Racial Differences in Utilization of Life-Sustaining vs Curative Inpatient Procedures After Stroke

Inpatient procedures are integral to routine stroke care. Common nondiagnostic procedures after stroke include intravenous thrombolysis (IVT), mechanical ventilation, hemicraniectomy, carotid revascularization (endarterectomy or stenting), gastrostomy, and tracheostomy. While some of these procedures are considered curative, aiming at improving functional status (IVT) or preventing further stroke (carotid revascularization), others are considered life-sustaining by preventing death in the short term (mechanical ventilation and hemicraniectomy) or long term (gastrostomy and tracheostomy). Race disparities among some stroke-related procedures have been described,¹ but a comprehensive comparison of procedure utilization by patients from different racial groups after stroke is lacking. In the present study, we compared racial differences in the use of 6 common nondiagnostic inpatient procedures after stroke; we hypothesized that curative procedures are underutilized while life-sustaining procedures are overutilized in minorities.

Data were obtained from the Nationwide Inpatient Sample.² We identified cases with the primary diagnosis of ischemic stroke by using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, and 436 between 2007 and 2011.³ For hemicraniectomy analysis, we excluded posterior circulation strokes (ICD-9-CM codes 433.01 and 433.21). To determine carotid revascularization only among strokes associated with carotid disease, we restricted the analysis to cases with ICD-9-CM codes 433.11, 433.31, and 433.91. Procedures were identified with the following ICD-9-CM codes: 43.11 (gastrostomy); 96.70, 96.71, 96.72, and 96.04 (mechanical ventilation); 31.1, 31.21, and 31.29 (tracheostomy); 99.10 (IVT); 01.24 and 01.25 (hemicraniectomy); and 38.12 and 00.63 (carotid revascularization). End-of-life care was identified by ICD-9-CM code V66.7. Because data from the Nationwide Inpatient Sample are publicly available and contain no personal identifying information, the Johns Hopkins institutional review board declared this study exempt from approval.

Patients with and without each procedure were compared using the χ² test and the Wilcoxon rank sum test for categorical and continuous variables (Stata version 13; StataCorp), respectively. Logistic regression was used to assess the association between race and the respective procedure. P < .05 was considered to be statistically significant.

Multivariable models for each procedure were adjusted for sociodemographic factors (age, sex, insurance status, and median household income per patient’s zip code), hospital characteristics (teaching status, bed size, location, region, annual volume of stroke cases, discharge quarter, and weekend admission status), and medical comorbidities and disease severity measures (hypertension, diabetes, dyslipidemia, coronary artery disease, peripheral vascular disease, congestive heart failure, atrial fibrillation, valvular disease, chronic kidney disease, anemia, thrombocytopenia, alcohol abuse, drug abuse, modified Charlson Comorbidity Index, and All-Patient Refined Diagnosis Related Group severity subclass). With the exception of the analysis of IVT as the outcome of interest, all models were also adjusted for end-of-life care, in-hospital mortality, and the use of IVT. Some models were additionally adjusted for common complications such as pneumonia, urinary tract infection, sepsis, gastrointestinal bleeding, deep vein thrombosis, pulmonary embolism, and hemicraniectomy (for analysis of tracheostomy, gastrostomy, mechanical ventilation, and carotid revascularization).

Patients undergoing life-sustaining procedures were more likely to be of a minority race than those not undergoing such procedures (38.4% vs 29.5% for gastrostomy, 48.0% vs 29.8% for tracheostomy, 36.5% vs 29.6% for mechanical ventilation, and 46.9% vs 29.8% for hemicraniectomy; P < .001 for all) (Table). In contrast, 27.4% of patients who underwent IVT were minorities, while 30.3% of patients who did not receive IVT were of a race other than white (P < .001). Similarly, minorities constituted only 17.4% of patients who underwent carotid revascularization, while representing 24.6% of patients who were not revascularized (P < .001).

In fully adjusted multivariable models, minority patients had significantly higher odds of gastrostomy (odds ratio [OR], 1.56 [95% CI, 1.48-1.65]), tracheostomy (OR, 1.44 [95% CI, 1.30-1.61]), mechanical ventilation (OR, 1.16 [95% CI, 1.09-1.24]), and hemicraniectomy (OR, 1.36 [95% CI, 1.11-1.66]) than white patients (Figure). In contrast, the adjusted odds of IVT (OR, 0.80 [95% CI, 0.75-0.86]) and carotid revascularization (OR, 0.57 [95% CI, 0.50-0.66]) were significantly lower in minority patients than in white patients.

We report underutilization of procedures with curative intent (IVT and carotid revascularization) and overutilization of life-sustaining procedures (gastrostomy, tracheostomy, mechanical ventilation, and hemicraniectomy) in ethnic minority patients with stroke. These results persisted after accounting for severity of medical comorbidities, end-of-life care, and in-hospital mortality, but we acknowledge that certain clinical characteristics not captured in the Nationwide Inpatient Sample, such as stroke severity, stroke location, and time to presentation, may partially explain our results.

Of note, both procedure groups differ in their strength of supporting evidence. While IVT and carotid revascularization have a longstanding track record of efficacy, convincing evidence supporting the use of gastrostomies and tracheostomies after stroke is lacking.^4,5 Hemicraniectomy after hemispheric stroke has been demonstrated to reduce mortality predominantly at the expense of increasing the proportion of patients with moderate or moderately severe disability, particularly in patients older than 60 years⁶; therefore, we considered hemicraniectomy a life-sustaining procedure.

Contrasting differences among procedure groups may allow for a bird’s-eye view of stroke-related procedure utilization. A better understanding of commonalities within and differences between curative and life-sustaining procedures may facilitate the development of effective strategies aimed at eliminating racial disparities in the delivery of stroke care.

Corresponding Author: Roland Faigle, MD, PhD, Department of Neurology, Johns Hopkins University, 600 N Wolfe St, Phipps 484, Baltimore, MD 21287 (rfaigle1@jhmi.edu).

Published Online: July 25, 2016. doi:10.1001/jamaneurol.2016.1914.

Author Contributions: Dr Faigle had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Faigle.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Faigle.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Faigle.

Administrative, technical, or material support: Urrutia.

Study supervision: Gottesman.

Conflict of Interest Disclosures: Dr Gottesman is an associate editor for Neurology. No other disclosures are reported.

Funding/Support: Dr Faigle is supported by an institutional KL2 grant from the Johns Hopkins Institute for Clinical and Translational Research, which is funded in part by grant KL2TR001077 from the National Center for Advancing Translational Sciences, a component of the National Institutes of Health (NIH), and the NIH Roadmap for Medical Research. Dr Cooper is supported by grant K24HL083113 from the National Heart, Lung, and Blood Institute.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.