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Outcomes for Black and White Patients After Certification of Nearby Stroke Centers
Yu-Chu Shen1,2, Anthony S Kim3, Renee Y Hsia4,5
1Department of Defense Management, Naval Postgraduate School, Monterey, California.
Insights
Stroke center certification increased stroke center admissions for both Black and White patients. However, disparities in acute stroke treatment and mortality rates persist, with Black patients experiencing worse outcomes.
Area of Science:
- Health Services Research
- Cardiovascular Diseases
- Health Equity
Background:
- Stroke center certification aims to improve acute ischemic stroke care and outcomes.
- Existing research does not clarify if these benefits extend equally to Black and White patients.
Purpose of the Study:
- To evaluate the impact of nearby stroke center certification on stroke care and outcomes for Black versus White patients.
- To identify potential disparities in the effectiveness of stroke center certification.
Main Methods:
- A difference-in-differences analysis of 2.1 million Medicare fee-for-service patients diagnosed with acute ischemic stroke (2009-2019).
- Compared changes in stroke center admission, thrombolytics, thrombectomy, and 90-day home status/1-year mortality between exposed and unexposed communities, stratified by race.
Main Results:
- Stroke center certification increased stroke center admissions similarly for Black and White patients.
- White patients saw increased thrombolytic use, while Black patients experienced decreased thrombolytic and thrombectomy rates.
- One-year mortality remained stable for White patients but increased for Black patients.
Conclusions:
- While stroke center certification improves access, it does not eliminate racial disparities in acute stroke treatment utilization.
- Persistent disparities in treatment and worse mortality outcomes for Black patients suggest systemic issues beyond center certification.
Importance:
It is unclear whether stroke center certification near a community is associated with similar benefits for Black and White patients.
Objective:
To assess changes in admission to stroke centers, receipt of acute stroke treatment, and health outcomes for Black compared with White patients after the certification of a new stroke center near their community.
Design, Setting, And Participants:
This cohort study comprises Medicare fee-for-service patients from urban US communities with a primary diagnosis of acute ischemic stroke between January 1, 2009, and December 31, 2019, and compares changes in outcomes. Statistical analysis was performed from September 2024 to April 2025.
Exposure:
When a patient's community was exposed to the certification of a nearby stroke center relative to a patient of the same self-reported race in a community that was not exposed to a stroke center certification.
Main Outcomes And Measures:
A difference-in-differences framework was used to compare changes in (1) stroke center admission, (2) receipt of acute stroke treatments (thrombolytics and thrombectomy), and (3) health outcomes (home at 90 days and 1-year mortality) among Black and White patients. The empirical model was a linear probability model with community fixed effects.
Results:
This study included 2.1 million patients with stroke (15% Black patients and 85% White patients; 57% women; 15% aged 65-69 years, 16% aged 70-74 years, 18% aged 75-79 years, 19% aged 80-84 years, and 32% aged ≥85 years). After a newly certified stroke center opened near a community, the probability of admission to the stroke center increased for both White patients (15.6 percentage points [pp]; 95% CI, 14.6-16.6 pp) and Black patients (14.6 pp; 95% CI, 13.2-15.9 pp). Thrombolytic therapy increased for White patients by 0.2 pp (95% CI, 0.0-0.4 pp) but decreased for Black patients by 0.4 pp (95% CI, -0.7 to -0.1 pp) compared with their control communities. Black patients also had a 0.5-pp decrease in thrombectomy (95% CI, -0.6 to -0.3 pp). One-year mortality remained stable for White patients, while mortality for Black patients increased by 0.5 pp (95% CI, 0.1-0.9 pp).
Conclusions And Relevance:
This cohort study of 2.1 million patients with stroke found that stroke center certification near a community was associated with similar increases in rates of admission to the stroke center for Black and White patients, but it was associated with increased rates of receiving thrombolytics only for White patients. Thrombolysis and thrombectomy rates did not increase for Black patients who were exposed to a newly certified stroke center nearby. This study suggests that, despite the expansion of certified stroke centers, disparities in stroke care between Black and White patients persist.
