Emmett Eva S, O'Connell Matthew D L, Pei Ruonan, Douiri Abdel, Wyatt David, Bhalla Ajay, Wolfe Charles D A, Marshall Iain J
School of Life Course and Population Sciences, King's College London, London, United Kingdom.
National Institute for Health and Care Research Applied Research Collaboration South London, London, United Kingdom.
JAMA Netw Open. 2025 Jan 2;8(1):e2453252. doi: 10.1001/jamanetworkopen.2024.53252.
Reducing the burden of stroke is a public health priority. While higher stroke incidence among ethnic minority populations (defined in the context of this study as individuals who are not White) is well established, reports on ethnic inequalities in care or outcomes are conflicting and often limited to hospital-admitted patients and short-term outcomes.
To investigate ethnic differences in stroke care and outcomes up to 5 years after stroke and describe temporal trends and contributory factors.
DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study enrolled participants from a geographically defined area of London, United Kingdom, with prospective follow-ups up to 5 years after stroke. Participants were adults with incident stroke in 1995 to 2021. Data were analyzed from May 2023 to October 2024.
Self-reported ethnicity, categorized as Black African, Black Caribbean, White, or other (eg, Asian, other Black ethnicity, or multiple ethnicities).
Outcomes of interest were stroke unit admission, thrombolysis rate, functional outcomes (measured using Barthel Index and Frenchay Activities Index), and survival.
Among 7280 patients (mean [SD] age, 69.3 [15.2] years; 3787 [52.0%] male) included, 3628 (63.2% of 3-month survivors) had 3-month follow-up data and 1951 (60.8% of 5-year survivors) had 5-year follow-up data. By ethnicity, 861 participants (11.8%) were Black African, 1089 (15.0%) were Black Caribbean, 4738 participants (65.1%) were White, and 592 participants (8.1%) identified as other ethnicity. Black African and Black Caribbean participants were younger than White participants (mean [SD] age, 59 [14] years, 68 [15] years, and 72 [14] years, respectively), with higher rates of hypertension (629 participants [75.0%], 805 participants [75.6%], and 2801 participants [61.8%], respectively), diabetes (246 participants [29.3%], 427 participants [40.2%], and 750 participants [16.5%], respectively), and body mass index greater than 25 (372 participants [69.0%], 370 participants [61.3%], and 1094 participants [51.6%], respectively). Black African and Black Caribbean participants had higher stroke unit admission rates than White participants in 1995 to 2003 (66 participants [42.6%], 129 participants [42.0%], and 573 participants [29.5%], respectively) but not thereafter. Black Caribbean participants had persistently lower thrombolysis rates (adjusted odds ratio compared with White participants, 0.56 [95% CI, 0.40-0.80]) and later hospital arrivals (arrival >4 hours after stroke onset: 217 Black African participants [53.8%]; 251 Black Caribbean participants [60.0%]; 654 White participants [51.2%]; P = .02). Black African and Black Caribbean participants had better survival than White participants (Black African participants: adjusted hazard ratio, 0.64 [95% CI, 0.54-0.77]; Black Caribbean participants: adjusted hazard ratio, 0.83 [95% CI, 0.74-0.94]) but poorer functional outcomes up to 5 years after stroke, with no significant changes over time.
This cohort study found major and persistent ethnic inequalities in stroke care and outcomes, and these disparities were not fully explained by sociodemographic or stroke-related factors or the high vascular risk factor prevalence in Black African and Black Caribbean participants. Drivers of poor functional outcomes require further research, but cardiovascular health-checks should be considered for Black African individuals at younger ages, and late hospital arrivals and low thrombolysis rates in Black Caribbean individuals might be amenable to tailored health campaigns.
减轻中风负担是一项公共卫生重点工作。虽然少数民族人群（在本研究背景下定义为非白人个体）中风发病率较高这一点已得到充分证实，但关于护理或结局方面的种族不平等报告相互矛盾，且往往局限于住院患者和短期结局。
调查中风后长达5年的中风护理及结局方面的种族差异，并描述时间趋势和促成因素。
设计、地点和参与者：这项基于人群的队列研究纳入了来自英国伦敦一个地理界定区域的参与者，对中风后长达5年进行前瞻性随访。参与者为1995年至2021年发生中风的成年人。数据于2023年5月至2024年10月进行分析。
自我报告的种族，分为非洲黑人、加勒比黑人、白人或其他（如亚洲人、其他黑人种族或多种族）。
感兴趣的结局包括入住中风单元、溶栓率、功能结局（使用巴氏指数和弗伦奇活动指数测量）以及生存率。
在纳入的7280例患者（平均[标准差]年龄，69.3[15.2]岁；3787例[52.0%]为男性）中，3628例（3个月幸存者的63.2%）有3个月随访数据，1951例（5年幸存者的60.8%）有5年随访数据。按种族划分，861名参与者（11.8%）为非洲黑人，1089名（15.0%）为加勒比黑人，4738名参与者（65.1%）为白人，592名参与者（8.1%）确定为其他种族。非洲黑人和加勒比黑人参与者比白人参与者年轻（平均[标准差]年龄分别为59[14]岁、68[15]岁和72[14]岁），高血压发病率更高（分别为629名参与者[75.0%]、805名参与者[75.6%]和2801名参与者[61.8%]），糖尿病发病率更高（分别为246名参与者[29.3%]、427名参与者[40.2%]和750名参与者[16.5%]），体重指数大于25的比例更高（分别为372名参与者[69.0%]、370名参与者[61.3%]和1094名参与者[51.6%]）。1995年至2003年期间，非洲黑人和加勒比黑人参与者入住中风单元的比例高于白人参与者（分别为66名参与者[42.6%]、129名参与者[42.0%]和573名参与者[29.5%]），但此后并非如此。加勒比黑人参与者的溶栓率持续较低（与白人参与者相比，调整后的优势比为0.56[95%置信区间，0.40 - 0.80]），且入院时间较晚（中风发作后>4小时入院：217名非洲黑人参与者[53.8%]；251名加勒比黑人参与者[60.0%]；654名白人参与者[51.2%]；P = 0.02）。非洲黑人和加勒比黑人参与者的生存率高于白人参与者（非洲黑人参与者：调整后的风险比为0.64[95%置信区间，0.54 - 0.77]；加勒比黑人参与者：调整后的风险比为0.83[95%置信区间，0.74 - 0.94]），但中风后长达5年的功能结局较差，且随时间无显著变化。
这项队列研究发现中风护理及结局方面存在重大且持续的种族不平等，这些差异不能完全由社会人口学因素、中风相关因素或非洲黑人和加勒比黑人参与者中高血管危险因素患病率来解释。功能结局不佳的驱动因素需要进一步研究，但对于较年轻的非洲黑人个体应考虑进行心血管健康检查，针对加勒比黑人个体入院较晚和溶栓率较低的情况，可能适合开展针对性的健康宣传活动。
