Racial and Geographical Differences in Stroke Care Remain Despite Effort to Increase Certification Adoption

Renee Y. Hsia, MD, MSc

An analysis of stroke certification adoption in the US from 2009 to 2019 showed that Black, racially segregated communities experienced the highest likelihood of adopting stroke care, as did high-income, economically segregated communities; however, despite this, access to stroke-certified hospitals was less available in Black, racially segregated communities. Investigators also found similar differences when stratified to rural and urban hospitals.¹

To better understand the likelihood of hospitals’ adopting stroke care certification, senior investigator Renee Y. Hsia, MD, MSc, professor of emergency medicine, University of California, San Francisco, and colleagues analyzed 4984 general acute nonfederal hospitals in the US from 2009 to 2019. National-, hospital-, and census-level data was used to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. There were 3 main hazard ratio (HR) models used: model 1 estimated unadjusted HRs; model 2 adjusted for population and hospital size; and model 3 controlled for hospital ownership, teaching hospital status, whether a hospital was part of a system, and mean occupancy rate, in addition to controlling for population and hospital size.

During that 10-year stretch, the total number of hospitals with stroke certification grew from 961 to 1763, most of which were primary stroke centers (PSCs)—the first certification type introduced in 2008—increasing from 961 in 2009 to 1363 in 2019. Among the total sample, 68% (n = 3390) of hospitals served non-Black, racially integrated communities; 9.8% (n = 486) served non-Black, racially segregated communities; 12.2% (n = 610) served Black, racially integrated communities; and 10.0% (n = 498) served Black, segregated communities.

Without controlling for population and hospital size, hospitals in predominantly Black, racially segregated hospital service areas (HSAs) were 1.67-fold more likely to adopt stroke care of any kind relative to predominately non-Black, racially segregated HSAs (HR, 1.67; 95% CI, 1.41-1.97). Black, racially segregated HSAs tended to cluster in areas with larger population size and after adjusting for population and hospital bed size, the likelihood of adopting stroke care among these communities were significantly lower than those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89).

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"In other words, on a per-capita basis, a hospital serving a predominantly Black, racially segregated community was 26% less likely to adopt stroke certification of any level than a hospital in a predominantly non-Black, racially segregated community,” Hsia et al wrote. "The other 3 types of communities had comparable population-adjusted adoption rates."

Similar patterns were observed in terms of ethnic differences, demonstrated by 1.22-fold higher odds to adopt stroke care for hospitals in predominantly Hispanic, ethnically segregated HSAs over predominately non-Hispanic, ethnically segregated HSAs (HR, 1.22; 95% CI, 1.01-1.47). Notably, the differences in the likelihood of adopting stroke care certification were not significant after accounting for population.

Since income segregation did not cluster in large HSAs like racial and ethnic segregation did, the main model showed that hospitals serving high-income areas had higher likelihoods of adopting any level of stroke care compared with those serving low-income, economically integrated areas (HR, 0.23; 95% CI, 0.24-0.34) and low-income, economically segregated areas (HR, 0.29; 95% CI, 0.24-0.34). Additionally, when comparing rural and urban hospitals, those in rural areas were much less likely to adopt any level of stroke care (HR, 0.10; 95% CI, 0.09-0.12).

When stratifying analysis by urban and rural hospitals, urban hospitals had similar results across all 3 models, whereas rural hospitals serving high-income, economically segregated communities were 3-fold more likely to adopt stroke care capacity than low-income, economically segregated communities (HR, 3.03; 95% CI, 1.59-5.56) or integrated communities (HR, 3.13; 95% CI, 1.64-5.88).

"There are several implications of this work,” the study investigators wrote. "Our 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."

REFERENCE
1. Shen Y, Sarkar N, Hsia RY. Structural inequities for historically underserved communities in the adoption of stroke certification in the United States. JAMA Neurol. Published online June 27, 2022. doi:10.1001/jamaneurol.2022.1621.