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Disparities in Prehospital Care of Acute Stroke Patients
Quick Takes
- Black patients presenting to the ED with stroke-like symptoms experienced longer time from symptom onset to ED presentation and lower use of EMS prenotification of the ED.
- Patients from lower socioeconomic status (SES) were less likely to receive EMS prenotification to the ED of a potential stroke than those from higher SES.
- Addressing this health inequity will require multipronged approaches from both the health system and public health agency at large.
Study Questions:
How do patient-level factors, including race/ethnicity and county-level socioeconomic status (SES) affect inequities in prehospital care of patients with stroke?
Methods:
The authors conducted a cross-sectional study of patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage in the American Heart Association Get With The Guidelines-Stroke registry. They identified patients presenting with stroke between July 2015 and December 2019 who had symptom onset <24 hours prior to presentation. They used multivariable logistic regression analysis to explore the use of emergency medical services (EMS) transport versus private vehicle transport, EMS prehospital notification versus no prehospital notification, and quantile regression was used to explore stroke symptom onset to time of arrival at the emergency department (ED).
Results:
The study included 606,369 patients, of whom 51.2% were men and 69.9% were White race. The median symptom onset to ED arrival was 176 minutes (interquartile range, 64-565 minutes). Black race was associated with a prolonged time from symptom onset to ED arrival (+28.21 minutes, 95% confidence interval [CI], 25.59-30.84 minutes) and a decreased odds of EMS prehospital notification (odds ratio [OR], 0.80; 95% CI, 0.78-0.82). Social deprivation index was not associated with differences in EMS use but was associated with a lower odds of EMS prehospital notification (upper vs. lower tertile, OR, 0.79; 95% CI, 0.78-0.81) and a longer time from symptom onset to ED arrival (upper vs. lower tertile, +2.56 minutes; 95% CI, 0.58-4.53 minutes).
Conclusions:
The authors conclude that Black race is associated with a prolonged time from stroke symptom onset until ED arrival and a decreased odds of EMS utilizing prehospital notification despite similar use of EMS versus private vehicle transport.
Perspective:
In the care of patients with stroke, every minute matters. Any delay in care can result in permanent disability and increase the risk of death. As such, it is imperative that our health systems ensure equitable and rapid care for all patients with stroke-like symptoms, regardless of race or SES. In this large nationwide study of patients presenting with ischemic or hemorrhagic stroke, important health inequities are described, particularly for Black patients. These include longer times from symptom onset to ED arrival and lower use of EMS prehospital notification. Additionally, patients with lower SES were also less likely to have EMS prehospital notification utilized.
Correcting these health inequities require a multipronged approach, including both public health measures (e.g., increased public awareness of stroke-like symptoms, improved trust in the EMS and health system among minority populations) and health system-specific interventions (e.g., more equitable use of prehospital notification by EMS of potential stroke patients, improved communication protocols, and partnership between EMS and EDs).
Clinical Topics: Prevention, Vascular Medicine
Keywords: Emergency Medical Service Communication Systems, Healthcare Disparities, Socioeconomic Factors, Stroke
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