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Original Research |

Racial Differences in Mortality Among Patients With Acute Ischemic Stroke: An Observational Study

Ying Xian, MD, PhD; Robert G. Holloway, MD, MPH; Katia Noyes, PhD, MPH; Manish N. Shah, MD, MPH; and Bruce Friedman, PhD, MPH
[+] Article and Author Information

From Duke Clinical Research Institute, Durham, North Carolina, and University of Rochester School of Medicine and Dentistry, Rochester, New York.


Disclaimer: This study used the linked SPARCS-SSADMF database. The interpretation and reporting of these data are the sole responsibility of the authors.

Acknowledgment: The authors thank Wenqin Pan, PhD, and Aijing Zhang Starr, MS, Duke Clinical Research Institute, Durham, North Carolina, for data support and suggestions on statistical analyses, and Timothy E. Quill, MD; Curtis G. Benesch, MD, MPH; and Kevin Fiscella, MD, MPH, of University of Rochester School of Medicine and Dentistry, Rochester, New York, for their thoughtful comments.

Grant Support: By an American Heart Association Founders Affiliate Predoctoral Fellowship Award (0815772D) (Dr. Xian); the National Center for Research Resources, a component of the National Institutes of Health (NIH) and the NIH Roadmap for Medical Research (1 UL1 RR024160-01) (Drs. Holloway and Noyes); and a Paul B. Beeson Career Development Award (NIA 1K23AG028942) (Dr. Shah).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0622.

Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Dr. Xian (e-mail, ying.xian@duke.edu).

Requests for Single Reprints: Robert G. Holloway, MD, MPH, Department of Neurology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 673, Rochester, NY 14642; e-mail, Robert_Holloway@URMC.Rochester.edu.

Current Author Addresses: Dr. Xian: Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27701.

Dr. Holloway: Department of Neurology, University of Rochester, 601 Elmwood Avenue, Box 673, Rochester, NY 14642.

Drs. Noyes and Friedman: Department of Community and Preventive Medicine, University of Rochester, 601 Elmwood Avenue, Box 644, Rochester, NY 14642.

Dr. Shah: Department of Emergency Medicine, University of Rochester, 601 Elmwood Avenue, Box 655, Rochester, NY 14642.

Author Contributions: Conception and design: Y. Xian, R.G. Holloway, M.N. Shah, B. Friedman.

Analysis and interpretation of the data: Y. Xian, R.G. Holloway, K. Noyes, M.N. Shah, B. Friedman.

Drafting of the article: Y. Xian, R.G. Holloway.

Critical revision of the article for important intellectual content: Y. Xian, R.G. Holloway, K. Noyes, M.N. Shah, B. Friedman.

Final approval of the article: Y. Xian, R.G. Holloway, K. Noyes, M.N. Shah, B. Friedman.

Provision of study materials or patients: Y. Xian, R.G. Holloway.

Statistical expertise: Y. Xian, K. Noyes, B. Friedman.

Obtaining of funding: Y. Xian, R.G. Holloway, M.N. Shah, B. Friedman.

Administrative, technical, or logistic support: Y. Xian, R.G. Holloway.

Collection and assembly of data: Y. Xian, B. Friedman.


Ann Intern Med. 2011;154(3):152-159. doi:10.7326/0003-4819-154-3-201102010-00004
Text Size: A A A

Background: Black patients are commonly believed to have higher stroke mortality. However, several recent studies have reported better survival in black patients with stroke.

Objective: To examine racial differences in stroke mortality and explore potential reasons for these differences.

Design: Observational cohort study.

Setting: 164 hospitals in New York.

Participants: 5319 black and 18 340 white patients aged 18 years or older who were hospitalized with acute ischemic stroke between January 2005 and December 2006.

Measurements: Influence of race on mortality, examined by using propensity score analysis. Secondary outcomes were selected aspects of end-of-life treatment, use of tissue plasminogen activator, hospital spending, and length of stay. Patients were followed for mortality for 1 year after admission.

Results: Overall in-hospital mortality was lower for black patients than for white patients (5.0% vs. 7.4%; P < 0.001), as was all-cause mortality at 30 days (6.1% vs. 11.4%; P < 0.001) and 1 year (16.5% vs. 24.4%; P < 0.001). After propensity score adjustment, black race was independently associated with lower in-hospital mortality (odds ratio [OR], 0.77 [95% CI, 0.61 to 0.98]) and all-cause mortality up to 1 year (OR, 0.86 [CI, 0.77 to 0.96]). The adjusted hazard ratio was 0.87 (CI, 0.79 to 0.96). After adjustment for the probability of dying in the hospital, black patients with stroke were more likely to receive life-sustaining interventions (OR, 1.22 [CI, 1.09 to 1.38]) but less likely to be discharged to hospice (OR, 0.25 [CI, 0.14 to 0.46]).

Limitations: The study used hospital administrative data that lacked a stroke severity measure. The study design precluded determination of causality.

Conclusion: Among patients with acute ischemic stroke, black patients had lower mortality than white patients. This could be the result of differences in receipt of life-sustaining interventions and end-of-life care.

Primary Funding Source: American Heart Association Founders Affiliate.

Figures

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Appendix Figure 1.
Distribution of propensity score for black and white patients.
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Appendix Figure 2.
Kaplan–Meier curves to assess the proportional hazards assumption.
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Appendix Figure 3.
Schoenfeld residual plots to assess the proportional hazards assumption.
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Figure 2.
Hazard ratio for death, by race (black vs. white).

* Propensity score was calculated by using age, sex, health insurance status, family income, principal diagnosis, 13 Charlson Comorbidity Index conditions, atrial fibrillation, hospital teaching status, hospital bed size, distance to the hospital, hospital site indicator, and interactions between these variables.

† The Elixhauser index was used to calculate the propensity score.

‡ Including all of the covariates for direct risk adjustment in the entire study population.

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Figure 1.
Cumulative hazard plot of death over time.
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