Original Article
Socioeconomic Disparities in the Utilization of Mechanical Thrombectomy for Acute Ischemic Stroke

https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.08.008Get rights and content

Background

Previous studies have demonstrated that socioeconomic disparities in access to treatment of cerebrovascular diseases exist. We studied the Nationwide Inpatient Sample (NIS) to determine if disparities exist in utilization of mechanical thrombectomy for acute ischemic stroke.

Methods

Using the NIS for the years 2006-2010, we selected all discharges with a primary diagnosis of acute ischemic stroke. Patients who received mechanical thrombectomy for stroke were identified by using the International Classification of Diseases, Ninth Revision, procedure code 39.74. We examined the utilization rates of mechanical thrombectomy by race/ethnicity (white, black, Hispanic, and Asian/Pacific Islander), income quartile (first, second to third, and fourth), and insurance status (Medicare, Medicaid, self-pay, and private). We also studied thrombectomy utilization rates at hospitals that performed thrombectomy.

Results

From 2006 to 2010, 2,087,017 patients were hospitalized with a primary diagnosis of acute ischemic stroke; 8946 patients (.4%) received mechanical thrombectomy. Compared with white patients, black patients had significantly lower rates of overall mechanical thrombectomy utilization (odds ratio [OR] = .59, 95% confidence interval [CI] = .55-.64, P < .0001) and at centers that offered mechanical thrombectomy (OR = .44, 95% CI = .41-.47, P < .0001). Compared with patients in the highest income quartile, patients in the lowest income quartile had significantly lower rates of mechanical thrombectomy utilization both overall (OR = .66, 95% CI = .62-.70, P < .0001) and at centers that offered mechanical thrombectomy (OR = .80, 95% CI = .75-.84, P < .0001). Compared with patients with private insurance, self-pay patients had significantly lower mechanical thrombectomy utilization both overall (OR = .71, 95% CI = .64-.78, P < .0001) and at centers that offered mechanical thrombectomy (OR = .81, 95% CI = .74-.90, P < .0001).

Conclusions

Significant socioeconomic disparities exist in the utilization of mechanical thrombectomy in the United States.

Introduction

The first endovascular clot retrieval device for acute ischemic stroke was approved by the US Food and Drug Administration in 2004. Since that time, endovascular clot retrieval has been evaluated in several published trials and has become an increasingly used treatment for a select group of patients with acute ischemic stroke.1 Previous studies have demonstrated that significant socioeconomic disparities exist in the utilization of treatments such as tissue plasminogen activator (tPA) for acute ischemic stroke.2, 3 Using the Nationwide Inpatient Sample (NIS), we sought to determine if any socioeconomic disparities exist in the utilization of mechanical thrombectomy for the treatment of acute ischemic stroke.

Section snippets

Patient Population

We purchased the NIS hospital discharge database for the period 2006-2010 from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, Rockville, MD. The NIS is a hospital discharge database representing 20% of all inpatient admissions to nonfederal hospitals in the United States. Patients who had a primary diagnosis of acute ischemic stroke were identified using International Classification of Diseases, Ninth Revision, codes 433, 434, 436, 437.0, and

Patient Population

Between 2006 and 2010, a total of 2,087,017 patients were hospitalized with a primary diagnosis of acute ischemic stroke; 8946 patients (.4%) received mechanical thrombectomy. A total of 4,34,570 (20.8%) patients with acute ischemic stroke were treated at centers that offered mechanical thrombectomy. The utilization rate of mechanical thrombectomy at these centers was 2.1% (8946/434,570). Race/ethnicity data were available for 1,662,379 patients; 1,208,157 (72.7%) of patients were white,

Discussion

Our study demonstrated that race, income quartile, and insurance status are associated with significant disparities in access to mechanical thrombectomy for the treatment of acute ischemic stroke. On our adjusted analysis pooling all patients with acute ischemic stroke, blacks and Hispanics were significantly less likely to receive mechanical thrombectomy than whites. Patients in the lower income quartiles were significantly less likely to receive mechanical thrombectomy than those in the

Conclusions

Our study demonstrated that between 2006 and 2010, socioeconomic disparities existed in the utilization of mechanical thrombectomy for the treatment of acute ischemic stroke. Some of these disparities can be explained by issues in access to care as patients of lower socioeconomic status were less likely to be treated at centers that offer mechanical thrombectomy. Important factors such as time to arrival, the presence of large-vessel thrombus and initial disease burden could not be controlled

References (21)

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