Stroke mortality and race: does access to care influence outcomes?

Stroke is the third leading cause of death in the United States. We investigated racial differences in death after hospital discharge for ischemic stroke in a large cohort of Veterans Health Affairs (VHA) stroke patients. We hypothesized that having access to VA care would ameliorate the excess stroke mortality rates in African-Americans (AA) reported in non-VA studies.

Hospital administrative data were used to identify all patients discharged from any VA hospital between October 1990 and September 1997 with a primary discharge diagnosis of ischemic stroke (ICD-9-CM codes 434 and 436). We obtained demographic data and clinical data recorded during the index hospitalization and after discharge, including deaths, from VA clinical and administrative databases. The Charlson comorbidity index was constructed for each patient from the index admission's discharge diagnoses. Patients were followed through 1998.

Of 55,094 VHA stroke patients discharged after ischemic strokes, 34,579 (63%) were white and 11,530 (21%) were AA. Charlson index was similar between the groups. One-year mortality rate was significantly higher for whites: Adjusting for demographic and clinical differences, being white remained predictive of higher mortality rates (multivariable hazard ratio, 1.06; 95% CI, 1.02 to 1.10). From Kaplan-Meier estimates, the probability that whites would survive for 1 year was 0.86 compared with 0.87 for AA.

Despite having similar severity of illness and adjusting for other clinical differences, mortality rate was marginally lower in AA after being discharged from VA hospitals after ischemic strokes. This is contrary to prior reports from non-VA hospitals and suggests the possibility of access to care playing a role in stroke deaths.