’s really going on at the grassroots level.”
However, he added, it’s possible that accessibility plays a role. He noted that Lubbock has the only Level 1 stroke center in west Texas; most stroke centers in the state are concentrated in cities in east and central Texas.
The investigators are embarking on further research to assess the impact of determinants of health on receipt of endovascular therapy and the role of stroke severity.
“In an ideal world, all patients who need thrombolytic therapy would get thrombolytic therapy within the recommended time window because the benefits are very clear,” said Dr. Kahathuduwa.
The findings may not be generalizable because they come from a single database. “Our findings need to be validated in another independent dataset before we can confidently determine what’s going on,” said Dr. Kahathuduwa.
A limitation of the study was that it is unknown how many of the participants were seen at the hospital within the recommended time frame and would thus be eligible to receive the treatment.
Commenting on the research, Martinson Arnan, MD , a vascular neurologist at Bronson Neuroscience Center, Kalamazoo, Michigan, said the study’s “exploratory finding” is important and “illuminates the potential impact of social determinants of health on disparities in acute stroke treatment.”
Neurologists consistently emphasize the principle that “time is brain” — that timely restoration of blood flow is crucial for minimizing morbidity associated with ischemic stroke. This study offers a potential opportunity to investigate how social determinants of health may affect stroke care, said Dr. Arnan.
However, he added, further research is needed “to understand whether the differences in outcomes observed here are influenced by levels of health education, concordance between patients and their treating providers, or other issues related to access barriers.”
The investigators and Dr. Arnan report no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
, early research shows.
“The findings should serve as an eye-opener that social determinants of health seem to be playing a role in who receives thrombolytic therapy, said study investigator Chanaka Kahathuduwa, MD, PhD, resident physician, Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock.
The findings were released ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology.
Contributor to Poor Outcomes
Social determinants of health are important contributors to poor stroke-related outcomes, the investigators noted. They pointed out that previous research has yielded conflicting results as to the cause.
Whereas some studies suggest poor social determinants of health drive increased stroke incidence, others raise the question of whether there are disparities in acute stroke care.
To investigate, the researchers used a publicly available database and diagnostic and procedure codes to identify patients presenting at emergency departments in Texas from 2016 to 2019 with ischemic stroke who did and did not receive thrombolytic therapy.
“We focused on Texas, which has a very large area but few places where people have easy access to health care, which is a problem,” said study co-investigator Chathurika Dhanasekara, MD, PhD, research assistant professor in the Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center.
The study included 63,983 stroke patients, of whom 51.6% were female, 66.6% were White, and 17.7% were Black. Of these, 7198 (11.2%) received thrombolytic therapy; such therapies include the tissue plasminogen activators (tPAs) alteplase and tenecteplace.
Researchers collected information on social determinants of health such as age, race, gender, insurance type, and residence based on zip codes. They computed risk ratios (RRs) of administering thrombolysis on the basis of these variables.
Results showed that Black patients were less likely than their White counterparts to receive thrombolysis (RR, 0.90; 95% CI, 0.85-0.96). In addition, patients older than 65 years were less likely those aged 18-45 years to receive thrombolysis (RR, 0.47; 95% CI, 0.44-0.51), and rural residents were less likely than urban dwellers to receive the intervention (RR, 0.60; 95% CI, 0.55-0.65).
It makes some sense, the researchers said, that rural stroke patients would be less likely to get thrombolysis because there’s a limited time window — within 4.5 hours — during which this therapy can be given, and such patients may live a long distance from a hospital.
Two other groups less likely to receive thrombolysis were Hispanic persons versus non-Hispanic persons (RR, 0.93; 95% CI, 0.87-0.98) and Medicare/Medicaid/Veterans Administration patients (RR, 0.77; 95% CI, 0.73-0.81) or uninsured patients (RR, 0.90; 95% CI, 0.94-0.87) vs those with private insurance.
Interestingly, male patients were less likely than female patients to receive thrombolysis (RR, 0.95; 95% CI, 0.90-0.99).
Surprising Findings
With the exception of the discrepancy in thrombolysis rates between rural versus urban dwellers, the study’s findings were surprising, said Dr. Kahathuduwa.
Researchers divided participants into quartiles, from least to most disadvantaged, based on the Social Vulnerability Index (SVI), created by the Centers for Disease Control and Prevention to determine social vulnerability or factors that can negatively affect a community’s health.
Among the 7930 individuals in the least disadvantaged group, 1037 received thrombolysis. In comparison, among the 7966 persons in the most disadvantaged group, 964 received thrombolysis.
After adjusting for age, sex, and education, investigators found that patients in the first quartile based on SVI were more likely to be associated with thrombolysis vs those in the second and third quartiles (RR, 1.13; 95% CI, 1.04-1.22).
The researchers also examined the impact of comorbidities using the Charlson Comorbidity Index. Patients with diabetes, hypertension, and high cholesterol in addition to signs of stroke would rouse a higher degree of suspicion and be more likely to be treated with tPA or tenecteplase, said Dr. Kahathuduwa.
“But even when we controlled for those comorbidities, the relationships we identified between health disparities and the likelihood of receiving thrombolysis remained the same,” said Dr. Kahathuduwa.
It’s not clear from this study what factors contribute to the disparities in stroke treatment. “All we know is these relationships exist,” said Dr. Kahathuduwa. “We should use this as a foundation to understand what’s really going on at the grassroots level.”
However, he added, it’s possible that accessibility plays a role. He noted that Lubbock has the only Level 1 stroke center in west Texas; most stroke centers in the state are concentrated in cities in east and central Texas.
The investigators are embarking on further research to assess the impact of determinants of health on receipt of endovascular therapy and the role of stroke severity.
“In an ideal world, all patients who need thrombolytic therapy would get thrombolytic therapy within the recommended time window because the benefits are very clear,” said Dr. Kahathuduwa.
The findings may not be generalizable because they come from a single database. “Our findings need to be validated in another independent dataset before we can confidently determine what’s going on,” said Dr. Kahathuduwa.
A limitation of the study was that it is unknown how many of the participants were seen at the hospital within the recommended time frame and would thus be eligible to receive the treatment.
Commenting on the research, Martinson Arnan, MD , a vascular neurologist at Bronson Neuroscience Center, Kalamazoo, Michigan, said the study’s “exploratory finding” is important and “illuminates the potential impact of social determinants of health on disparities in acute stroke treatment.”
Neurologists consistently emphasize the principle that “time is brain” — that timely restoration of blood flow is crucial for minimizing morbidity associated with ischemic stroke. This study offers a potential opportunity to investigate how social determinants of health may affect stroke care, said Dr. Arnan.
However, he added, further research is needed “to understand whether the differences in outcomes observed here are influenced by levels of health education, concordance between patients and their treating providers, or other issues related to access barriers.”
The investigators and Dr. Arnan report no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
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