Clinical Context

Every patient with stroke is different, but a previous study by Oliver Otite and colleagues found patterns of bias in the application of intravenous (IV) thrombolysis and thrombectomy among patients with acute stroke in the US.^[1] They evaluated national data from diagnosis codes between 2008 and 2017, and the results of their study were published in the August 2021 issue of Stroke.

Several major biases were identified. Adults older than 80 years were less likely to receive IV thrombolysis or thrombectomy compared with younger adults, and Black patients were less likely to receive these procedures compared with White patients. However, rates of IV thrombolysis use and thrombectomy generally increased during the study period, and did so in a way that reduced these age- and race-based disparities. Women were less likely than men to receive IV thrombolysis in 2008 to 2009, but this disparity resolved by 2016 to 2017. Women were more likely than men to receive thrombectomy in 2016 to 2017.

Many variables can contribute to these disparities, one of which is the level of expertise and equipment required to manage acute stroke. The current study examines potential structural barriers to stroke care in the form of stroke certification of hospitals.

Study Synopsis and Perspective

Hospitals in low-income and rural areas of the United States are much less likely to adopt stroke certification than hospitals in high-income and urban communities, a new study shows.

Further, other results showed that after adjustment for population and hospital size, access to stroke-certified hospitals is significantly lower in Black, racially segregated communities.

The study was published online in JAMA Neurology on June 27, 2022.^[2]

Noting that stroke-certified hospitals provide higher-quality stroke care, the authors, led by Yu-Chu Shen, PhD, Naval Postgraduate School, Monterey, California, conclude that their "findings suggest that structural inequities in stroke care may be an important consideration in eliminating stroke disparities for vulnerable populations."

In an audio interview on the JAMA Neurology website, senior author Renee Y. Hsia, MD, from the University of California, San Francisco, said: "Our findings show there are clear disparities in which communities are getting access to stroke certified hospitals."^[3]

She called for more help for hospitals in underserved areas to obtain stroke certification.

Dr Hsia explained that hospitals can seek certification at their own expense, and that although stroke care is expensive, it is also lucrative in terms of reimbursement. So it tends to be the private for-profit hospitals that seek these certifications. "If you are a county hospital on a really tight budget, you're not going to have the extra cash on hand to be applying for stroke certification," she commented.

This can result in an increase in hospitals with stroke certification--just not in the areas that need it the most.

Dr Hsia points out that this has happened in cardiac care. One study showed a 44% increase in hospitals providing percutaneous coronary intervention during a 10-year period, but the percentage of the population that had better access increased by less than 1%.

"In general, in the US we have a mentality that 'more is better,' and because there is no government regulation in healthcare, any time a hospital applies for these specialized services we just generally think that's a good thing. But this might not always be the case," Dr Hsia noted. "We have a very market-based approach, and this doesn't lead to equity. It leads to profit maximization, and that is not synonymous with what's good for patients or populations."

She suggested that in the future, the process of certification should include some consideration of how it will affect population-based equity.

"Rather than rubber stamping an application just because hospitals have certain resources, we need to ask what the benefit is of providing this service," Dr Hsia said. "Does this community really need it? If not, maybe we should invest these resources into helping a hospital in a community that needs it more."

Dr Hsia explained that she and her colleagues conducted their study to investigate whether there were structural issues that might be contributing to disparities in stroke care.

"We like to think emergency stroke care is equitable. Anyone can call 911 or go the [emergency department]. But, actually, there is a big disparity on who receives what type of care," she said. "We know Black patients are less likely to receive thrombolytics and mechanical thrombectomy compared to White patents. And wealthy patients are more likely to receive thrombectomy compared to patients from the poorest ZIP codes."

She said that there is a tendency to think this is a result of some sort of bias on the part of healthcare professionals. "We wanted to look deep down in the system, and whether the built environment of healthcare supply and geographic distribution of services contributed to access and treatment inequities."

The study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental United States from January 2009 to December 2019. National, hospital, and census data were used to identify historically underserved communities by racial and ethnic composition, income distribution, and rurality.

A total of 4984 hospitals were assessed. Results showed that during the 11-year study period, the number of hospitals with stroke certification grew from 961 (19%) to 1763 (35%).

Without controlling for population and hospital size, hospitals in predominantly Black, racially segregated areas were 1.67-fold more likely to adopt stroke care of any level than those in predominantly non-Black, racially segregated areas (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.41-1.97).

However, after adjustment for population and hospital size, the likelihood of adopting stroke care among hospitals serving Black, racially segregated communities was significantly lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89).

"In other words, on a per-capita basis, a hospital serving a predominantly Black, racially segregated community was 26% less likely to adopt stroke certification of any level than a hospital in a predominantly non-Black, racially segregated community," the authors state.

In terms of socioeconomic factors, hospitals serving low-income, economically integrated (HR, 0.23) and low-income, economically segregated (HR, 0.29) areas were far less likely to adopt any level of stroke care certification than hospitals serving high-income areas, regardless of income segregation.

Rural hospitals were also much less likely to adopt any level of stroke care than urban hospitals (HR, 0.10).

"Our results suggest that it might be necessary to incentivize hospitals operating in underserved communities to seek stroke certification or to entice hospitals with higher propensity to adopt stroke care to operate in such communities so access at the per-patient level becomes more equitable," the authors say.

This project was supported by the Pilot Project Award from the National Bureau of Economic Research Center for Aging and Health Research, funded by the National Institute on Aging and by the National Center for Advancing Translational Sciences, National Institutes of Health. Dr Shen and Dr Hsia have received grants from the National Institute of Aging and the National Heart, Lung, and Blood Institute.

JAMA Neurol. Published online June 27, 2022.

Clinical Implications

• A previous study found that older adults and Black adults had lower rates of treatment with IV thrombolysis and thrombectomy for acute stroke, but these disparities declined with time. Treatment was more equitable in comparing women and men.
• The current study finds that access to hospitals with stroke certification was lower in Black, low-income, and rural communities. Hispanic ethnicity did not significantly influence access to hospitals with stroke certification.
• Implications for the healthcare team: The healthcare team should advocate for advancing the level of care for acute stroke in their institution, particularly if the community serviced has traditionally experienced barriers to advanced stroke care.

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