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A Statement for Healthcare Professionals from the AHA/ASA

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Presentation on theme: "A Statement for Healthcare Professionals from the AHA/ASA"— Presentation transcript:

0 Race-Ethnic Disparities in Stroke Care: The American Experience
AHA/ASA Scientific Statement Race-Ethnic Disparities in Stroke Care: The American Experience

1 A Statement for Healthcare Professionals from the AHA/ASA
Writing Committee Salvador Cruz-Flores, MD, MPH, FAHA, Chair Alejandro Rabinstein, MD, Vice-Chair Jose Biller, MD, FAHA Mitchell S. V. Elkind, MD, MS Patrick Griffith, MD Philip B. Gorelick, MD, MPH, FAHA George Howard, PhD, FAHA Enrique C. Leira, MD, MS, FAHA Lewis B. Morgenstern, MD, FAHA Bruce Ovbiagele, MD, MS, FAHA Eric Peterson, MD, MPH, FAHA Wayne Rosamond, PhD, MS, FAHA Brian Trimble, MD Amy L. Valderrama, PhD, RN ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

2 Slide Set developed by: Aaron Anderson MD Member Stroke Council Professional Education Science Sub-Committee ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

3 Purpose Describe the effect of race and ethnicity on stroke epidemiology, personal beliefs, access to care, response to treatment, and participation in clinical research Determine the state of knowledge on factors that may explain disparities in stroke care Identify gaps in knowledge to guide future research ©2011 American Heart Association, Inc. All rights reserved. Cruz-Flores et al. Published online in Stroke May 26, 2011

4 Methods Members appointed by the AHA Stroke Council Scientific Statement Oversight Committee (SOC) Reviewed relevant literature with emphasis on reports published since 1972 Peer reviewed and final approval by the AHA Science Advisory and Coordinating Committee (SACC) ©2011 American Heart Association, Inc. All rights reserved. Cruz-Flores et al. Published online in Stroke May 26, 2011

5 I. Introduction: Background
Racial and ethnic minorities 28% of the US population; expected 40% by 2030 Striking lifespan disparities between different racial-ethnic groups in the US 86.7 Asian women to 61.7 African American men Cardiovascular disease, including stroke, was largest contributor to these disparities ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores et al. Published online in Stroke May 26, 2011

6 II. Definitions: Race and Ethnicity
Race encompasses related factors Biological and geographic origins, ancestry, culture, economics, politics, and racism Ethnicity has been proposed as a replacement category for race Share ancestry, history or culture, highlight cultural and social characteristics rather than biological ones ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

7 II. Definitions: Race and Ethnicity
Federal government defined Race White Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Ethnicity Hispanic/Latino origin Not of Hispanic/Latino origin Despite the limitations, these categories provide the framework to begin our discussion ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

8 III. Epidemiology: Risk Factor Burden
African Americans Higher prevalence of hypertension, diabetes, and left ventricular hypertrophy compared to whites Hispanics Higher prevalence of metabolic syndrome and diabetes compared to whites and African Americans American Indians/Alaskan Natives Higher prevalence of at least two risk factors compared to Whites ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

9 III. Epidemiology: Prevalence, Incidence and Recurrence
African Americans Prevalence of stroke is about 4.0% More likely to report stroke symptoms, experience transient ischemic attacks, be hospitalized for stroke, and have about twice the number of incident strokes as whites Disparity in stroke incidence is prominent among younger adults Risk ratio of first ever stroke in African Americans compared to Whites 4.18 (95% CI ) in those years and 2.02 ( ) in those years ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

10 III. Epidemiology: Prevalence, Incidence and Recurrence
Hispanics Prevalence of stroke is about 2.6% High risk ratio of stroke among Mexican Americans compared to whites RR 2.04 (95% CI ) in those years Higher incidence of transient ischemic attacks, intracerebral hemorrhage, and subarachnoid hemorrhage than non-Hispanic whites American Indians/Alaskan Natives Prevalence of stroke is about 6.0% ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

11 III. Epidemiology: Stroke Mortality
African Americans Bear the highest burden of stroke mortality Age-specific stroke mortality is approximately three times that of non-Hispanic whites for ages between 45 and 64 High mortality risks remains after adjustment for socioeconomic status No differences of in-hospital mortality and case fatality rates among different racial groups ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

12 III. Epidemiology: Stroke Mortality, Prevalence, Incidence and Recurrence
Racial and Ethnic minorities have excess deaths from stroke Experience greater years of potential life lost compared to non-Hispanic whites Risk ratio for stroke mortality in all racial and ethnic minorities is higher in the age group Poor understanding of socioeconomic factors and social networks hinders the development of effective interventions to reduce these disparities ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

13 IV. Differences in Disease Awareness
Minorities have decreased awareness of Nature of stroke Signs and symptoms of stroke The need for urgent treatment Risk factors for stroke Education improves knowledge and awareness Long-term effects of educational campaigns remain unknown and need further research ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

14 V. Differences in Attitudes, Beliefs and Compliance
Medication compliance is reduced in minority groups Patient-specific barriers Forgetfulness, medications not needed when one feels well or associated with impotence, denial of disease, belief medications cause kidney disease or diabetes, and no desire to take medications for rest of life Medication-specific barriers Side effects of medications: allergies, hives, loss of libido Disease-specific barriers absence of symptoms implies lack of need for treatment ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

15 V. Differences in Attitudes, Beliefs and Compliance
Other potential causes of non-compliance Inability to afford medications Lower health literacy Perceived or true presence of racial discrimination during the interaction with the healthcare system Socio-cultural interventions Limited evidence of improved communication, education and awareness among minorities ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

16 VI. Disparities in Access to Care
Acute Stroke Treatment Minorities less likely to utilize emergency medical services Minorities have delayed arrival times and longer waiting times in Emergency Departments Contributes to lower likelihood of receiving thrombolysis Lack of awareness, language barriers, fear of revealing immigration status Evidence suggests the potential existence of bias in the delivery of care ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

17 VI. Disparities in Access to Care
Stroke Rehabilitation Minorities have equal access to rehabilitation services Minorities have longer stays and poorer functional status compared to whites Stroke Prevention Services Minorities less likely to receive medications for secondary stroke prevention Behavioral modification programs may be effective in minority populations ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

18 VI. Disparities in Access to Care: Potential Contributing and Confounding Factors
Income Lower SES in minorities compared to whites Insurance Limited access to primary and secondary prevention Mistrust Racially concordant visits have favorable communication characteristics Providers for minorities Less likely to be board-certified in their specialty System Delay from 911 call to arrival Delay in time to head CT Lack of Awareness Language and poor communication are barriers in Hispanic communities ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

19 VII. Disparities in Quality of Stroke Care
Referral to Neurologists Minority patients are less likely to be evaluated by a neurologist Treatment with Thrombolytic Therapy Disparities at several levels in chain of survival in acute stroke care ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

20 VII. Disparities in Quality of Stroke Care
Primary and Secondary Prevention Minorities inadequately treated with primary and secondary stroke prevention strategies Community healthcare workers may help provide preventive care and education for minorities Use and Outcomes of Carotid Endarterectomy More studies are needed to determine presence and identify causes Intracerebral or Subarachnoid Hemorrhage Paucity of data on disparities of surgical care ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

21 VIII. Differences in Access to Research
Participation of Minorities in Clinical Research Literature contradicts assumptions that minority subjects are reluctant to participate in research Barriers to Participation in Clinical Research Social support Education about the nature of the research Trust in study personnel ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

22 VIII. Differences in Access to Research
Cultural Characteristics (attitudes, beliefs, perceptions) Mistrust of physicians and medical research Supported by studies in recent history in which effective treatment was withheld Fatalistic attitudes about disease and stroke Structural Factors Failure to network with local organizations Physician interest in referring their patients ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

23 IX. Future Directions Develop strategies aimed at reducing race-ethnic disparities in stroke Support programs designed to identify responsible factors for disparities Universal nomenclature needed to account for common characteristics of each minority group ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

24 X. Conclusions Race-ethnic disparities in stroke care exist
Marked among minorities <65 years of age SES and low education are barriers to delivery of effective health care Deficiencies exist in the healthcare system Changes need to ease access and improve modification of vascular risk factors Call for further research and public health policy development ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

25 Recommendations Standardize definitions for racial and ethnic groups
Implement programs to increase stroke awareness Establish programs to increase provider cultural competence Promote research to better define factors contribute to disparities ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011

26 Recommendations Increase health care access by broadening insurance coverage in minority populations Expand national strategies for the hospital-based implementation of quality improvement in acute stroke care Clinical trials to find interventions to reduce the existent disparities Expand federal support for trials targeted to minority populations ©2011 American Heart Association, Inc. All rights reserved Cruz-Flores Published online May 26, 2011


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