Mehta Amol M, Polineni Sai P, Polineni Praneet, Dhamoon Mandip S
Department of Neurology Icahn School of Medicine at Mount Sinai New York NY USA.
Feinberg School of Medicine Northwestern University Chicago IL USA.
J Am Heart Assoc. 2025 Apr;14(7):e037125. doi: 10.1161/JAHA.124.037125. Epub 2025 Mar 26.
Structural racism and rural/urban differences in stroke care affect care delivery and outcomes. We explored the interplay among structural racism, urbanity, and intravenous thrombolysis (tissue plasminogen activator) and endovascular thrombectomy (ET).
In this retrospective study using complete, deidentified inpatient Medicare data (2016-2019), we identified incident acute ischemic stroke admissions, demographics, and hospital-level variables. Medicare beneficiaries aged ≥65 years with incident acute ischemic stroke admission in large metropolitan and nonurban settings were included. Validated structural racism metrics at the county level and a composite structural racism score that incorporated measures of segregation, housing, employment, education, and income were studied. Among 951 914 patients, rural hospitals demonstrated lower intensive care unit capacity (27.5% versus 88.6%), stroke certification (5.3% versus 38.4%), and rates of tissue plasminogen activator (1.6% versus 12.3%) and ET (<1% versus 3.8%). Large metropolitan areas demonstrated higher levels of income inequality (Gini index -0.15 versus 0.11 SD), and racial segregation (dissimilarity index 0.29 SD higher than the US mean). The composite structural racism score was associated with increased odds of tissue plasminogen activator receipt (odds ratio, 1.47 [95% CI, 1.33-1.63]) and ET (odds ratio, 4.15 [95% CI, 2.98-5.79]). Despite greater access to stroke care in urban areas, a persistent racial disparity remained, with Black patients less likely to receive tissue plasminogen activator (odds ratio, 0.70 [95% CI, 0.68-0.72]) and ET (odds ratio, 0.63 [95% CI, 0.60-0.66]) compared with White patients.
We found persistent disparities in stroke care access and outcomes, influenced by structural racism and rural-urban differences. Further research should explore interactions between structural racism, urbanity, and health care delivery to inform effective interventions.
结构性种族主义以及中风护理方面的城乡差异会影响护理服务的提供和治疗结果。我们探讨了结构性种族主义、城市化与静脉溶栓（组织型纤溶酶原激活剂）和血管内血栓切除术（ET）之间的相互作用。
在这项回顾性研究中，我们使用完整的、经过身份识别处理的住院医疗保险数据（2016 - 2019年），确定了急性缺血性中风的住院病例、人口统计学特征和医院层面的变量。纳入了年龄≥65岁、在大城市和非城市地区因急性缺血性中风入院的医疗保险受益人。研究了县级经过验证的结构性种族主义指标以及一个综合结构性种族主义得分，该得分纳入了隔离、住房、就业、教育和收入等衡量指标。在951914例患者中，农村医院的重症监护病房容量较低（27.5%对88.6%）、中风认证率较低（5.3%对38.4%）、组织型纤溶酶原激活剂使用率较低（1.6%对12.3%）以及ET使用率较低（<1%对3.8%）。大城市地区的收入不平等程度较高（基尼系数 -0.15对0.11标准差），种族隔离程度较高（差异指数比美国平均水平高0.29标准差）。综合结构性种族主义得分与接受组织型纤溶酶原激活剂治疗的几率增加（优势比，1.47[95%CI，1.33 - 1.63]）和ET治疗的几率增加（优势比，4.15[95%CI，2.98 - 5.79]）相关。尽管城市地区获得中风护理的机会更多，但种族差异仍然存在，与白人患者相比，黑人患者接受组织型纤溶酶原激活剂治疗的可能性较小（优势比，0.70[95%CI，0.68 - 0.72]），接受ET治疗的可能性也较小（优势比，0.63[95%CI，0.60 - 0.66]）。
我们发现中风护理的可及性和治疗结果存在持续差异，这受到结构性种族主义和城乡差异的影响。进一步的研究应探索结构性种族主义、城市化与医疗服务提供之间的相互作用，以指导有效的干预措施。
