Individual and County-Level Social Determinants of Health and Acute Reperfusion Therapies: Get With The Guidelines-Stroke Registry Results.

Background: The associations between individual- and county-level social determinants of health and reperfusion therapies (thrombolysis or thrombectomy) for acute ischemic stroke have been described separately, but they are rarely studied together.

Methods and results: We identified 1.5 million patients aged ≥40 years with acute ischemic stroke between January 1, 2015 and December 31, 2019 from the Get With The Guidelines-Stroke registry in the United States. We ascertained age, sex, rural residence, and ethnicity or race at the individual level, and poverty, unemployment, and lower education (defined as less than high school) at the county level. We used multivariable log-binomial regression models estimated using generalized estimating equations methods to account for county-level clustering and adjusted for comorbidities. About 13.4% (n=203 800) patients received reperfusion therapy. Black (adjusted risk ratio [aRR, 1.06 [95% CI, 1.04-1.07]) and Hispanic (aRR, 1.36 [95% CI, 1.33-1.40]) patients were more likely to receive it compared with White patients, as were those in counties with lower education (aRR, 1.08 [95% CI, 1.07-1.09]). Older adults (5-year increase in age aRR, 97 [95% CI, 0.97-0.97]), rural residents (aRR, 0.58 [95% CI, 0.56-0.59]), and those with missing last known well time (aRR, 0.30 [95% CI, 0.29-0.30]) were less likely to receive it. Missing last known well was less likely in Hispanic (aRR, 0.94 [95% CI, 0.92-0.95]) and Asian (aRR, 0.93 [95% CI, 0.90-0.96]) patients compared with White patients and more likely in those residing in counties with high unemployment (aRR, 1.07 [95% CI, 1.06-1.08]).

Conclusions: Individual- and county-level social determinants of health were associated with reperfusion therapies and missing last known well times. Understanding the mechanisms by which these factors could affect treatment eligibility through time-based criteria can help increase reperfusion therapies for all.