Sun Philip Y, Lian Kendra, Markovic Daniela, Ibish Abdullah, Faigle Roland, Gottesman Rebecca Fran, Towfighi Amytis
Department of Neurology, David Geffen School of Medicine at University of California - Los Angeles, Los Angeles, California, USA.
Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
Cerebrovasc Dis. 2024 Nov 5:1-13. doi: 10.1159/000542384.
Stroke mortality has declined, with differential changes by race; stroke is now the 5th leading cause of death overall, but 2nd leading cause of death in Black individuals. Little is known about recent race/ethnic and sex trends in in-hospital mortality after acute ischemic stroke (AIS) and whether system-level factors contribute to possible differences.
Using the National Inpatient Sample, adults (≥18 years) with a primary diagnosis of AIS from 2006 to 2017 (n = 643,912) were identified. We assessed in-hospital mortality by race/ethnicity (White, Black, Hispanic, Asian/Pacific Islander [API], other), sex, and age. Hospitals were categorized by proportion of White patients served: "≥75% White hospitals," "50-75% White hospitals," and "<50% White hospitals." Using survey adjusted logistic regression, the association between race/ethnicity and odds of mortality was assessed, adjusting for key sociodemographic, clinical, and hospital characteristics (e.g., age, comorbidities, stroke severity, do not resuscitate orders, and palliative care).
Overall, mortality decreased from 5.0% in 2006 to 2.9% in 2017 (p < 0.01). Comparing 2012-2017 to 2006-2011, there was a 68% reduction in mortality odds overall after adjusting for covariates, most prominent in White individuals (69%) and smallest in Black individuals (57%). Compared to White patients, Black and Hispanic patients had lower odds of mortality (adjusted odds ratio [aOR] 0.82, 95% CI 0.78-0.87 and aOR 0.93, 95% CI 0.87-1.00), primarily driven by those >65 years (age × ethnicity interaction p < 0.01). Compared to White men, Black, Hispanic, and API men, and Black women had lower aOR of mortality. The differences in mortality between White and all the other race/ethnic groups combined were most pronounced in ≥75% White hospitals (aOR 0.80, 0.74-0.87) compared to 50-75% White hospitals (aOR 0.85, 0.79-0.91) and <50% White hospitals (aOR 0.88, 0.81-0.95; interaction effect: p < 0.01).
AIS mortality has decreased dramatically in recent years in all race/ethnic subgroups. Overall, while individuals of other race/ethnic subgroups had lower mortality odds compared to White individuals, this effect was significantly lower in hospitals serving predominantly White patients compared to those serving minority populations. Further study is needed to understand these differences and to what extent sociocultural, biological, and system-level factors play a role. Category: Health services, quality improvement, and patient-centered outcomes were the elements used to categorize the study sample.
卒中死亡率有所下降，不同种族的下降幅度存在差异；卒中目前是总体第五大死因，但在黑人个体中是第二大死因。关于急性缺血性卒中（AIS）后住院死亡率的近期种族/族裔和性别趋势以及系统层面因素是否导致可能的差异，我们了解甚少。
利用全国住院患者样本，确定了2006年至2017年期间主要诊断为AIS的成年人（≥18岁）（n = 643,912）。我们按种族/族裔（白人、黑人、西班牙裔、亚裔/太平洋岛民[API]、其他）、性别和年龄评估住院死亡率。医院按所服务白人患者的比例分类：“白人患者比例≥75%的医院”、“白人患者比例50 - 75%的医院”和“白人患者比例<50%的医院”。使用调查调整后的逻辑回归，评估种族/族裔与死亡几率之间的关联，并对关键的社会人口学、临床和医院特征（如年龄、合并症、卒中严重程度、不要复苏医嘱和姑息治疗）进行调整。
总体而言，死亡率从2006年的5.0%降至2017年的2.9%（p < 0.01）。将2012 - 2017年与2006 - 2011年进行比较，在调整协变量后，总体死亡几率降低了68%，在白人个体中最为显著（69%），在黑人个体中最小（57%）。与白人患者相比，黑人和西班牙裔患者的死亡几率较低（调整后的优势比[aOR]为0.82，95%置信区间为0.78 - 0.87和aOR为0.93，95%置信区间为0.87 - 1.00），主要由65岁以上人群驱动（年龄×种族交互作用p < 0.01）。与白人男性相比，黑人、西班牙裔和API男性以及黑人女性的aOR死亡率较低。白人与所有其他种族/族裔群体合并后的死亡率差异在白人患者比例≥75%的医院中最为明显（aOR为0.80，0.74 - 0.87），相比之下，白人患者比例50 - 75%的医院（aOR为0.85，0.79 - 0.9）和白人患者比例<50%的医院（aOR为0.88，0.81 - 0.95；交互作用效应：p < 0.01）。
近年来，所有种族/族裔亚组的AIS死亡率均显著下降。总体而言，虽然其他种族/族裔亚组的个体与白人个体相比死亡几率较低，但与服务少数族裔人群的医院相比，在主要服务白人患者的医院中这种效应明显较低。需要进一步研究以了解这些差异以及社会文化、生物学和系统层面因素在多大程度上起作用。类别：卫生服务、质量改进和以患者为中心的结果是用于对研究样本进行分类的要素。
