Racial/Ethnic Disparities Persist in Treatment of Poststroke Complications

Black individuals, and to a lesser extent their Hispanic counterparts, are less likely than non-Hispanic white patients to receive medical therapies for a host of poststroke complications, data spanning two decades show.

The gaps—which were seen when it came to treatment of arousal/fatigue, spasticity, mood and sleep problems, bladder and bowel incontinence, and seizure—improved over the course of the study period but persisted, particularly for Black patients, Kent Simmonds, DO, PhD (UT Southwestern Medical Center, Dallas, TX), reported last week at the International Stroke Conference in Dallas.

Although the study was not designed to look for reasons for the disparate care, Simmonds told TCTMD it’s likely that there are multiple factors contributing, including the quality of relationships between physicians and patients, unconscious bias, awareness among clinicians to look for and treat these issues, and comfort among patients and their families in bringing some of these complications to the attention of the care team.

A big part of addressing these racial/ethnic disparities “is to bring up awareness just so that providers themselves are asking about these specific issues and how they may or may not be affecting patients,” Simmonds said. “Stroke is devasting for patients, and I just think that we owe it to them to do what we can to try to treat and minimize the symptoms and try to improve their quality of life.”

Prior studies have identified racial/ethnic disparities in terms of stroke incidence, mortality, and disability in the United States, but less work has focused on the treatment of poststroke complications.

Stroke Complications Over Time

For the current study, Simmonds and his colleagues examined electronic medical records from 51 large healthcare organizations. The analysis included 348,286 adults who were treated for a first-time stroke between 2002 and 2022—75% were non-Hispanic white, 19% non-Hispanic Black, and 7% Hispanic.

The investigators used matched propensity scores to compare medical treatment of poststroke complications between non-Hispanic white and Black patients (63,733 matched pairs) and non-Hispanic white and Hispanic patients (24,009 matched pairs) at three time points after the stroke: 14 days, 90 days, and 1 year.

Stroke is devasting for patients, and I just think that we owe it to them to do what we can to try to treat and minimize the symptoms and try to improve their quality of life. Kent Simmonds

At all time points, Black patients were less likely than their white counterparts to be treated for most poststroke complications. The largest gap was seen at 14 days for treatment of arousal/fatigue (RR 0.58; 95% CI 0.54-0.62), with RRs ranging from 0.64 to 0.99 for the other conditions. There was a general trend toward weakening relationships over time, but at 1 year, Black patients were still less likely to be treated for all complications except for bowel incontinence.

Patterns were similar when comparing Hispanic patients with non-Hispanic white individuals, although the magnitude of the differences were smaller than what was observed for Black versus white patients.

All of the differences lessened—or even reversed in some cases among the Hispanic group—when comparing the second half of the study period with the first. “So it’s the glass half full, if you will,” Simmonds told TCTMD. When [health] systems themselves focus on reducing these differences, they can be reduced or eliminated.”

Causes and Solutions

More work is needed to determine the exact causes of the observed disparities, Simmonds said. Access to care doesn’t seem to explain the gaps, he noted, because the number of ambulatory visits at 90 days was higher in Black versus white patients (18 vs 13) and only slightly lower in Hispanic versus white patients (11 vs 13; P < 0.01 for both).

“I think, in part, it’s the quality of the relationship between the provider and the patient, where some of these differences, especially for poststroke complications like fatigue and depression, are not necessarily as obvious or evident as issues like hypertension that can be more easily measured,” he said, adding that “these could be more-subjective, soft factors that require providers and patients to have a little bit of a deeper conversation.”

He suggested that differences between racial/ethnic groups in terms of how comfortable patients are with discussing certain types of complications with their doctors could be playing a role, acknowledging, too, that unconscious bias on the part of the treating physician also could be contributing.

In a video commentary, Karen Furie, MD (Brown University, Providence, RI), vice chair of the American Heart Association’s stroke brain health science subcommittee, said, “Fortunately, there’s a lot we know about how to help patients recover, but clinicians can’t treat unless patients and families make them aware of the issues of mood, level of function, and potential complications. This study, hopefully, is one of many that will help us identify communities that need more help and help healthcare providers do more to standardize the delivery of care for patients and families in the postacute period.”

These findings should spark additional studies to explore why these gaps persist, Furie said. “We really need to have a better understanding of why these differences exist and how we might change our practice, standardize interventions, and deliver equitable care based on demographics and geographical factors.”