Examining the Impact of Area Deprivation on Endovascular Stroke Therapy Access

Equitable access to health care is heavily affected by socioeconomic factors. However, the effects of such disparities in accessing life-saving treatments remain incompletely characterized. Here we explore the impact of disparities on access to endovascular treatments for large vessel occlusion acute ischemic stroke.

From our prospectively maintained multihospital registry, we identified patients with large vessel occlusion acute ischemic stroke from January 2019-June 2020. Patient addresses and zip codes were matched to census-tract level area deprivation index (ADI) scores that were obtained from Neighborhood Atlas. ADI is a validated neighborhood-level measure that uses variables such as income, education, and employment to quantify the level of deprivation in an area. The primary outcome was use of endovascular thrombectomy by ADI tertile, adjusted for age, Alberta Stroke Program Early CT [Computed Tomography] Score, and National Institutes of Health Stroke Scale score, and was determined using multivariable logistic regression and expressed as odds ratio (OR [95% CI]). Secondary outcomes included use of intravenous tissue plasminogen activator, 90-day disability outcomes, last known well to arrival, transfer status, and discharge disposition.

Among 484 patients with large vessel occlusion acute ischemic stroke, the median age was 70, 46.5% were female, 41.5% were non-Hispanic White, 28.1% were non-Hispanic Black, and 15.5% identified as Hispanic. Median national ADI was 57.5 (interquartile range, 33-78). ADI was significantly associated with race, a higher prevalence of stroke risk factors (hypertension, diabetes, hyperlipidemia, prior strokes), and a higher last known well to arrival time. In the univariable analysis and generalized mixed-effects logistic model, patients with acute ischemic stroke large vessel occlusion in greater ADI neighborhoods had lower odds of undergoing endovascular treatments compared with the lowest ADI group (OR = 0.45, P value = 0.014); however, no significant difference was observed in the odds of receiving intravenous tissue plasminogen activator between the different groups.

Patients residing in disadvantaged neighborhoods (greater ADI regions) may have reduced rates of reperfusion therapy, despite comparable acute stroke presentation symptoms. These findings are consistent with prior studies demonstrating poorer health outcomes in these populations.