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Race/Ethnicity, Quality of Care, and Outcomes in Ischemic Stroke

Lee H. Schwamm, MD; Mathew J. Reeves, PhD; Wenqin Pan, PhD; Eric E. Smith, MD, MPH; Michael R. Frankel, MD;

DaiWai Olson, PhD, RN; Xin Zhao, MS; Eric Peterson, MD, MPH; Gregg C. Fonarow, MD

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DisclosuresThe Get With The Guidelines– Stroke (GWTG) program is provided by the American Heart Association/American Stroke Association. The data analyzed in this manuscript was collected while the GWTG program was supported in part through an unrestricted educational grant from Boeringher-Ingelheim Pharmaceutical.

The individual author disclosures are listed in the manuscript.

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Background• Prior studies suggest differences in stroke care

associated with race/ethnicity. We sought to determine whether such differences existed in a population of black, Hispanic, and white patients hospitalized with stroke among hospitals participating in a quality-improvement program.

• Previous reports have demonstrated that participation in the Get With The Guidelines – Stroke (GWTG-Stroke), a national quality initiative of the American Heart Association, is associated with improved guideline adherence for patients hospitalized with Stroke.

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IntroductionData supports that race/ethnicity related differences exist in stroke care. These differences could lead to increased risk of recurrent stroke. The burden of stroke is higher in black and Hispanic patients compared to white patients.1 Several studies have suggested that ethnic/race differences exist in the quality of care and outcomes for hospitalized stroke patients.2

1. Lloyd-Jones D et al. Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119:480-6.

2. Stansbury JP, Jia H, Williams LS, Vogel WB, Duncan PW. Ethnic disparities in stroke: epidemiology, acute care, and post acute outcomes. Stroke. 2005;36:374-86.

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Objective

The GWTG-Stroke Program has the potential to influence the quality of care and outcomes of ethnic patients hospitalized with stroke. The purpose of the paper was to evaluate whether race/ethnicity related differences exist in stroke care among hospitals participating in the GWTG-Stroke program.

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MethodsData were collected from 397,257 patients admitted with ischemic stroke to 1181 hospitals participating in the GWTG-Stroke program were evaluated from April 1, 2003- September 30, 2008.

The hospitals were participating in the Get With the Guidelines–Stroke Program (GWTG-Stroke).

3 groups were analyzed: Black, Hispanic and White patients. 7 evidence-based performance measurements were used to

evaluate the quality of care of these patients. Hospital characteristics were evaluated.

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Patient Characteristics By Race

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Variable Level Total N Overall White Black Hispanic

Total Study Pop 397257 397257 314230 63561 19466Age Median Years

(IQR) 74 (61-82) 76 (64-83) 64 (54-75) 68 (56-78)

Gender Female 52.73 52.59 54.92 47.79Arrival Mode EMS 60.09 61.31 56.12 54.57

Other 39.41 38.22 43.32 44.82Medical History

Atrial Fib/Flutter Yes 18.12 20.38 8.81 12.09Stroke/TIA Yes 30.60 30.00 33.90 29.63CAD/Prior MI Yes 28.04 29.64 21.23 24.39Carotid Stenosis Yes 4.55 5.17 1.99 2.85Diabetes Mellitus Yes 29.95 26.95 40.68 43.25PVD Yes 5.20 5.48 4.09 4.18Hypertension Yes 74.24 72.47 82.58 75.57Dyslipidemia Yes 36.17 37.39 30.51 34.99Smoker Yes 19.34 18.08 26.48 16.59

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Results• Blacks were 16 percent less likely than whites to receive the clot-busting

drug tissue plasminogen activator (tPA) and to receive anticoagulants for atrial fibrillation.

• Blacks were 12 percent less likely than whites to receive deep vein thrombosis prevention and to be discharged with anti-clotting medications.

• Blacks were 3 percent less likely than whites to receive early anti-clotting medications.

• Blacks were 9 percent less likely than whites to receive cholesterol-lowering therapy.

• Blacks were 15 percent less likely than whites and Hispanics were 18 percent less likely than whites to receive smoking cessation counseling.

• Overall, blacks were 10 percent less likely than whites to receive “defect free care,” which is defined as the proportion of patients who receive all of the interventions for which they are eligible.

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GWTG-Stroke Adherence to Defect-Free Measure by Race/Ethnicity

Schwamm et al. Circulation. 2010 epub April 6Trend of improvement over time was significant within eachpatient group (black, Hispanic, white; P<0.001)

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Results• Hispanic patients received comparable quality of care and in-

hospital mortality to that of white patients after adjustment for patient and hospital level variables, but a greater odds to exceed the median length of stay (OR 1.16; 1.11-1.20) and be discharged home (OR 1.13; 1.08-1.18)

• Black patients with stroke are at an increased risk of recurrent stroke because they received fewer evidence based care processes than Hispanic or white patients, but over the three time period, the quality of care differences were reduced for all three ethnic groups.

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Results• Black (47.9 percent) and Hispanic (52.6 percent) patients

were more likely to be discharged to home compared to white patients (44.0 percent), who were more likely to be discharged to a skilled nursing facility compared to black and Hispanic patients.

• Black (4.37 percent) and Hispanic (4.90 percent) patients were less likely than white patients (6.06 percent) to die in the hospital.

• Black (6.60 days) and Hispanic (6.34 days) patients had longer hospital stays than whites (5.49 days).

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Limitations• The GWTG-Stroke is a voluntary program and could over-

represent high-performing hospitals. • Hispanic ethnicity may be under-reported in this registry

because of variability between hospitals in the process to establish patient ethnicity.

• Data were collected by chart review and thus depend on the accuracy and completeness of documentation.

• The GWTG-Stroke database does not track inpatient provider specialty, and this may influence mortality and quality of care.

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Conclusion

• Black patients with stroke received fewer evidence-based care processes than Hispanic or white patients.

• These differences could lead to increased risk of recurrent stroke.

• Quality of care improved substantially in the Get With The Guidelines-Stroke Program over time for all 3 racial/ethnic groups.

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“These findings tell us that a focused, systematic quality improvement intervention, such as this, can improve care, regardless of race and ethnicity, what remains is to identify the causes of these differences in care among ethnic groups so we can develop strategies to eliminate that small but persistent disparity.”

Lee Schwamm, MDGWTG Steering Committee Chair

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