Racial disparities in stroke care

Clinicians are working against the clock when caring for stroke patients: To benefit from first-line treatment for acute ischemic stroke, patients must receive tissue-type plasminogen activator (tPA) injection within 4.5 hours of symptom onset — preferably within 60 minutes of when the patient arrives at the hospital. The treatment window for another option, mechanical thrombectomy (MT), may extend to 24 hours for some patients, but for most, a shorter time to treatment is critical.    

However, partly because Black, Hispanic, and Asian patients are more likely to experience delays in care than White patients, they are less likely to receive tPA or MT, which can lead to higher rates of intracranial hemorrhage or death.

Though patient-level knowledge gaps — such as not recognizing stroke symptoms or a hesitation to call emergency medical services (EMS) — can delay treatment, provider- and system-level failures also contribute to inequitable care. For example, some studies have shown that compared to White patients, Black patients experience longer wait times in the ED, Black and Hispanic patients are less likely to be referred to acute stroke care teams or facilities, and Asian patients are less likely to be correctly diagnosed with stroke.

J&J MedTech Neurovascular developed a Racial Disparity in Stroke Care (RDiSC) Dashboard that analyzes and maps racial and geographical disparities in MT utilization among patients in core-based statistical areas (CBSAs) across the United States. The RDiSC Dashboard ranks and sorts CBSAs into disparity index deciles indicating a low (1–3), moderate (4–7), and high (8–10) disparity.

7 ways health systems can reduce disparities and improve stroke outcomes

While managing the broad risk factors for stroke — such as high blood pressure — reduces the overall incidence of stroke, it doesn’t impact racial disparities in stroke care. But tackling systemic issues, like ED wait times, can make a significant difference. Here are seven best practice strategies health systems should prioritize addressing to equitably improve stroke outcomes:

1.      Educate patients to increase use of EMS. When patients know the signs of stroke and the importance of timely stroke treatment, they are more likely to call EMS to get to the hospital faster. In-hospital learning sessions, culturally appropriate educational materials, and enhanced educational materials about stroke have been shown to shorten ED arrival times for Black and Hispanic patients.    

2.      Shorten door-to-needle (DTN) time for more effective tPA intervention. For the best outcomes, stroke patients should receive the tPA injection within 60 minutes of arrival in the ED. The American Heart Association and American Stroke Association’s Target: Stroke initiative provides strategies to lower DTN times to under 60 minutes, including EMS pre-notification and rapid brain imaging.

3.      Optimize transfer patterns. Implementing accurate and feasible prediction scales can help EMS identify patients with stroke faster, so they can be routed to the correct care. In addition, tracking which stroke patients are transferred to acute stroke centers can show whether marginalized populations are receiving appropriate referrals and help EDs decide where to send patients with suspected stroke.

4.      Streamline evaluation and referral with telemedicine. “Telestroke” initiatives reduce disparities among patient populations by further shortening the time to diagnosis and treatment. For example, the Medical University of South Carolina’s telestroke program shortened wait times in the ED from 38 to 20 minutes by using telemedicine to perform consults on the way to the hospital.

5.      Ensure interpreters are available for all patients whose preferred language isn’t English. Stroke patients who need to wait for interpretation services may experience delays in treatment. Making interpreters available to patients with limited English proficiency may reduce wait times and improve outcomes.   

6.      Track ED wait times. Using an annual dashboard to track ED wait times and other time-to-treatment data, patient experience data, and developing audit and feedback reports may also help illuminate and prevent care discrepancies along the stroke patient pathway.

7.      Provide defect-free stroke care by sticking to guidelines. Consistently adhering to evidence-based guidelines for stroke prevents the underuse or overuse of treatments, ensuring equitable care for all patients. 

For more information, read the Executive report: Closing the racial and ethnic disparity gap in stroke care, and visit the J&J MedTech Digital Health Equity Hub. (Ikeme S, et al., Johnson & Johnson MedTech Neurovascular (formerly CERENOVUS), 2024)  

We see it as our responsibility to educate healthcare providers, policymakers, and patients about stroke and the barriers that exist to proper patient care. Johnson & Johnson MedTech, Neurovascular (formerly CERENOVUS) works alongside physicians to identify and understand unmet clinical needs and collaborate on interdisciplinary research. We work to advance patient access to care through partnerships with advocacy organizations across the globe. Our work to address disparities in stroke care focuses on educating communities of color on the signs and symptoms of stroke and the physician community on the systematic barriers that prevent – and need to be improved for - equal access to stroke care.