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. 2016 Jul;47(7):1893-8.
doi: 10.1161/STROKEAHA.115.012631. Epub 2016 Jun 2.

Where to Focus Efforts to Reduce the Black-White Disparity in Stroke Mortality: Incidence Versus Case Fatality?

George Howard  1 , Claudia S Moy  2 , Virginia J Howard  2 , Leslie A McClure  2 , Dawn O Kleindorfer  2 , Brett M Kissela  2 , Suzanne E Judd  2 , Fredrick W Unverzagt  2 , Elsayed Z Soliman  2 , Monika M Safford  2 , Mary Cushman  2 , Matthew L Flaherty  2 , Virginia G Wadley  2 ; REGARDS Investigators*
Affiliations

Where to Focus Efforts to Reduce the Black-White Disparity in Stroke Mortality: Incidence Versus Case Fatality?

George Howard et al. Stroke. 2016 Jul.

Abstract

Background and purpose: At age 45 years, blacks have a stroke mortality ≈3× greater than their white counterparts, with a declining disparity at older ages. We assess whether this black-white disparity in stroke mortality is attributable to a black-white disparity in stroke incidence versus a disparity in case fatality.

Methods: We first assess if black-white differences in stroke mortality within 29 681 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort reflect national black-white differences in stroke mortality and then assess the degree to which black-white differences in stroke incidence or 30-day case fatality after stroke contribute to the disparities in stroke mortality.

Results: The pattern of stroke mortality within the study mirrors the national pattern, with the black-to-white hazard ratio of ≈4.0 at age 45 years decreasing to ≈1.0 at age 85 years. The pattern of black-to-white disparities in stroke incidence shows a similar pattern but no evidence of a corresponding disparity in stroke case fatality.

Conclusions: These findings show that the black-white differences in stroke mortality are largely driven by differences in stroke incidence, with case fatality playing at most a minor role. Therefore, to reduce the black-white disparity in stroke mortality, interventions need to focus on prevention of stroke in blacks.

Keywords: blacks; continental population groups; incidence; mortality; stroke.

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Figures

Figure 1
Figure 1
Age-specific (for age 45 and over) Black-to-White mortality ratio for deaths from cerebrovascular diseases (ICD-10: 160 – 169) in the United States for years 2003 to 2007 (inclusive). Note that both the number of people dying of stroke, and the number of people in the population, are from a census (Census of the population and U.S. Vital Statistics) and include all people in the US. As such, there is no sampling variation of the estimated age-specific mortality rates underlying the mortality ratio, and hence no sampling variation (and hence no confidence bounds) on the mortality ratios.
Figure 2
Figure 2
A and B: Black-to-White hazard ratio (with 95% confidence limits) for fatal stroke (mortality analysis) after adjustment for sex. Figure 1A provides the hazard ratio from a model with age as a categorical variable, while 1B from a model with age as a continuous variable.
Figure 3
Figure 3
A and B: Black-to-White hazard ratio (with 95% confidence limits) for any stroke (incidence analysis) after adjustment for sex. Figure 2A provides the hazard ratio from a model with age as a categorical variable, while 2B from a model with age as a continuous variable.
See this image and copyright information in PMC

References

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