"Many studies have shown race- or ethnic-based differences in health-related services," says the study's lead author Larry B. Goldstein, M.D., director of the Duke Center for Cerebrovascular Disease at Duke University and a neurologist at the Durham VA Medical Center in Durham, N.C. "We found no race- or ethnic-based differences in the evaluations or immediate outcomes of stroke patients cared for at VA hospitals."
This may indicate that unmeasured barriers to care contribute to the discrepancy in care elsewhere, he says. The VA health system in the United States is open to all qualifying veterans, thus eliminating socioeconomic barriers to care and inequities consistently documented in previous studies conducted elsewhere. For this reason, Goldstein and his colleagues thought this population would be ideal for studying race-based differences in stroke care. They turned to the Veterans Administration Acute Stroke (VASt) Study for answers.
Conducted at nine geographically separated U.S. sites from 1995 to 1997, the VASt study prospectively collected data from 1,073 patients hospitalized with acute stroke of different types. For the current study, the researchers focused on the 775 patients (average age 71) with ischemic stroke. Nonwhite patients included 226 blacks, 28 Hispanics and one Asian American. White patients accounted for 520 of the enrollees. Because this was a veteran population, women comprised only 2 percent of the patients.
The researchers compared the care of white versus nonwhite patients as a group. However, the results were substantially the same when Hispanics were excluded from the analysis, and whites were compared directly to blacks. Hispanics were not studied separately because of their small number but researchers believe their care wouldn't differ from the others.
In comparing whites to nonwhites, researchers found that the different types of ischemic stroke – such as those caused by a blood clot in the artery (atherothrombotic), strokes related to narrowing of the small blood vessels inside the brain (lacunar), or ones caused by a blood clot traveling from the heart (cardioembolic) – occurred at similar rates.
Rates were similar for diagnostic procedures such as brain scans (91 percent of whites, 92.2 percent of nonwhites); magnetic resonance imaging (36.2 percent of whites, 41.6 percent of nonwhites); and carotid ultrasound (64 percent of whites, 62 percent of nonwhites).
Goldstein says rates were also similar for treatments such as clot-busting drugs (0.6 percent of whites, 0.4 percent of nonwhites); blood-thinning drugs (93.2 percent of whites, 92.1 percent of nonwhites); carotid endarterectomy (1.5 percent whites, 0.8 percent nonwhites); physical therapy (70.5 percent of whites, 74.9 percent of nonwhites); speech therapy (9.6 of whites, 12.6 percent of nonwhites) and occupational therapy (16 percent of whites, 19.6 percent of nonwhites). The proportion of patients discharged with little or no disability was also similar – 52 percent of whites and 50 percent of nonwhites.
The only differences detected were with the frequency of angiography and routine electrocardiogram (ECG). Angiography was performed more often in whites than nonwhites – 8.5 percent vs. 3.1 percent. ECG was performed more often in nonwhites than whites – 81.6 percent vs. 73.5 percent.
"The reason for the difference in the use of ECG is uncertain," Goldstein says, noting that routine ECG should generally be performed in all stroke patients. "Based on our interpretation of the data, the higher use of angiography in whites may have been due to clinical differences between the patient groups, but this is speculative.
"Many studies suggest that African Americans have a greater risk of the types of stroke that are caused by blood vessel problems in the brain as compared with whites and that whites may have a greater risk of strokes related to narrowing of the large blood vessels in the neck leading to the brain," Goldstein says. "We found no difference in stroke type among the VA patients in this study." In addition, he says, "We speculate that the differences in stroke subtypes found in other studies may have occurred because of differences in the use of preventive therapies, such as the use of anti-hypertensive therapy. Access to preventive therapies is the same once the patient is cared for in the VA system."
In an accompanying editorial Edgar Kenton, M.D., professor of clinical neurology at Thomas Jefferson University in Wynnewood, Pa., expressed concern about the disparate use of angiography and ECG tests uncovered at the VA. Angiography is more definitive while the ECG is often inconclusive, he says.
"One must continue to examine the attitudes and preconceptions of health care providers in the management of patients with stroke or at risk for stroke," he states. "Stroke is an equal-opportunity disease and therefore deserves equal access to definitive diagnostic studies."
Goldstein's coauthors were David B. Matchar, M.D.; Jennifer Hoff-Lindquist; Gregory P. Samsa, Ph.D.; and Ronnie D. Horner, Ph.D. The study was partially funded by the Department of Veterans Affairs and the National Institutes of Health.
NR03-1041 (Stroke/Goldstein)
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