UCSF-led study finds racial disparity in use of key treatment for stroke

May 02, 2001

Researchers led by UCSF scientists are reporting that a highly effective clot busting drug for stroke is significantly underutilized in all patient populations at U.S. academic medical centers, and is strikingly underutilized in African Americans.

The study, reported in the May issue of Stoke: Journal of the American Heart Association, showed that among 1,195 stroke patients seen at 42 academic medical centers around the country, only 49 patients, or 4.1 percent, received the drug, known as tPA. Of the 285 African Americans in the study, only three (1.1 percent) received tPA compared with 42 (5.3 percent) of the 788 Caucasians. In other words, African Americans were one fifth as likely to receive the drug as Caucasians.

The racial discrepancy persisted after adjusting for age, gender, insurance status, and severity of stroke.

Importantly, most of the patients in the study were not eligible to receive the drug, as it must be delivered within three hours of onset of symptoms and most patients did not reach a hospital emergency department during that time. In addition, a small number of patients were not medically eligible for the risky therapy.

This fact -- that most people do not reach the hospital in time to receive the drug - is one of the key findings of the study, and indicates that society must do a better job of educating all people about the early warning signs of stroke and the importance of getting to the hospital in time to receive early treatment, says lead author S. Claiborne Johnston, MD, MPH, UCSF assistant professor of neurology.

But an even more revealing, and troubling, aspect of the study, says Johnston, is the magnitude of the racial discrepancy in the use of tPA.

"Society as a whole, not just the medical community, is responsible for the significant racial discrepancy this study reveals," says Johnston. "Factors contributing to the problem might include the need for more education on symptoms of stroke within the African American community or greater distrust of the medical system by African Americans. It's also possible that patients are refusing the drug, as it is considered an aggressive, high-risk therapy, and that this isn't documented. Another possible factor is racial prejudice, though in this case it would most likely be not that doctors care less about African Americans, but that they may have preconceived notions about whether African Americans are willing to accept aggressive, risky treatments."

To tease out whether African Americans and others were not getting the drug because they were poor candidates or because doctors were not offering it, the researchers examined the records of a subgroup of patients who had been deemed medically eligible to receive tPA. Among these 189 patients, only 20.6 percent received the drug. Only three of 36 African Americans (8.3 percent) received the drug compared to 34 of 138 (24.6 percent) of Caucasians. Thus, in this eligible group, African Americans were one third as likely to receive tPA as those who were Caucasians.

The racial discrepancy persisted after adjusting for age, gender, insurance status, and severity of stroke.

While the numbers of Latinos, Asians and Native Americans seen in the study were small, indicating that they were seen less often at these centers, the rates of use of the drug in these groups were not significantly different from those of Caucasians.

To evaluate regional differences in tPA delivery, the authors also performed a larger but less detailed confirmatory study that included 8,608 stroke patients treated at 66 academic medical centers around the country. Notably, for reasons not yet clear, the ethnic disparity was not seen in medical centers in the Southeastern United States.

But in the Northeast, less than one percent of African Americans received tPA, while 2.3 percent of Caucasians did. In the Midwest and West, the rates were 2.1 percent and 1 percent for African Americans and 4.8 percent and 3 percent for Caucasians.

"Though a more detailed analysis of factors predicting tPA treatment is required, we have to consider the possibility that racism contributed to the disparity in treatment," report the University of California San Francisco and Yale University School of Medicine researchers in their paper.

"Giving tPA is considered high-risk, so there are many factors that physicians are weighing when they decide whether or not to utilize it," says Johnston. "But we took these variables into consideration in the subgroup we studied and still couldn't rule out the possibility that racism was a key factor. Practitioners need to examine their own motivations when withholding this proven therapy. Just being educated to the fact of this discrepancy will be important for leading physicians to fix it."

Johnston said he suspects that at least part of the discrepancy is explained by the possibility that some physicians have preconceived ideas that African Americans' are more averse to risky medical procedures. The study did not examine this possibility, but it has been reported in the use of some aggressive procedures for cardiovascular disease and cancer.

An accompanying editorial in the journal urges healthcare professional to pay serious attention to the results, particularly because African Americans have a greater risk of stroke than Caucasians and are more likely to die from stroke.

Notably, the type of medical insurance coverage a patient had was independently associated with tPA treatment. After adjustment for ethnicity, age, sex, stroke severity and ethnicity, those patients with Medicaid or without insurance were one ninth as likely to receive tPA as those with private medical insurance.

The researchers cited numerous studies in their paper reporting that African Americans are less likely than Caucasians to receive a number of aggressive medical therapies, including coronary artery angioplasty, bypass surgery and tumor resection of colon and lung cancer. (Socioeconomic status also influences utilization of medical services, they say, but the effect of ethnicity persists after correction for income.)

But reductions in ethnic disparities at academic medical centers have been documented during the last decades, says Johnston, indicating, he says, that there is reason to hope that there will be improvements in stroke treatment.

In January 2000, former U.S. Department of Health and Human Services Secretary Donna E. Shalala and Surgeon General David Satcher released Healthy People 2010, the nation's health goals for this decade. One of two major themes of Healthy People 2010 is the elimination of racial and ethnic disparities in health status.

Intravenous tPA, or tissue-type plasminogen activator, is the first proven therapy for acute ischemic stroke. It acts by dissolving blood clots blocking either the arteries leading to the brain or those in the brain itself. Approved by the Food and Drug Administration in 1996, its use has been recommended in published neurology consensus guidelines. The study examined medical records established during six months in 1999.

tPA is considered a high-risk therapy, but the majority of patients will benefit from the drug, says Johnston. Still, he says, the drug is associated with an increased chance of bleeding into the brain, and this makes some physicians uncomfortable and more resistant to using the drug.

Patients who would be ineligible for treatment would include those who arrived at the hospital more than three hours after the onset of symptoms, were already receiving blood-thinning treatment, had acute high blood pressure, internal bleeding, evidence of extensive tissue damage from the stroke (detected through a CT scan), or a minor or improving medical condition.

The researchers focused their study on academic medical centers because the institutions were most likely to have the necessary resources to support tPA administration, including physicians with stroke expertise and sophisticated interpretation of head CT scans. Given the resources of academic medical centers and the fact that they generally offer the most aggressive treatments, nonacademic centers probably use the drug even less frequently, the researchers say.
Co-authors of the study were Lawrence H. Fung, BA, a visiting medical student at UCSF; Leslie A. Gillum, MD, a UCSF neurology resident; Wade S. Smith, MD, PhD, UCSF professor of neurology and director of the UCSF Stroke Service; Lawrence M. Brass, MD, neurology, epidemiology and public health, and Judith H. Lichtman, PhD, associate research scientist, both of Yale University School of Medicine and Andrew N. Brown, MD, MPH, formerly of UCSF.

The study was funded by the National Institutes of Health.

University of California - San Francisco

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