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April 19, 2022; 98 (16) Research Article

Race-Ethnic Disparities in Rates of Declination of Thrombolysis for Stroke

View ORCID ProfileScott J. Mendelson, View ORCID ProfileShuaiqi Zhang, Roland Matsouaka, Ying Xian, Shreyansh Shah, Barbara L. Lytle, View ORCID ProfileNicole Solomon, View ORCID ProfileLee H. Schwamm, View ORCID ProfileEric E. Smith, View ORCID ProfileJeffrey L. Saver, Gregg Fonarow, Jane Holl, View ORCID ProfileShyam Prabhakaran
First published February 28, 2022, DOI: https://doi.org/10.1212/WNL.0000000000200138
Scott J. Mendelson
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Shuaiqi Zhang
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Roland Matsouaka
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Ying Xian
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Shreyansh Shah
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Barbara L. Lytle
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Nicole Solomon
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Lee H. Schwamm
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Eric E. Smith
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Jeffrey L. Saver
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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  • ORCID record for Jeffrey L. Saver
Gregg Fonarow
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Jane Holl
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Shyam Prabhakaran
From the Department of Neurology (S.J.M., J.H., S.P.), Biological Sciences Division, University of Chicago, IL; Duke Clinical Research Institute (S.Z., R.M., Y.X., S.S., B.L.L., N.S.), Durham, NC; Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston; Neurology (E.E.S.), Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles; and Division of Cardiology (G.F.), Ronald Reagan–UCLA Medical Center, Los Angeles, CA.
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Citation
Race-Ethnic Disparities in Rates of Declination of Thrombolysis for Stroke
Scott J. Mendelson, Shuaiqi Zhang, Roland Matsouaka, Ying Xian, Shreyansh Shah, Barbara L. Lytle, Nicole Solomon, Lee H. Schwamm, Eric E. Smith, Jeffrey L. Saver, Gregg Fonarow, Jane Holl, Shyam Prabhakaran
Neurology Apr 2022, 98 (16) e1596-e1604; DOI: 10.1212/WNL.0000000000200138

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Abstract

Background and Objectives Prior regional or single-center studies have noted that 4% to 7% of eligible patients with acute ischemic stroke (AIS) decline IV tissue plasminogen activator (tPA). We sought to determine the prevalence of tPA declination in a nationwide registry of patients with AIS and to investigate differences in declination by race/ethnicity.

Methods We used the Get With The Guidelines–Stroke registry to identify patients with AIS eligible for tPA and admitted to participating hospitals between January 1, 2016, and March 28, 2019. We compared patient demographics and admitting hospital characteristics between tPA-eligible patients who received and those who declined tPA. Using multivariable logistic regression, we determined patient and hospital factors associated with tPA declination.

Results Among 177,115 tPA-eligible patients with AIS at 1,976 sites, 6,545 patients (3.7%) had tPA declination as the sole documented reason for not receiving tPA. Patients declining treatment were slightly older, were more likely to be female, arrived more often at off-hours and earlier after symptom onset, and were more likely to present to Primary Stroke Centers. Compared with non-Hispanic White, non-Hispanic Black race/ethnicity was independently associated with increased (adjusted odds ratio [aOR] 1.21, 95% CI 1.11–1.31), Asian race/ethnicity with decreased (aOR 0.72, 95% CI 0.58–0.88), and Hispanic ethnicity (any race) with similar odds of tPA declination (OR 0.98, 95% CI 0.86–1.13) in multivariable analysis.

Discussion Although the overall prevalence of tPA declination is low, eligible non-Hispanic Black patients are more likely and Asian patients less likely to decline tPA than non-Hispanic White patients. Reducing rates of tPA declinations among non-Hispanic Black patients may be an opportunity to address disparities in stroke care.

Glossary

AIS=
acute ischemic stroke;
aOR=
adjusted odds ratio;
GWTG-Stroke=
Get With The Guidelines–Stroke;
NIHSS=
NIH Stroke Scale;
tPA=
tissue plasminogen activator

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Editorial, page 647

  • Podcast: NPub.org/Podcast9816

  • Received June 3, 2021.
  • Accepted in final form January 18, 2022.
  • © 2022 American Academy of Neurology
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Disputes & Debates: Rapid online correspondence

  • Reader Response: Race-Ethnic Disparities in Rates of Declination of Thrombolysis for Stroke
    • Santiago Ortega-Gutierrez, Neurointerventional Neurologist, The University of Iowa Hospitals and Clinics
    • Aayushi Garg, Neurology Resident, The University of Iowa Hospitals and Clinics
    • Mudassir Farooqui, Researcher, The University of Iowa Hospitals and Clinics
    • Juan Vivanco-Suarez, Research Fellow, The University of Iowa Hospitals and Clinics
    • Milagros Galecio-Castillo, Research Fellow, The University of Iowa Hospitals and Clinics
    Submitted May 31, 2022
  • Reader Response: Race-Ethnic Disparities in Rates of Declination of Thrombolysis for Stroke
    • Karan Patel, Medical Student, Cooper Medical School of Rowan University
    • Jared Wolfe, Medical Student, Cooper Medical School of Rowan University
    • James E. Siegler, Vascular Neurologist, Cooper University Hospital
    Submitted April 26, 2022
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