Profound Disparities By Race in Delivery of Care to Stroke Patients Interview with:

Romanus Roland Faigle, M.D., Ph.D. Assistant Professor of Neurology The Johns Hopkins Hospital

Dr. Roland Faigle

Romanus Roland Faigle, M.D., Ph.D.
Assistant Professor of Neurology
The Johns Hopkins Hospital What is the background for this study?

Response: Stroke care entails a variety of procedures and interventions, which generally fall into one of the two following categories: 1) curative/preventative procedures (such as IV thrombolysis and carotid revascularization), which intent to prevent injury and restore function; and 2) life-sustaining procedures (such as gastrostomy, mechanical ventilation, tracheostomy, and hemicraniectomy), which intent to address complications from a stroke and to prevent death. The use of curative/preventative procedures is supported by excellent evidence and is guided by well-defined criteria, while those are largely lacking for life-sustaining procedures. Therefore, curative/preventative are desirable for eligible patients, while life-sustaining procedures indicate the need to address undesired complications and in itself have questionable utility. We wanted to determine whether race differences in the use of the individual stroke-related procedures exist, and whether presence and directionality of differences by race follow a pattern unique to each of the 2 procedure groups. What are the main findings?

Response: The main finding in our study is that curative/preventative procedures (IV thrombolysis and carotid revascularization) are underutilized in minorities, while life-sustaining procedures (gastrostomy, mechanical ventilation, tracheostomy, and hemicraniectomy) are overutilized in minorities (compared to whites). This was the case despite accounting for medical comorbidities, stroke risk factors, and withdrawal of care status. What should readers take away from your report?

Response: What was striking in our study was that, in minorities, underutilization of desirable (curative/preventative) procedures with excellent evidence for good outcome is paired with overutilization of procedures meant for “damage control” and based on (in some instances) shaky evidence. This may indicate that minorities are at a disadvantage on 2 separate accounts in the course of their stroke care: first they receive fewer “good” desirable procedures (with the intent to cure and prevent, backed by excellent evidence for functional improvement), and independently thereof, they receive too much of the “bad” undesirable procedures (those that address complications, and have poor supporting evidence to result in good outcome).

This observation suggests profound disparities by race in stroke delivery of care, What recommendations do you have for future research as a result of this study?

Response: We need to better understand the mechanisms and causes underlying the observed differences. We did not specifically address this in our study, but the underlying causes are likely multifactorial, including differences in health literacy, and access to care. In addition, implicit racial bias, by definition a subconscious bias, may contribute by influencing how physicians select patients, make recommendations to patients, or communicate with patients and their families. Although the diversity in the physician community has been increasing in recent years, communication barriers and distrust in the medical system remain, particularly among minority and non-English speaking patients who are most commonly interacting with a white physician. Preexisting patient beliefs and attitudes either on the basis of religious beliefs or cultural attitudes may also play a role.

I think future studies will focus on investigating some of these mechanisms. Studying medical decision-making, implicit bias, and patient-provider communication behavior is complex and challenging, but I think we have to look beyond the “hard data” commonly collected in our existing studies and databases to effectively explore these mechanisms. Addressing some of these mechanisms in future studies will help us to better understand and address the observed disparities in care delivery and hopefully improve patient outcomes. Thank you for your contribution to the community.


Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on July 25, 2016 by Marie Benz MD FAAD