The Impact of Stroke Disparities in Black Americans
The Impact of Stroke Disparities in Black Americans
Written by Erin Shufflebarger, MD
Edited by Lauren Walter, MD
Over the last year, the COVID-19 pandemic has brought to light the devastating reality and implications of health disparities both globally and in the United States (US).(1) It’s important to have a working definition of key terms in this discussion. Disparity is defined as “a noticeable and usually significant difference or dissimilarity”.(2) A prominent category of disparities in the United States relates to health and healthcare. Health disparity has been defined as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.”(3) This discussion will focus on stroke disparities, specifically racial stroke disparities present between Black or African Americans and whites.
Stroke is a leading cause of both mortality and serious long-term disability in the US.(4) Many modifiable risk factors for stroke have been identified, as have non-modifiable risk factors including age, sex, and race. Specifically, Blacks have a higher incidence of stroke when compared to whites and also have the highest stroke death rate of any racial/ethnic group in the US.(5) This disparity is partly attributed to the higher prevalence of modifiable risk factors for stroke among Blacks, including hypertension, diabetes, and obesity.(6) However, this is a complex issue with multiple causative factors, some of which are still unclear. The literature describes racial disparities in stroke morbidity, stroke mortality, access to acute stroke treatment and rates of thrombectomy,(7) access to stroke rehab, and access to stroke preventative services.8 Multiple studies also describe racial disparities in public awareness and recognition of common stroke symptoms.(9-12)
As mentioned previously, there is higher incidence, morbidity, and mortality due to stroke among Blacks compared to whites.(13) Data from 2010 showed a self-reported stroke rate of 2.4% among white respondents compared to almost 4% for Black respondents.(14) Interestingly, this disparity in stroke incidence is most pronounced among younger adults. The stroke incidence rate among Black adults age 45-54 is four times higher than that of white adults of the same age. This incidence rate ratio decreases as age increases.(15) Furthermore, these trends persist when considering disparities in stroke mortality. Stroke mortality is equal between Black and white patients older than 85 years, but for patients younger than 65, stroke mortality in Blacks is three times that of non-Hispanic whites.(16) Disparities in morbidity also exist, with Black stroke survivors noted to have a higher burden of disability than white stroke survivors.(8)
More Black Americans are having strokes, more Black Americans are left with greater disability from stroke, and more Black Americans, notably younger adults, are dying from stroke.
Hypertension, diabetes, high cholesterol, smoking, and obesity are examples of modifiable risk factors for stroke and are all prevalent among Blacks. Notably, more than two-thirds of Black Americans have at least one modifiable stroke risk factor.(17) It goes without saying that this greater risk factor burden contributes to higher stroke incidence and mortality. Moreover, Blacks have poorer control of stroke risk factors. A study published in 2006 found that while Black participants had greater awareness and treatment rates of their hypertension, adequate control of hypertension was less common in black participants than white participants.(18) It then follows that while increasing awareness and treatment of risk factors is important, this alone may not be adequate to decrease risk of stroke.
Racial disparities in public awareness and recognition of common stroke symptoms have also been described. Stroke preparedness for timely recognition and medical care is a complex issue with many essential steps including public awareness and recognition of the signs and symptoms of stroke, activation of the prehospital system and prompt transport to the hospital for evaluation.(19)
While there is a poor understanding of stroke across the general population, Blacks are at higher risk for inability to identify signs of stroke and appropriate action to take when concerned for stroke.(20) This is significant because the available therapies for stroke are time-sensitive(21) and, unfortunately, delays between the onset of stroke symptoms and arrival to medical care persist among Blacks.(22).
The most recent guidelines from the American Heart Association (AHA) /American Stroke Association (ASA) reflect this sentiment in calling for the creation and implementation of stroke educational programs. More specifically, the AHA/ASA guidelines recommend programs created to reach certain populations, particularly racial/ethnic minorities, who are at risk for having a lack of stroke awareness and delays in seeking medical care for stroke symptoms.(23)
Disparities also exist related to access to care. As previously highlighted, lower stroke awareness can lead to delays in arrival to medical care. Other causes for delay have also been described including lower use of ambulance services and longer emergency department waiting times for Black patients.(8) Disparities have also been noted in specific treatments, with Blacks being less likely to receive thrombolysis when compared to whites.(8) A recent study evaluating over 200,000 admissions to endovascular centers found lower rates of utilization of both thrombolysis and mechanical thrombectomy for Black patients.(24)
This issue has significant impact on the daily work of emergency medicine clinicians. Approximately 130 million people annually seek care in the emergency department (ED).(25) Emergency medicine clinicians play an integral role in the diagnosis and early management of patients presenting with concern for acute stroke symptoms as well as routinely providing care for those with stroke risk factors. Patients with chronic illnesses often use the ED rather than routine primary care for both their emergent and non-emergent medical needs.(26) The ED is unique in the community in its ability to care for all patients including the disadvantaged, disenfranchised, and most vulnerable. Therefore, the reality of health disparities is profoundly apparent daily in EDs throughout the US. The recognition and characterization of health disparities, in this case stroke disparities, is critically important. Much of the existing literature to date has focused on describing the discrepancies that exist and need to be addressed. Exposing disparities is a crucial step in directing future intervention.
There is still much work that needs to be done in order to adequately bridge the gap and address these disparities repeatedly described in the literature. The ED is a potential site for implementation of interventions to address these disparities.
Possible interventions in this setting include education to increase stroke knowledge and preparedness and education about patient’s current risk factors for stroke and ways to modify them. Furthermore, patients in the ED can be offered assistance establishing care with a primary care physician for close management of chronic conditions that place them at higher risk for stroke.
Unfortunately, there is not a single solution that will fix the existing disparities. This is a complex issue that is still not completely understood. Public health and medical communities must continue to work diligently to understand and address the responsible factors in pursuit of the goal of health equity, the “attainment of the highest level of health for all people.”(2)
References
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