Analysis Documents Lingering Racial, Ethnic Gaps Despite Gains in National Stroke Quality Initiative

The nationwide Target: Stroke quality initiative has improved outcomes for individuals of all races and ethnic groups with acute ischemic stroke in the United States, yet disparities in care persist. So concludes a new study of more than 1 million patients presented at the International Stroke Conference 2024. The study was recognized with the conference’s Stroke Care in Emergency Medicine Award and simultaneously published in JAMA Network Open.

“Our analysis shows that thrombolysis frequency, timeliness and functional outcomes have continued to improve across all racial and ethnic groups of patients presenting within 4.5 hours of symptom onset,” says the study’s first author, Shumei Man, MD, PhD, Director of the Thrombectomy-Capable Stroke Center at Cleveland Clinic Fairview Hospital and Section Leader of Teleneurology at Cleveland Clinic. “The observed care metrics at hospitals participating in the Get With The Guidelines–Stroke initiative did not have significant racial and ethnic disparities. However, after adjusting for patient and hospital factors, Asian, Black and Hispanic patients are still less likely to receive thrombolysis or to be treated within guideline-recommended door-to-needle times. Furthermore, Asian, Black and Hispanic patients are more likely to present after 4.5 hours of stroke onset, which makes them ineligible for thrombolysis treatment.”

Initiated by the American Heart Association (AHA) and American Stroke Association (ASA) in 2010, Target: Stroke is a three-phase quality initiative with iteratively more stringent time goals for thrombolysis. No analysis has yet examined race- and ethnicity-specific progress during each Target: Stroke phase. Importantly, the study authors note, no studies have been able to delineate the exact diversion point leading to the generally reported racial and ethnic disparity in treatment with thrombolysis, which has been shown to save lives and improve functional recovery from stroke.

Study design and results

To fill that gap, the multicenter author team analyzed data from 1,053,539 patients treated at hospitals participating in the AHA/ASA’s Get With the Guidelines–Stroke program for ischemic stroke. The four primary outcomes evaluated were:

• Thrombolysis rates overall
• Proportion of patients receiving thrombolysis with a door-to-needle (DTN) time ≤ 60 minutes
• Rates of thrombolysis in ≤ 3 hours among eligible patients who arrived in ≤ 2 hours
• Rates of thrombolysis in ≤ 4.5 hours among eligible patients who arrived in ≤ 3.5 hours

The cohort was evenly divided by sex (50.4% female; 49.6% male). Nearly two-thirds (74.1%) of the patients were white (median age, 75), 15.2% were Black (median age, 64), 7.3% were Hispanic (median age, 68) and 2.8% were Asian (median age, 72).

“Our previous research showed that early thrombolysis is associated with better functional outcomes and lower rates of long-term mortality,” Dr. Man says. “One of the critical questions we wanted to answer with this study was whether racial and ethnic disparities occurred during delayed hospital arrival or treatment provision by the hospitals.”

Compared with the period before Target: Stroke, unadjusted thrombolysis rates across all ethnic groups increased — specifically, from 10% to 15% in 2003 to 43% to 46% in 2021 — with no racial or ethnic disparity. In adjusted analyses, the odds of receiving thrombolysis were significantly lower for Asian, Black and Hispanic patients than for their white counterparts (adjusted odds ratios [ORs] during Target: Stroke phase III = 0.85, 0.75 and 0.86, respectively).

Similarly, across all racial and ethnic groups, DTN times ≤ 60 minutes increased from 26% to 28% in 2009 to 66% to 72% in 2021, with no disparity. However, Asian, Black and Hispanic patients were significantly less likely to receive thrombolysis with a DTN time ≤ 60 minutes than their white counterparts (adjusted ORs during Target: Stroke phase III = 0.91, 0.78 and 0.87, respectively).

“In contrast to the DTN time metrics, we found no ethnic or racial disparities in thrombolysis rates among patients who arrived in ≤ 2 hours and were treated in ≤ 3 hours or among those who arrived in ≤ 3.5 hours and were treated in ≤ 4.5 hours,” Dr. Man explains. “There may be multiple reasons for this phenomenon — such as slower deliberations among patients in non-white ethnic minority groups because of suspicion about the treatment or medical system, desire to consult more family members, or concern about costs — but the final decisions are the same when the window of treatment is closing.”

Looking at clinical outcomes, the investigators found improvement among all racial and ethnic groups compared with the period before Target: Stroke, and in phase III, odds of ambulation at discharge had increased for white, Asian, Black and Hispanic patients.

Opportunity for more timely hospital arrival

An important opportunity identified by this analysis is that a large proportion of patients from all racial and ethnic backgrounds arrive at the hospital after the 4.5-hour thrombolysis time window. Moreover, the analysis shows that this number has been increasing, likely due to more patients with long driving distances being treated at Get With The Guidelines–Stroke hospitals. Notably, Asian, Black, and Hispanic patients are more likely to arrive at the hospital after the 4.5-hour window compared with white patients.

“In 2021, 55% of Asian and Black patients arrived at the hospital more than 4.5 hours after having an ischemic stroke compared with 48% of white patients,” Dr. Man notes. “That’s a significant difference and may negatively affect those patients’ outcomes because thrombolytic treatment has been proven to improve functional outcomes and reduce death after ischemic stroke.”

More education and research needed to address disparities

The results essentially confirmed the authors’ hypothesis that racial and ethnic disparity in administration of thrombolytics derived from delays in both hospital arrival and hospital treatment provision.

Dr. Man recommends several strategies to address these disparities. “Better and more culturally tailored education is needed about the signs of stroke for individuals in the entire population, especially non-white racial and ethnic groups,” she says. “We need research to understand and overcome the reasons for slower decision-making for these groups after hospital arrival. Although quality reporting typically uses face value without risk adjustment, we should consider incorporating risk-adjusted quality measures or quality reporting by race and ethnicity.”