Towfighi, Amytis

Background Despite its approval for acute ischemic stroke >25 years ago, intravenous thrombolysis (IVT) remains underused, with inequities by age, sex, race, ethnicity, and geography. Little is known about IVT rates by insurance status. Methods and Results We assessed temporal trends from 2002 to 2015 in IVT for acute ischemic stroke in the Nationwide Inpatient Sample using adjusted, survey ‐ weighted logistic regression. We calculated odds ratios for IVT for each category in 2002 to 2008 (period 1) and 2009 to 2015 (period 2). IVT use for acute ischemic stroke increased from 1.0% in 2002 to 6.8% in 2015 (adjusted annual relative ratio, 1.15). Individuals aged ≥85 years had the most pronounced increase during 2002 to 2015 (adjusted annual relative ratio, 1.18) but were less likely to receive IVT compared with 18‐ to 44‐year‐olds in period 1 (adjusted odds ratio [aOR], 0.23) and period 2 (aOR, 0.36). Women were less likely than men to receive IVT, but the disparity narrowed over time (period 1: aOR, 0.81; period 2: aOR, 0.94). Inequities in IVT resolved for Hispanic individuals in period 2 (aOR, 0.96) but not for Black individuals (period 2: aOR, 0.81). The disparity in IVT for Medicare patients, compared with privately insured patients, lessened over time (period 1: aOR, 0.59; period 2: aOR, 0.75). Patients treated in rural hospitals remained less likely to receive IVT than in urban hospitals; a more dramatic increase in urbanity widened the inequity (period 2, urban nonteaching versus rural: aOR, 2.58, period 2, urban teaching versus rural: aOR, 3.90). Conclusions IVT for acute ischemic stroke increased among adults. Despite some encouraging trends, the remaining disparities highlight the need for intensified efforts at addressing inequities.

Background: Intravenous thrombolysis (IVT) was approved for acute ischemic stroke (AIS) 25 yrs ago, yet few AIS patients receive it, with inequities by race/ethnicity, sex, and geography. With expanding evidence-based programs, we hypothesized increases in IVT utilization and reduction in inequities. Methods: Using the Nationwide Inpatient Sample (NIS), we assessed temporal trends from 2002 to 2015 in IVT for AIS (weighted N=6,694,081) by sex, race/ethnicity, age, insurance, and hospital location/teaching status strata using survey - weighted logistic regression. Covariates included socio-demographics, comorbidities, and hospital characteristics. We calculated odds ratios for IVT by each category in 2002-2008 and 2009-2015. Results: IVT for AIS increased from 1.0% in 2002 to 6.8% in 2015, with an overall adjusted annual relative ratio (AARR) of 1.15 (CI 1.14-1.16). Individuals 18-44 yrs had the highest rate of IVT in 2015. The very elderly (≥85 yrs) had the most pronounced increase in IVT (AARR 1.18, CI 1.17-1.19). The sex disparity in IVT improved, but in 2009-2015, women were still 6% less likely to receive IVT than men (Fig 1). Individuals 18-44 yrs were ~3-fold more likely to receive IVT than the very elderly. IVT inequities for black and Hispanic stroke survivors lessened, but blacks remained ~20% less likely than whites to receive IVT. Government-insured patients were ~25% less likely to receive IVT compared to privately insured. Urban AIS patients were up to 4-fold more likely to receive IVT than rural dwellers. Conclusion: From 2002 through 2015, IVT for AIS in the U.S. increased regardless of race/ethnicity, sex, and age among ≥18 yrs, with the most pronounced increase among the very elderly. Despite encouraging trends, only 1 in 15 AIS patients received IVT and persistent inequities remain for blacks, women, government-insured, and rural stroke survivors, highlighting the need for intensifying stroke literacy and preparedness and enhancing systems of care.

Background and Purpose— The American Heart Association’s Life’s Simple 7 (LS7) defines ideal cardiovascular health by 7 metrics: not smoking, regular physical activity, normal body mass index, blood pressure, plasma glucose, and total cholesterol levels, and a healthy diet. We assessed prevalence and predictors of ideal LS7 among US stroke survivors. Methods— Among 67 514 participants in the National Health and Nutrition Examination Surveys from 1988 to 1994 and 1999 to 2014, 1597 adults (≥18 years) had self-reported history of stroke. LS7 metrics were categorized as poor, intermediate, and ideal; ideal LS7 scores were calculated (1 point for each ideal metric met). Trends in poor, intermediate, and ideal cardiovascular health were assessed. Odds of low (0–1) versus high (≥4) ideal LS7 scores were assessed according to sex, race, poverty income ratio, and education level, before and after adjusting for covariates. Results— Only 1 participant met all ideal LS7 metrics. The proportion with low LS7 score increased from 17.9% in 1988 to 1994 to 35.4% in 2011 to 2014 ( P <0.001). Over that time frame, prevalence of poor blood pressure (≥140/90 mm Hg) and poor cholesterol (≥240 mg/dL) decreased (45.2%–26.5% and 37.2%–10.3%), whereas prevalence of poor body mass index (≥30 kg/m 2 ), poor diet (healthy eating index score <50), and poor physical activity (0 minutes moderate/vigorous activity per week) increased (26.9%–39.0%; 14.2%–50.6%; 44.6%–70.9%; all P <0.05). After adjustment, black race (odds ratio, 2.29; 95% CI, 1.17–4.48), poverty income ratio ≤200% (odds ratio, 2.20, 95% CI, 1.11–4.36), and ≤12th grade education (odds ratio, 4.50; 95% CI, 2.27–8.92) were associated with low ideal LS7 scores. Conclusions— Over the past 3 decades, blood pressure and cholesterol control among stroke survivors improved, but rates of obesity, poor diet, and physical inactivity increased. Stroke survivors who are black, poor, or less educated are less likely to have ideal cardiovascular health.