Ten-Year Trend in Age, Sex, and Racial Disparity in tPA (Alteplase) and Thrombectomy Use Following Stroke in the United States

Abstract

Background and Purpose: IV tPA (intravenous thrombolysis with alteplase) and mechanical thrombectomy (MT) utilization increased in acute ischemic stroke hospitalizations in the United States over the last decade. It is uncertain whether this increase occurred equally across all age, sex, and racial groups. Methods: Adult acute ischemic stroke hospitalizations (weighted n=4 442 657) contained in the 2008 to 2017 National Inpatient Sample were identified using International Classification of Diseases codes. Proportions of hospitalizations with IV tPA and MT were computed according to age, sex, and race. Joinpoint and multivariable-adjusted logistic regression models were used to evaluate trends over time. Results: Across this period, 32.4% of all hospitalizations were in patients ≥80 years, and 64.7% of these were women. IV tPA and MT use differed by age with highest proportion of utilization of both treatments in patients aged 18 to 39 years (IV tPA, 12.3%) and lowest percentage in patients aged ≥90 years (IV tPA, 7.9%). Utilization of both procedures increased over time in all age groups, but the pace of increase was faster in patients ≥90 years compared with patients aged 18 to 39 years (MT: odds ratio, 1.25 [95% CI, 1.20–1.35] per unit increase in year, P interaction <0.001). Frequency of utilization of IV tPA and MT was lower in Black patients compared with White patients in most age groups. Usage of both procedures increased over time in all races and after 2015, IV tPA utilization was >10% in all demographic subgroups except in Black patients 60 to 79 years and Black patients ≥80 years. Analysis of race-by-time interaction revealed the Black-vs-White treatment gaps for IV tPA (odds ratio, 1.02 [95% CI, 1.01–1.03]) and MT (odds ratio, 1.08 [95% CI,1.05–1.12]) declined over time (both P interaction <0.01). Sex-related differences in IV tPA use were noted, but this gap also declined over time. Conclusions: Age- and sex-related treatment gaps in IV tPA and MT reduced over the last decade. Racial disparity in IV tPA and MT utilization persists with particularly lower frequency of usage of both acute stroke treatments in Black patients compared with White patients, but race-associated treatment gaps also declined over time.

The relationship between stroke system organization and disparities in access to stroke center care in California

“…Our findings also reinforce prior literature, as we found that stroke patients from racial or ethnic minority groups in California had lower odds than White patients of receiving reperfusion interventions. 31 , 32 , 33 , 34 This was true for both receipt of alteplase and EVT. Our findings are also consistent with prior work highlighting urban‐rural disparities in access to acute stroke care 35 , 36 that are likely contributing to known rural disparities in stroke patient outcomes.…”

Rates of intravenous thrombolysis and endovascular therapy for acute ischaemic stroke in China between 2019 and 2020

“…(2019) 27 Germany 2016 227687 patients with ischaemic stroke the G-DRG data 14·9% (33916/227687) Otite et al. (2021) 18 US 2008–2017 4442657 patients with ischaemic stroke from National Inpatient Sample 7·0-12·3% across the age spectrum Aguiar de Sousa et al. (2019) 37 44 European countries 2016–2017 1913985 patients with ischaemic stroke from 44 European countries 7·30% Richter et al.…”

“…(2017) 26 US 2003–2016 2437975 patients with ischaemic stroke from 2222 hospitals 3·3% in 2016 Otite et al. (2021) 18 US 2008–2017 4442657 patients with ischaemic stroke from National Inpatient Sample 0·7–2·8% across the age spectrum Chen et al. (2019) 6 China 2015 1826332 patients with ischaemic stroke from 1267 tertiary hospitals 0·45% Aguiar de Sousa et al.…”

“…The US and Germany also showed a similar trend. 18 , 19 , 26 , 27 Our analysis revealed that approximately 95% of EVTs for AIS were performed in tertiary hospitals. To date, secondary hospitals have limited access to neurological intervention centres, and most patients are referred to high-level hospitals to obtain a thrombectomy-capable facility.…”

“…Notably, the IVT rate in China is still much lower than that in developed countries. The IVT rate was 11·7∼18·2% in the US in 2017 18 and 16·3% in Germany in 2019. 19 There are still big challenges for IVT in China.…”