Sherman Lecture: Are We Aiming at the Correct Targets to Reduce Disparities in Stroke Mortality? Celebration, Reflection, and Redirection

Abstract

Although deaths from stroke have been reduced by 75% in the past 54 years, there has been virtually no reduction in the relative magnitude of Black-to-White disparity in stroke deaths, or the heavier burden of stroke deaths in the Stroke Belt region of the United States. Furthermore, although the rural-urban disparity has decreased in the past decade, this reduction is largely attributable to an increased stroke mortality in the urban areas, rather than reduced stroke mortality in rural areas. We need to focus our search for interventions to reduce disparities on those that benefit the disadvantaged populations, and support this review using relatively recently developed statistical approaches to estimate the magnitude of the potential reduction in the disparities.

Keywords: Stroke Belt; cardiovascular disease; racial disparity; risk score; rural; stroke disparities.

Figure 1. Age‐adjusted stroke mortality for the population aged ≥45 years, 1968 through 2021.

Data are from 1968 through 1978 from ICD‐8 (codes 430–438), 1979 through 1998 from ICD‐9 (codes 430–438), and 1999 through 2021 from ICD‐10 (codes I60–I69). ICD‐8, ICD‐9, ICD‐10 indicate International Classification of Diseases, Eighth Revision, Ninth Revision, Tenth Revision, respectively.

Figure 2. Temporal changes (1968 through 2021) in the Black‐to‐White disparity in stroke mortality.

A, Age‐adjusted stroke mortality for the non‐Hispanic White and non‐Hispanic Black population, aged ≥45 years, 1968 through 2021. Data 1968 through 1978 from ICD‐8 (codes 430–438), 1979 through 1998 from ICD‐9 (codes 430–438), and 1999 through 2021 from ICD‐10 (codes I60–I69). B, Black‐to‐White stroke mortality ratio. ICD‐8, ICD‐9, ICD‐10 indicate International Classification of Diseases, Eighth Revision, Ninth Revision, Tenth Revision, respectively.

Figure 3. Temporal changes (1968 through 2021) in the magnitude of the Stroke Belt disparity in stroke mortality.

A , Age‐adjusted stroke mortality for the Stroke Belt states (Alabama, Arkansas, Georgia, Mississippi, Louisiana, North Carolina, South Carolina, Tennessee) and the remainder of the nation, for the population aged ≥45 years, 1968 through 2021. Data 1968 through 1978 from ICD‐8 (codes 430–438), 1979 through 1998 from ICD‐9 (codes 430–438), and 1999 through 2021 from ICD‐10 (codes I60–I69). B, Stroke Belt to non‐Stroke‐Belt stroke mortality ratio. ICD‐8, ICD‐9, ICD‐10 indicate International Classification of Diseases, Eighth Revision, Ninth Revision, Tenth Revision, respectively.

Figure 4. Temporal changes (1999 through 2020) in the magnitude of the rural–urban disparity in stroke mortality.

A, Age‐adjusted stroke mortality for the by NCHS urbanization codes at the county level, for the population aged ≥45 years, 1999 through 2020 (ICD‐10). Note that both the vertical and horizontal axes differ from Figures 2 and 3. B, Stroke‐Belt to non‐Stroke‐Belt stroke mortality ratio, 1999 through 2021 from ICD‐10 (codes I60–I69). Note that both the vertical and horizontal axes differs from Figures 2 and 3. ICD‐10 indicates International Classification of Diseases, Tenth Revision; and NCHS, National Center for Health Statistics.