Addressing stroke care access disparities

recent systematic review of disparities in access to stroke treatment between racial minorities and white patients examined 30 studies published from Jan. 1, 2010, to April 5, 2021. There are significant barriers to quality care and resulting poorer outcomes for Black, Hispanic, Asian, and Native American stroke patients when compared with white patients.  Specifically, white patients used emergency medical services more often, arrived at the hospital for stroke treatment sooner, and received life-saving stroke treatments (intravenous thrombolysis and thrombectomy) more frequently. 

One way to mitigate these life-altering disparities is a comprehensive approach that improves the stroke system of care across the board. A good place to start is access.

Stroke thrombectomy is a minimally invasive and highly effective procedure that uses a catheter, guided by x-ray, to reopen blocked arteries in the brain quickly. It significantly improves the chances that a patient will not only survive a stroke but perhaps make a full recovery.

However, access is limited and inequitable, with less than 15 percent of eligible patients receiving it. Rates of utilization are far lower among minority patients compared to white patients. “Racial Disparity in Mechanical Thrombectomy Utilization: Multicenter Registry Results from 2016-2020” analyzed the records of 34,596 patients across five years, 42 hospitals, and 12 states and found that Black stroke patients were 28 percent less likely than white patients to undergo thrombectomy.

In large part, these disparities can be attributed to outdated policies guiding stroke treatment. Right now, most states do not have clear protocols to ensure that a person who is having a severe stroke is transported directly to a Level 1 stroke center, where highly trained stroke teams can remove the clot quickly. Instead, patients may be taken to the nearest hospital, which might not have the capability to provide thrombectomy, which then requires additional time for inter-hospital transfer to one that can. This delays the time to thrombectomy by several hours, which leads to a lower chance of surviving, and if patients do survive, they have a much higher likelihood of lifelong disability.

Such delays disproportionately affect racial minorities, with a greater proportion of white patients (37.4 percent) arriving within 3 hours from onset of stroke symptoms than Black (26.0 percent) and Hispanic (28.9 percent) patients. To address this, states must update their triage and transport protocols to guarantee that all severe stroke patients are transferred to thrombectomy-capable hospitals without inefficient inter-hospital transfers.

Fortunately, the model needed for prehospital stroke triage already exists. In cases of traumatic injury, patients are assessed in the field, and the critically injured are transported directly to Level 1 trauma centers. This eliminates unnecessary transfers and delays in treatment and ensures that every person, no matter their location, is transported to the best facility to address their specific injuries. Gaining time in transfers can mean the difference between life and death or independence and life-long disability.

We have seen some recent progress at the federal level toward updating EMS protocols nationwide. The federal omnibus appropriations package included language endorsing updated EMS triage and transport protocols for stroke patients, and newly published National Model EMS Clinical Guidelines from the National Association of State EMS Officials also urged states and localities to take these lifesaving actions. Moreover, legislation has been passed at the state level in North Carolina, Florida, Virginia, Ohio, Tennessee, Arizona, and Florida, and Massachusetts, Michigan, Georgia, and Pennsylvania are currently working to improve stroke care.

But more must be done. In the absence of consistent stroke transport and triage laws, far too much is left to interpretation, allowing powerful individual and institutional biases to interfere with efficient and equitable care. We must urge legislative changes across the country that improve access to stroke treatments for everyone.

Dr. Michael Chen is a neurointerventionalist and professor of Neurology, Neurosurgery and Radiology at Rush University Medical Center in Chicago. He is the president of the Society of NeuroInterventional Surgery, supporting its Get Ahead of Stroke® campaign to improve systems of care for stroke patients.May is Stroke Awareness Month.