Black patients in segregated communities may be more likely to live near certified stroke centers in urban areas, but because of crowding, shortages of beds and critical care staff, they may be less likely than White patients in high-income areas to be seen as quickly and treated on time.
Although stroke patients living in “segregated” Black communities are nearly twice as likely to live near a hospital with a certified stroke center, they are significantly less likely to be treated on time than patients in predominantly White areas, according to a study published online on June 27 in JAMA Neurology.
After taking into account population size and hospital bed capacity, the likelihood of receiving care at a hospital with stroke certification was 26 percent less likely in primarily Black areas than in mostly White communities, even though patients were 1.67 times more likely to live near certified hospitals, researchers found in the retrospective analysis of census data and records for 4,984 nonfederal hospitals between 2009 and 2019. Of these, 961 were stroke certified in 2009, versus 1,763 in 2019.
A possible explanation for the racial disparity is that Black segregated communities tended to “cluster” in areas with larger populations, creating greater demand for beds and stroke services, the researchers said. “Crowding may prevent patients from accessing the stroke center, and even if they do access it, they may not be able to be seen as quickly due to shortages of beds, critical care physicians, nurses and equipment.”
A significant disparity in access to stroke centers was also found when the investigators compared residents' resource levels. In predominantly high-income areas, individuals were three to four times more likely to live close to a hospital with a certified stroke center compared with their counterparts in predominantly low-income areas. Hospitals in low-income communities were less likely to have adopted any level of stroke care certification and those in rural areas were 43 percent less likely to have stroke center certification.
How society determines what health care services provide is “largely left to the market,” said corresponding author Renee Y. Hsia, MD, professor and associate chair of health services in the department of emergency medicine at the University of California, San Francisco, School of Medicine.
“This means that it is less often the case that the local or regional or federal governments are actually setting up or financing health care services based on the actual underlying need of the community, but that hospitals decide to offer specialty services based on their own determination, largely driven by economic reasons,” she told Neurology Today.
As secondary analyses, the investigators adjusted for each variable, taking population and hospital size into account. “Controlling for population size is important in our context because emergency department capacity constraints have been associated with poorer quality of care and outcomes for stroke,” Dr. Hsia said.
“For example, the same-sized hospital covering 1000 versus one million residents means fewer residents have to compete for access, and similar logic applies to controlling for hospital bed capacity.
“While critically ill patients with stroke may be pushed to the front of the line for receiving care, other factors, such as intensive care unit beds, critical care physicians, nurses, equipment, and other shared resources that are commonly used for other conditions may be in short supply. In hospitals with capacity constraints, these resources are stretched thin, negatively affecting quality of care for patients with stroke.”
The study combined a data set of hospital stroke certification at nonfederal hospitals, with national, hospital, and census data used to define historically underserved communities by racial and ethnic composition, income distribution, and rurality.
For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. The researchers then used estimated proportional hazard ratios to compare adoption of stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity.
They categorized hospitals in large-population areas serving an average population of 1.29 million compared with non–Black, racially segregated hospital service areas (average population of 307,768). A total of 3390 hospitals (68.0 percent) served non–Black, racially integrated communities; 486 (9.8 percent) served non–Black, racially segregated communities; 610 (12.2 percent) served Black, racially integrated communities; and 498 (10.0 percent) served Black, segregated communities.
In models not accounting for population size, hospitals serving Black, racially segregated communities had the highest hazard ratio for adopting stroke care certification (hazard ratio [HR], 1.67; 95 percent CI, 1.41-1.97). But when controlled for population and hospital size, the hazard ratio was 26 percent lower for facilities serving Black, racially segregated communities compared to White areas.
Moreover, the hazard ratio in low-income communities was lower than in high-income communities, regardless of their level of economic segregation. The researchers also reported that rural hospitals were much less likely to adopt any level of stroke care certification than urban hospitals (HR, 0.43; 95 percent CI, 0.35-0.51).
“The decision to open a new stroke center should take into account population size and underlying needs of the community that the center will serve,” said Dr. Hsia. “Policymakers may want to consider how they can reduce financial barriers for hospitals in these communities where certified stroke centers are needed,” she said.
“The results suggest that it might be necessary to incentivize hospitals operating in underserved communities to seek stroke certification or to entice hospitals with higher propensity to adopt stroke care to operate in such communities, so access at the per-patient level becomes more equitable. Identification of barriers to certification could help shed light on potential policy interventions,” according to the authors.
“Because most of our health care services are provided privately, whether not-for-profit or for-profit hospital chains, that means that these specialty services, such as certified stroke care, tends to pop up more often in areas where there are affluent, privately insured patients, and less where the reimbursement is low,” according to Dr. Hsia.
“Ultimately, as a society, we need to decide whether or not the way we have chosen to structure the health care system—how we deliver and pay for care—is what we want to continue to have, or whether we want to change it. The only way to change the structural basis of these built-in disparities is to fundamentally reform the way we finance and deliver care.”
“Certainly, there are other less fundamental ways to try to address it, including local or federal policy legislation or regulation about how we decide hospitals are able to qualify and be certified for providing specialized care,” Dr. Hsia continued.
“If an area already has existing and sufficient services for a certain type of care, it could be advisable on a policy level to encourage the growth of specialized care services such as stroke care in more underserved areas, whether through more creative financing or using technology such as tele-stroke or mobile stroke units to provide this care to populations who need access.”
“The study does seem to support what many in our community often suspect—that stroke certification is less commonly available in underserved communities. What we don't yet know are the drivers for that disparity—lack of specialty physicians or physician leaders, hospital or system level factors, insurance, and overall financial health of centers in those communities,” said Kevin Sheth, MD FAAN, professor of neurology and neurosurgery and division chief of neurocritical care and emergency neurology at Yale School of Medicine.
Alejandro Rabinstein, MD, FAAN, professor of neurology at Mayo Clinic Rochester said the study results were “concerning.”
“Despite extensive efforts from the American Heart Association and other professional organizations, disparities remain in the quality of stroke care available to rural and low-income sectors of our society,” Dr. Rabinstein said. “Stroke certification is a very constructive but relatively demanding process that requires proof of training and presence of conditions that small hospitals in low-income and rural communities may not be able to meet.”
He told Neurology Today that greater support for these smaller hospitals should be a priority.
“On the other hand, the results of the study in regards to the hospitals serving Black, racially segregated communities requires a different interpretation. The results suggest insufficiency rather than lack of availability of quality stroke care. In those communities, additional stroke centers may be necessary to meet the demand in populous urban areas.”
Bruce Ovbiagele, MD, FAAN, professor of neurology at the University of California, San Francisco, and chief of staff at the San Francisco Veterans Affairs Health Care System, told Neurology Today that he was not surprised by the study's findings, but such disparities are not limited to stroke.
“There are all sorts of other conditions that must be considered, but it's nice to have empirical evidence of access to stroke-certified hospitals that considers the magnitude of difference,” said Dr. Ovbiagele, who served for six years as professor of neurology and chair of the Department of Neurology at the Medical University of South Carolina (MUSC).
“Most hospitals, especially in rural and lower-income areas, do not have the resources or policies in place to address the issues highlighted in the study,” he said, noting that virtual care might help alleviate such differences—especially with regard to administration of tissue plasminogen activator to reduce the severity of strokes.”
“When I was in South Carolina we created our own network for telestroke. There was a network of 35 hospitals where virtual evaluation and guidance for tPA administration was made available around the clock throughout the state, including outlying hospitals.”
The REACH Stroke Network links rural hospitals with stroke experts from the Medical University of South Carolina. With the use of technology like telemedicine, doctors in remote hospitals can consult with experts on ambiguous cases. Today, 96 percent of patients are within 1 hour of access to stroke experts where they may receive urgent evaluation and treatment and, if needed, transfer to MUSC Health for additional diagnosis and treatment. These experts remotely provide urgent consultations after virtually examining patients and brain imaging studies through a specialized computer connection.
“We know this works because the VA has a national telestroke network linking all VA hospitals, with stroke experts available, including many rural centers. We need to double-down on increasing telestroke availability, but not to overlook opportunities for other telemedicine options.”
Your message has been successfully sent to your colleague.
Vol. 22, Issue 15 - p. 1-11
Your message has been successfully sent to your colleague.
This website uses cookies. By continuing to use this website you are giving consent to cookies being used. For information on cookies and how you can disable them visit our Privacy and Cookie Policy.