Addressing Race-Ethnic Disparities in Stroke Care

Two recently issued decennial reports have underscored the clear imperative to address race-ethnic disparities in health. First, the 2010 U.S. Census has documented profound changes in the racial and ethnic composition of the U.S. population. Racial and ethnic minorities now account for 28% of the population, with 16.3% identifying as Hispanic or Latino, 12.6% identifying as black or African American, 5.0% identifying as Asian and Pacific Islander, and 0.9% identifying as American Indian and Alaska Native.[1] Moreover, there has been a 43% increase in the Hispanic or Latino population over the last 10 years and minority births are expected to outnumber births of white or European ancestry for the first time this year.[1] Therefore understanding and addressing race-ethnic disparities will continue to become more and more relevant in the coming decades.

Well-documented and persistent race-ethnic disparities in overall health outcomes are superimposed upon these demographic trends, with burdens often disproportionately borne by the most disadvantaged groups. Accordingly, the U.S. Department of Health and Human Services has updated its 10-year health promotion and disease prevention goals with a continued and fundamental emphasis on reducing these disparities - though notably this elusive goal was also a central feature of goals featured in the previous Healthy People 2010 report issued in 2000.[2]

In light of these important demographic trends and the large contribution of cardiovascular disease to health disparities overall, there is a clear imperative to reassess our current understanding of race-ethnic disparities in stroke care in the United States. Accordingly, in this issue of Stroke, Cruz-Flores and colleagues have reviewed the key literature on race-ethnic disparities in stroke care in the United States over the past 40 years and composed a scientific statement from the American Heart Association/American Stroke Association (AHA/ASA) that will form the blueprint for continued efforts by practitioners and policy makers alike to understand and address these challenging issues.[3]

The overall picture that the authors present is at once humbling and hopeful. First, there is the stark reminder of the substantial differences in the distribution of risk factor burdens across racial and ethnic groups. For example, nearly one-half of African Americans report having more than two important vascular risk factors,[4] and the prevalence of diabetes in African Americans and Hispanics is roughly double that of whites.[5] The higher prevalence of these important cerebrovascular risk factors contribute to an increased incidence of stroke in these groups as well, with disproportionate impacts at younger ages.

But there is much more at play here than a simplistic application of well-established relationships between vascular risk factors and stroke in these race and ethnic groups: For example, a greater awareness of hypertension and a greater likelihood of receiving treatment for hypertension among African Americans in the REGARDS study did not translate into a greater likelihood of achieving blood pressure control compared with whites.[6] Another hint of the underlying complexity of these race-ethnic disparities is that against a backdrop of a greater than 70% decrease in age-standardized stroke mortality over the past 50 years, there has a stubbornly persistent mortality gap from stroke among African Americans, particularly among younger age groups who have an age-specific mortality from stroke is three times that of non-Hispanic whites[7] - a troubling situation that contributes to a particularly high disease burdens in terms of years of potential life lost and long-term disability. Yet Hispanic populations appear to have a similar or lower mortality after stroke compared with non-Hispanics (with the possible exception of younger Hispanics)[8] despite higher rates of diabetes and metabolic syndrome.

So, although differences in the burden of risk factors across racial and ethnic groups are clear contributors to observed differences in stroke incidence, the authors provide us with a more comprehensive view of various contributions to these observed race-ethnic disparities. The statement certainly incorporates the best available data (as well as the lack of data) along the entire continuum of stroke care, including disease awareness, access to acute treatments including thrombolysis for stroke and carotid endarterectomy, access to stroke rehabilitation, neurology specialist care, and access and intensity of prevention interventions. But it also delves into the biosocial complexity required to understand important social, cultural, and systemic determinants of health such as differences in socioeconomic status and insurance, attitudes, beliefs, provider interactions, and perceived and potential bias in the health care system in an objective and methodological fashion. Important highlights here include the role of denial of disease, lower health literacy, and perceived or actual racial discrimination during health care interactions on stroke care, as well the impact of cultural and language barriers to appropriate access of emergency stroke services and the role the mistrust of the health care system and fatalism on prevention and treatment efforts. As for readily available targets for study and intervention, the authors point out specific gaps in knowledge that should be addressed with high-quality research, such as a better understanding of disparities in the care of hemorrhagic stroke or the longer-term impacts of sociobehavioral interventions. And there are ripe opportunities for continuing to develop and tailor innovative interventions that take into account our understanding of the biosocial model of care as exemplified by such interventions that engage key community participants such as beauticians in African-American communities or civic institutions such as churches.[9,10] Similarly, practitioners and training programs should continue to emphasize the importance of developing culturally competent providers and researchers and to specifically address the troubling trend of decreasing participation of minority populations in clinical research. Finally, the finding that race-ethnic disparities appear to be mitigated in the greater than 65 population under Medicare would be consistent with the notion that expanding access to nonelderly population through health care reform may help to reduce disparities as well. There is still much work to do.

Finally, in this age of pharmacogenetics and the interest in exploiting racial genetic polymorphisms in biomedicine, an important cautionary note is in order - one that is specifically addressed by the authors at the outset of the AHA statement: First, there are inherent limitations in the concept of race, particularly when applied to biologic processes and when attempts are made to use racial group as a proxy for genetic variation.[11] Next, there will be growing challenges to the interpretation of self-reported data and evolving racial categories, as the recent experience with multiple-race combinations within the latest U.S. Census[1] and the debate over recent categories promulgated by the National Institutes of Health has shown us. Caution is necessary when applying an overly definitive racial essentialism in biomedicine and conflating biologic determinants of health (age, sex, genetics) and social and cultural determinants such as access to care, income, and insurance status. But the continued importance of specifically examining, understanding, and addressing these race-ethnic disparities in our society, despite these conceptual limitations, seems apparent.[12]

If we are to make continued progress in reducing death and disability from stroke, we must overcome the substantial and persistent race-ethnic disparities in stroke care that the United States continues to have that are underscored in this report. With careful use of race-ethnic categories as well as a healthy respect for the full spectrum of biosocial complexity, there is reason to believe that a combination of innovative high-quality research, targeted and more widely applied interventions, and social and systemic change will lead to measurable progress in reducing and eliminating these disparities in the next years and decades to come.