Expanding access to life-saving treatment is key to reducing disparities in stroke outcomes

A recent systematic review of disparities in access to stroke treatment between racial minorities and white patients examined 30 studies published from January 1, 2010 to April 5, 2021. There are significant barriers to quality care and better outcomes poor for black, Hispanic, Asian and Native American stroke patients compared to white patients. Specifically, white patients used emergency medical services more often, arrived at the hospital earlier for stroke treatment, and received life-saving treatments (intravenous thrombolysis and thrombectomy) more frequently.

One way to mitigate these life-changing disparities is through a comprehensive approach that improves the stroke care system at all levels. A good starting point is access.

Stroke thrombectomy is a minimally invasive and highly effective procedure that uses a catheter, guided by X-rays, to quickly reopen blocked arteries in the brain. This greatly improves the chances that a patient will not only survive a stroke, but possibly make a full recovery.

However, access is limited and inequitable, with less than 15% of eligible patients receiving it. Utilization rates are much lower among minority patients than among white patients. “Racial Disparity in Mechanical Thrombectomy Utilization: Multicenter Registry Results from 2016-2020” analyzed the records of 34,596 patients over five years, 42 hospitals and 12 states and found that black stroke patients were 28% less likely than white patients to undergo thrombectomy.

In large part, these disparities can be attributed to outdated policies guiding stroke treatment. Currently, most states do not have clear protocols to ensure that someone with a severe stroke is transported directly to a Level 1 stroke center, where highly trained stroke teams can quickly remove the clot. Instead, patients may be taken to the nearest hospital, which may not have the capacity to provide thrombectomy, which then requires additional time for inter-hospital transfer to the one that does. may. This delays the time to thrombectomy by several hours, reducing the chances of survival, and if patients survive, they have a much higher chance of lifelong disability.

These delays disproportionately affect racial minorities, with a greater proportion of white patients (37.4%) arriving within 3 hours of onset of stroke symptoms than black (26.0%) and Hispanic patients (28.9%). To address this issue, states should update their triage and transport protocols to ensure that all severe stroke patients are transferred to hospitals capable of performing thrombectomy without ineffective inter-hospital transfers.

Fortunately, the model needed for prehospital stroke triage already exists. In the event of a traumatic injury, patients are assessed in the field and the seriously injured are transported directly to Level 1 Trauma Centers. This eliminates unnecessary transfers and treatment delays and ensures that every person, regardless of location , is transported to the best facility to treat her specific injuries. Saving time in transfers can mean the difference between life and death or independence and lifelong disability.

We have seen recent progress at the federal level toward updating EMS protocols nationwide. The federal omnibus appropriation package included language endorsing updated EMS triage and transport protocols for stroke patients, and the National EMS Model Clinical Guidelines recently released by the National Association of EMS Leaders. states also urged states and localities to take these vital steps. Additionally, laws have been passed at the state level in North Carolina, Florida, Virginia, Ohio, Tennessee, Arizona, and Florida, and Massachusetts, Michigan, Georgia, and Pennsylvania are currently working on improve stroke care.

But more needs to be done. In the absence of consistent stroke transportation and triage laws, far too much is left to interpretation, allowing powerful individual and institutional biases to interfere with effective and equitable care. We must demand legislative changes across the country that improve access to stroke treatment for everyone.

Dr. Michael Chen is a Neurointerventionist and Professor of Neurology, Neurosurgery, and Radiology at Rush University Medical Center in Chicago. He is the President of the Society of NeuroInterventional Surgery, supporting its Get Ahead of Stroke® campaign to improve systems of care for stroke patients. May is Stroke Awareness Month.

About Antoine L. Cassell

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