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

Kori S Zachrison; Margaret E Samuels-Kalow; Sijia Li; Zhiyu Yan; Mathew J Reeves; Renee Y Hsia; Lee H Schwamm; Carlos A Camargo Jr

doi:10.1002/emp2.12706

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

J Am Coll Emerg Physicians Open. 2022 Mar 14;3(2):e12706. doi: 10.1002/emp2.12706. eCollection 2022 Apr.

Authors

Kori S Zachrison¹, Margaret E Samuels-Kalow¹, Sijia Li¹, Zhiyu Yan², Mathew J Reeves³, Renee Y Hsia^{4

5}, Lee H Schwamm², Carlos A Camargo Jr¹

Affiliations

¹ Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA.
² Department of Neurology Massachusetts General Hospital Boston Massachusetts USA.
³ Department of Epidemiology and Biostatistics Michigan State University East Lansing Michigan USA.
⁴ Department of Emergency Medicine University of California San Francisco San Francisco California USA.
⁵ Philip R. Lee Institute for Health Policy Studies University of California San Francisco San Francisco California USA.

Abstract

Background: There are significant racial and ethnic disparities in receipt of reperfusion interventions for acute ischemic stroke. Our objective was to determine whether there are disparities in access to stroke center care by race or ethnicity that help explain differences in reperfusion therapy and to understand whether interhospital patient transfer plays a role in improving access.

Methods: Using statewide administrating data including all emergency department and hospital discharges in California from 2010 to 2017, we identified all acute ischemic stroke patients. Primary outcomes of interest included presentation to primary or comprehensive stroke center (PSC or CSC), interhospital transfer, discharge from PSC or CSC, and discharge from CSC alone. We used hierarchical logistic regression modeling to identify the relationship between patient- and hospital-level characteristics and outcomes of interest.

Results: Of 336,247 ischemic stroke patients, 55.4% were non-Hispanic White, 19.6% Hispanic, 10.6% non-Hispanic Asian/Pacific Islander, and 10.3% non-Hispanic Black. There was no difference in initial presentation to stroke center hospitals between groups. However, adjusted odds of reperfusion intervention, interhospital transfer and discharge from CSC did vary by race and ethnicity. Adjusted odds of interhospital transfer were lower among Hispanic (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98) and non-Hispanic Asian/Pacific Islander patients (OR 0.84, 95% CI 0.79 to 0.90) and odds of discharge from a CSC were lower for Hispanic (OR 0.91, 95% CI 0.85 to 0.97) and non-Hispanic Black patients (OR 0.74, 95% CI 0.67 to 0.81).

Conclusions: There are racial and ethnic disparities in reperfusion intervention receipt among stroke patients in California. Stroke system of care design, hospital resources, and transfer patterns may contribute to this disparity.

Keywords: disparities; ischemic stroke; reperfusion; stroke center; thrombolysis.