Associations Between Measures of Structural Racism and Receipt of Acute Ischemic Stroke Interventions in the United States.

Background: Structural racism and rural/urban differences in stroke care affect care delivery and outcomes. We explored the interplay among structural racism, urbanity, and intravenous thrombolysis (tissue plasminogen activator) and endovascular thrombectomy (ET).

Methods and results: In this retrospective study using complete, deidentified inpatient Medicare data (2016-2019), we identified incident acute ischemic stroke admissions, demographics, and hospital-level variables. Medicare beneficiaries aged ≥65 years with incident acute ischemic stroke admission in large metropolitan and nonurban settings were included. Validated structural racism metrics at the county level and a composite structural racism score that incorporated measures of segregation, housing, employment, education, and income were studied. Among 951 914 patients, rural hospitals demonstrated lower intensive care unit capacity (27.5% versus 88.6%), stroke certification (5.3% versus 38.4%), and rates of tissue plasminogen activator (1.6% versus 12.3%) and ET (<1% versus 3.8%). Large metropolitan areas demonstrated higher levels of income inequality (Gini index -0.15 versus 0.11 SD), and racial segregation (dissimilarity index 0.29 SD higher than the US mean). The composite structural racism score was associated with increased odds of tissue plasminogen activator receipt (odds ratio, 1.47 [95% CI, 1.33-1.63]) and ET (odds ratio, 4.15 [95% CI, 2.98-5.79]). Despite greater access to stroke care in urban areas, a persistent racial disparity remained, with Black patients less likely to receive tissue plasminogen activator (odds ratio, 0.70 [95% CI, 0.68-0.72]) and ET (odds ratio, 0.63 [95% CI, 0.60-0.66]) compared with White patients.

Conclusions: We found persistent disparities in stroke care access and outcomes, influenced by structural racism and rural-urban differences. Further research should explore interactions between structural racism, urbanity, and health care delivery to inform effective interventions.