Geographic and Regional Variability in Racial and Ethnic Disparities in Stroke Thrombolysis in the United States

Abstract

Background and purpose: Intravenous thrombolysis (IVT) after ischemic stroke is underutilized in racially/ethnically minoritized groups. We aimed to determine the regional and geographic variability in racial/ethnic IVT disparities in the United States.

Methods: Acute ischemic stroke admissions between 2012 and 2018 were identified in the National Inpatient Sample. Multivariable logistic regression was used to test the association between IVT and race/ethnicity, stratified by geographic region and controlling for demographic, clinical, and hospital characteristics.

Results: Of the 545 509 included cases, 47 031 (8.6%) received IVT. Racially/ethnically minoritized groups had significantly lower adjusted odds of IVT compared with White people in the South Atlantic region (odds ratio [OR], 0.86 [95% CI, 0.82-0.91]), the East North Central region (OR, 0.91 [95% CI, 0.85-0.97]) and the Pacific region (OR, 0.90 [95% CI, 0.85-0.96]). In the South Atlantic region, IVT use in racial/ethnic minority groups was below the national average of all racial/ethnic minority patients (P=0.002). Compared with White patients, Black patients had lower odds of IVT in the Middle Atlantic region (OR, 0.84 [95% CI, 0.78-0.91]), the South Atlantic region (OR, 0.78 [95% CI, 0.74-0.82]), and the East North Central region (OR, 0.86 [95% CI, 0.79-0.93]). In the South Atlantic region, this difference was below the national average for Black people (P<0.001). Hispanic patients had significantly lower use of IVT only in the Pacific region (OR, 0.92 [95% CI, 0.85-0.99]), while Asian/Pacific Islander patients had lower odds of IVT in the Mountain (OR, 0.76 [95% CI, 0.59-0.98]) and Pacific region (OR, 0.89 [95% CI, 0.82-0.97]).

Conclusions: Racial/ethnic disparities in IVT use in the United States vary by region. Geographic hotspots of lower IVT use in racially/ethnically minoritized groups are the South Atlantic region, driven predominantly by lower use of IVT in Black patients, and the East North Central and Pacific regions.

Keywords: African Americans; ethnic groups; geographic locations; minority groups; stroke; thrombolytic therapy.

Figure 1.. Regional variability in IVT disparities for all racial/ethnic minority groups.

IVT use in racial/ethnic minority groups compared to White people stratified by geographic region (A); and color-coded U.S. map representing IVT treatment differences in racial/ethnic minority groups compared to White people by geographic region (B). Green areas indicate no disparity, i.e. no IVT underutilization compared to White people (OR>1); green-yellow checkered areas indicate no statistically significant disparity (OR<1, but 95% CI including 1); yellow areas indicate a disparity (i.e. lower use) comparable to the national average (OR and 95% CI <1, but not significantly below the national average); and the red areas indicate a disparity below the national average (OR and 95% CI <1, and statistically significantly below the national average).

Figure 2.. Regional variability in IVT disparities by race/ethnicity.

IVT use in Black (A), Hispanic (C), and Asian/PI (E) patients compared to White people stratified by geographic region, and corresponding color-coded U.S. maps (B, D, and F, respectively).