Disparities in brain health comorbidity management in intracerebral hemorrhage

Abstract

Background: Intracerebral hemorrhage (ICH) disproportionally affects underserved populations, and coincides with risk factors for cardiovascular events and cognitive decline after ICH. We investigated associations between social determinants of health and management of blood pressure (BP), hyperlipidemia, diabetes, obstructive sleep apnea (OSA), and hearing impairment before and after ICH hospitalization.

Methods: Survivors of the Massachusetts General Hospital longitudinal ICH study between 2016 and 2019 who received healthcare at least 6 months after ICH were analyzed. Measurements of BP, LDL and HbA1c and their management in the year surrounding ICH and referrals for sleep studies and audiology up to 6 months after ICH were gathered from electronic health records. The US-wide area deprivation index (ADI) was used as proxy for social determinants of health.

Results: The study included 234 patients (mean 71 years, 42% female). BP measurements were performed in 109 (47%) before ICH, LDL measurements were performed in 165 (71%), and HbA1c measurements in 154 (66%) patients before or after ICH. 27/59 (46%) with off-target LDL and 3/12 (25%) with off-target HbA1c were managed appropriately. Of those without history of OSA or hearing impairment before ICH, 47/207 (23%) were referred for sleep studies and 16/212 (8%) to audiology. Higher ADI was associated with lower odds of BP, LDL, and HbA1c measurement prior to ICH [OR 0.94 (0.90-0.99), 0.96 (0.93-0.99), and 0.96 (0.93-0.99), respectively, per decile] but not with management during or after hospitalization.

Conclusion: Social determinants of health are associated with pre-ICH management of cerebrovascular risk factors. More than 25% of patients were not assessed for hyperlipidemia and diabetes in the year surrounding ICH hospitalization, and less than half of those with off-target values received treatment intensification. Few patients were evaluated for OSA and hearing impairment, both common among ICH survivors. Future trials should evaluate whether using the ICH hospitalization to systematically address co-morbidities can improve long-term outcomes.

Keywords: diabetes; hearing impairment; hyperlipidemia; intracerebral hemorrhage; obstructive sleep apnea; social determinants of health.

Figure 1

Study flow. From the prospective longitudinal cohort of patients with intracerebral hemorrhage and available electronic health care data at Massachusetts General Hospital those who survived more than 6 months and received care within the Massachusetts General Hospital provider network were included.

Figure 2

Comorbidity management in the 12 months surrounding ICH. Proportion of patients that were evaluated for hypertension, hyperlipidemia, diabetes, obstructive sleep apnea, and hearing impairment.

Figure 3

Treatment patterns of hyperlipidemia (A) and diabetes (B) in the 12 months surrounding ICH. Proportion of ICH patients with LDL measurements, target values, and treatment changes. Among patients with off-target values of LDL and HbA1c, the majority did not receive appropriate management. There was no association between area deprivation index and the achievement of LDL goals or the change in treatment.