Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021

Abstract

ImportanceUnderstanding is needed of racial and ethnic–specific trends in care quality and outcomes associated with the US nationwide quality initiative Target: Stroke (TS) in targeting thrombolysis treatment for acute ischemic stroke.ObjectiveTo examine whether the TS quality initiative was associated with improvement in thrombolysis metrics and outcomes across racial and ethnic groups.Design, Setting, and ParticipantsThis retrospective cohort study included patients who presented within 4.5 hours of ischemic stroke onset at hospitals participating in the Get With The Guidelines–Stroke initiative from January 1, 2003, to December 31, 2021. The data analysis was performed between December 15, 2022, and November 27, 2023.ExposuresTS phases I (2010-2013), II (2014-2018), and III (2019-2021).Main Outcomes and MeasuresThe primary outcomes were thrombolysis rates and time metrics. Patient function and mortality were secondary outcomes.ResultsAnalyses included 1 189 234 patients, of whom 1 053 539 arrived to the hospital within 4.5 hours. The cohort included 50.4% female and 49.6% male patients and 2.8% Asian [median (IQR) age, 72 (61-82) years], 15.2% Black [median (IQR) age, 64 (54-75) years], 7.3% Hispanic [median (IQR) age, 68 (56-79) years], and 74.1% White [median (IQR) age, 75 (63-84) years] patients). Unadjusted thrombolysis rates increased in both the pre-TS (2003-2009) and TS periods in all racial and ethnic groups from 10% to 15% in 2003 to 43% to 46% in 2021, but disparities were observed in adjusted analyses and persisted in TS phase III, with Asian, Black, and Hispanic patients having significantly lower odds of receiving thrombolysis than White patients (adjusted odds ratio, 0.85 [95% CI, 0.81-0.90], 0.76 [95% CI, 0.74-0.78], and 0.86 [95% CI, 0.83-0.89], respectively). Door-to-needle (DTN) times improved in all racial and ethnic groups during TS, with DTN times of 60 minutes or less increasing from 26% to 28% in 2009 to 66% to 72% in 2021. However, in adjusted analyses, racial and ethnic disparities emerged. During TS phase III, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis with a DTN time of 60 minutes or less compared with White patients (risk-adjusted odds ratios, 0.91 [95% CI, 0.84-0.98], 0.78 [95% CI, 0.75-0.81], and 0.87 [95% CI, 0.83-0.92], respectively). During TS, clinical outcomes improved for all racial and ethnic groups from pre-TS, with TS phase III showing higher odds of ambulation at discharge among Asian, Black, Hispanic, and White patients. Asian, Black, and Hispanic patients were less likely to present within 4.5 hours.Conclusions and RelevanceIn this cohort study of patients with ischemic stroke, the TS quality initiative was associated with improvement in thrombolysis frequency, timeliness, and outcomes for all racial and ethnic groups. However, disparities persisted, indicating a need for further interventions.

Prevalence of Stroke — Behavioral Risk Factor Surveillance System, United States, 2011–2022

“…Consistent with previous analyses ( 2 ), states in the highest quantile of stroke prevalence included many in the southeastern United States (a region known as the stroke belt). Increased stroke survival could also contribute to increased stroke prevalence; the rate of thrombolytic therapy for acute ischemic stroke among all racial and ethnic groups increased from 10%–15% during 2003–2009, to 43%–46% in 2021 ( 8 ). However, disparities persisted, with Asian, Black, and Hispanic patients having lower odds than did White patients of getting to the hospital within 4.5 hours of ischemic stroke onset and of receiving thrombolysis ( 8 ).…”

“…Awareness and knowledge of stroke signs and symptoms have increased among US adults, although there is room for improvement ( 10 ). Better recognition of stroke signs and symptoms might have potentially contributed to increased stroke prevalence, because earlier stroke treatment contributes to improved outcomes ( 8 ). Advancing focused evidence-based practices and programs for stroke awareness, prevention, and treatment is essential for improving the cerebrovascular health of the nation.…”

Neurocritical Care for Patients With Ischemic Stroke

“…As with all aspects of stroke care, thrombectomy is subject to disparities in access and utilization. These disparities exist with regard to race, ethnicity, geography, sex, and gender 7–11 . There are vast differences globally in access to thrombectomy, postthrombectomy care, and rehabilitation 12 .…”