(Stroke. 2000;31:563.)
© 2000 American Heart Association, Inc.
Original Contributions |
Racial Variation in Initial Stroke Severity
From the Epidemiologic Research and Information Center at Durham (R.D.H., S.B.A., E.Z.O.); the Center for Health Services Research in Primary Care (R.D.H., L.J.E., J.H., S.B.A., D.B.M., E.Z.O.) and Speech-Language Pathology Service (C.A.S.-H.), VA Medical Center; the Division of Biometry, Department of Community and Family Medicine (L.J.E.), and the Division of General Internal Medicine, Department of Medicine (R.D.H., C.A.S.-H., D.B.M., E.Z.O.), Duke University Medical Center; and the Center for Clinical Health Policy Research (D.B.M.), Duke University, Durham, NC. Correspondence to Ronnie D. Horner, PhD, HSR&D/ERIC (152), VA Medical Center, Building 16, Room 70, 508 Fulton St, Durham, NC 27705.
 |
Abstract |
|---|
 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Background and Purpose—Blacks experience greater morbidity and mortality from stroke than do whites. The degree to which this is due to the severity of the initial stroke is not known. The objective of this study is to determine whether there is a racial difference in initial stroke severity.
Methods—A secondary analysis of a prospective cohort of 984 veterans (29.7% black) admitted to any of 9 geographically diverse Veterans Administration Hospitals for acute stroke between April 1995 and March 1997 was performed. Initial stroke severity was ascertained by using the modified Canadian Neurological Scale (CNS) applied retrospectively to medical record data. Stroke severity, unadjusted and adjusted for covariates, was compared between black and white patients.
Results—Blacks had greater initial stroke severity than did whites (mean CNS score 7.96 versus 8.32, respectively; P=0.039), with a 0.5-point difference on the scale corresponding to a single-level decrement in either speech or strength of half of an extremity. This difference persisted with adjustment for other important predictors of stroke severity (P=0.035). However, there was no significant racial difference in severity when CNS scores were collapsed into a priori clinically relevant categories.
Conclusions—Compared with whites, blacks show greater severity of stroke at hospital admission. It remains uncertain whether the relatively small but significant difference at presentation fully explains the striking racial differences in morbidity and mortality from stroke.
Key Words: blacks • cerebrovascular disorders • disease severity
|
Introduction |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Whereas the average life expectancy for whites in the United States is at an all time high at 76.8 years, the average life expectancy for blacks is 6.6 years less.1 Stroke is the single most important contributor to excess mortality among blacks, accounting for 28% of the black-white mortality difference.2 Blacks aged 35 to 74 years are nearly twice as likely to suffer from stroke,3 4 more than twice as likely to die from strokes,5 6 and significantly more likely to have greater residual physical and functional deficits should they survive a stroke.7 A number of factors may contribute to these racially disparate outcomes, including system-related factors (such as inequities in access to care or treatment within the hospital setting), patient-related factors (such as delay between ictus and presentation), and disease related factors (particularly the initial severity of the stroke).
Multiple studies have found that the severity of the initial neurological deficit is the greatest single determinant of outcome for patients with stroke.8 9 Indeed, a racial difference in initial stroke severity is likely in view of documented racial variation in characteristics associated with more severe strokes, including comorbid risk factors,10 11 distribution of vascular pathology,12 13 14 15 16 stroke type (eg, hemorrhagic versus ischemic),17 and usage of preventative therapy (eg, carotid endarterectomy and aspirin).18
To date, few studies have evaluated racial variation in stroke severity. Kuhlemeier and Stiens19 concluded that blacks tend to have more severe strokes on the basis of short-term outcomes; the authors specifically describe higher percentages of black patients who become comatose or die during short-term hospitalization. Another recent study found that among Medicare patients, blacks had a higher frequency of motor deficits at admission than did whites.20 Although these studies suggest that the initial lesion may be more severe in blacks than whites, neither study directly assessed stroke severity at admission or separated the effects of race from socioeconomic factors or access to care issues.
In the present study, we provide evidence regarding racial differences in initial stroke severity. We applied a validated stroke severity scale to a cohort of veterans suffering from acute stroke on the first day of hospitalization. Our hypothesis was that blacks, even when participating in an equal-access health care system such as the Veterans Health Administration (VHA), have more severe initial neurological deficits when presenting with acute stroke than do whites.
|
Subjects and Methods |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Study Design
This is a secondary analysis of data from the VA Acute Stroke Study, a 9-site nation-wide prospective cohort study of 1073 patients with acute stroke who were clinically managed within the VHA.21 All patients were hospitalized between April 1, 1995, and March 31, 1997. The 9 sites are located across the United States, with 4 of the sites located in the "stroke belt" (ie, the southeastern United States); for reasons of confidentiality, the individual sites are not identified. The study involved following patients from presentation through 1 year after stroke with a focus on key acute care practices received and a broad array of physical and psychological health outcomes experienced. Data on acute care practices were obtained from medical record review, and data on health outcomes were obtained from telephone interviews conducted at
1 month, 6 months, and 12 months after admission. The study was
approved by the Internal Review Board at each of the 9 sites.
Patient Population
Patients were identified within 48 hours of admission by a
research assistant who screened the hospital’s admission logbook for
patients admitted with symptoms suggestive of stroke. The diagnosis was
confirmed by review of medical records and discussions with the
attending physician. To ensure that no stroke patient was missed, the
hospital’s computerized discharge files were screened for patients
with a discharge diagnosis of intracerebral
hemorrhage (International Classification of Diseases, 9th
Revision, Clinical Modification [ICD-9-CM] code 431) or acute
cerebral infarct (ICD-9-CM code 434 or 436). A final review of the
medical record was conducted to exclude patients whose stroke was
iatrogenic, secondary to brain tumor or trauma, occurring during
hospitalization for other medical condition(s), an extension of
previous stroke, or occurring >7 days before admission. However,
patients with a history of stroke(s) in which the index stroke was not
considered an extension of a previous stroke were considered eligible
for enrollment. Thus, the cohort was composed of patients with acute
intracerebral hemorrhagic or ischemic
stroke.
For the present analysis, women were excluded because they constituted only 1.6% of the cohort. Patients whose racial self-description was neither "African American" nor "white" (3.1%) were also excluded to produce more homogeneous racial cohorts. This left a cohort of 984 male veterans that was 29.7% black and 70.3% white. Medical records were available for all enrolled patients.
Stroke Severity
Stroke severity at admission was determined by using a modified
Canadian Neurological Scale (CNS) as described by Goldstein and
Chilukuri.22 This instrument has been demonstrated to be
both valid and reliable in assessing stroke severity.22 23
All assessments were performed by a single trained rater (M.R.J.) and
were based on admission day data recorded by physicians who were
unaware of the study hypothesis.
The modified CNS is an aggregate ordinal scale that produces discrete scores ranging from 0 to 11.5 (stepwise by 0.5). Clinical factors that determine scoring include level of consciousness, orientation, language, and motor function.22 For the purposes of calibrating the scale, we created logical clinical categories of stroke severity. Specifically, scores were categorized as "mild" (scores 8.5 to 11.5), "moderate" (scores 6.0 to 8.0), and "severe" (scores 0.0 to 5.5) for each race. These categories reflect clinical syndromes. Mild is defined as nonmotor deficits or mild hemiparesis with or without dysarthria and without alteration in sensorium. Moderate refers to moderate/severe hemiparesis with or without dysarthria and with or without disorientation or isolated receptive aphasia. Finally, severe refers to comatose, hemiplegic, or globally aphasic patients. The severity categories, and cut points that define them, also follow natural clusters in the data and mirror a predictive model derived in a previous study for the original CNS.24
To determine intrarater reliability, 100 randomly selected cases were
reevaluated by the primary rater without knowledge of previously
derived CNS scores. To determine interrater reliability, both the main
rater and a second trained observer (C.A.S.-H.) independently scored 63
additional patients who had participated in the pilot phase of the VA
Acute Stroke Study. Both intrarater and interrater reliability were
high, with weighted 
values of 0.77 and 0.79, respectively, showing
excellent agreement.25
Secondary Outcomes
To determine the prognostic capabilities of the CNS scale scores
and to relate our findings to previous studies, we also examined 2
clinically based secondary end points.19 Admission or
transfer to an intensive care unit was measured as a dichotomous
variable (1 indicated admission or transfer to intensive care unit
at any point in the index hospitalization as noted in the medical
record, and 0 indicated all patient care outside of the intensive
care setting). In-hospital mortality was likewise measured by a
dichotomous variable.
Primary Independent Variable and Covariates
The primary independent variable was racial group, which was
determined by patient self-report. Years of educational and marital
status also were obtained by a structured telephone interview conducted
at 1-month after admission for stroke. Interviews were not obtained for
patients who either died before the interview (n=107), were unable to
be contacted before the interview date had passed (n=188), or were
unable to communicate and had no proxy informant (n=42). Information
for patients who were demented, comatose, or with significant receptive
aphasia was obtained from proxy respondents.
Other demographic data (age and sex) was obtained from the medical record, as was smoking status (in pack years). Stroke subtype (infarct versus intracerebral hemorrhage) and presence of comorbid conditions, such as diabetes mellitus, hypertension, atrial fibrillation, congestive heart failure, and prior stroke, were determined by ICD-9-CM discharge diagnoses for the stroke admission and verified by medical record review. History of stroke, history of transient ischemic attack, and origin of admission (recorded as either from a nursing home or not from a nursing home) were assessed from the medical record and used as proxy measures of the burden of disease before the index stroke.
Data Analysis
Characteristics for patients were compared by a
2 analysis for categorical
variables and Student t test for continuous
variables. Because the CNS is an ordinal scale, mean CNS scores for
each racial group were calculated and compared with use of a
Wilcoxon rank sum test. Proportions of patients falling into
the mild, moderate, and severe categories of stroke severity were then
compared between races by 2 analysis.
A value of P
0.05 was considered significant.
To assess the influence of important demographic and comorbid
conditions on stroke severity, we used the general linear model to
perform multivariable linear regression analyses. Because
of the large number of covariates, a model building technique was used
to develop the final regression model. First, bivariable regression
models were tested; these models involved each explanatory variable
and race (main effects only, no interaction at this stage) to determine
whether the variable was significant (at the P0.10
level) over and beyond having race in the model. After the first stage
of model building, 11 predictor variables were used in an initial
multivariable regression model (race, atrial fibrillation, origin
of admission, prior stroke, diabetes mellitus, type of stroke, income,
hypertension, marital status, smoking, and congestive heart failure).
Second, a backward selection technique was used to reduce the initial
multivariable model. Each variable not significant at the
P0.05 level was removed, and the model was refit until a
final reduced model having only main effects was achieved. Finally,
interactions between race and the other predictor variables in the
final model were investigated. Assumptions underlying the model were
assessed and found to have been met. Last, secondary outcomes were
compared between races by 2
analysis.
|
Results |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Cohort Characteristics
Blacks and whites differed in several characteristics that may be associated with stroke severity (Table 1
). Blacks more often had been given a
diagnosis of hypertension but less often had concomitant
ischemic heart disease. Blacks reported substantially lower
cigarette use than did whites. We found no statistically significant
difference between races in the prevalence of congestive heart failure,
atrial fibrillation, or diabetes mellitus within our cohort.
|
Blacks were less likely to be married or to have a high school or greater level of education. We observed no racial difference in mean age among our stroke patients. There were also no racial differences in any of our proxy measures of disease burden before admission, including prior stroke, prior transient ischemic attack, and admission from a nursing home. Furthermore, there was no racial difference in prevalence of intracerebral hemorrhage. Nor was there a racial difference in the time between stroke onset and presentation at the hospital: 76.4% of blacks and 75.7% of whites presented within 48 hours of stroke onset.
Stroke Severity
The mean CNS score was lower for blacks than for whites,
indicating more severe strokes (Figure). In the
unadjusted analysis, the absolute difference between races was
0.36 scale points (P=0.039). Prior studies suggest that a
0.5 difference in individual patients’ scores corresponds to a
clinically important difference, such as a single-level decrement in
speech or strength of an extremity.23 24 However, as
shown in Table 2, this statistically and
clinically significant difference was not present when the CNS
scores were collapsed into the predefined categories
(P=0.304).
|
|
Table 3 shows that after adjusting for
potentially confounding factors, race remained a significant
independent predictor of severity (P=0.0035). There were no
significant interactions between race and the other predictor
variables used in the final model.
|
Atrial fibrillation and intracerebral hemorrhage were both associated with more severe strokes. Indicators of poor prior function (prior stroke and admission from nursing home) were also independent predictors. Age, income, marital status, smoking history, alcohol consumption, diabetes mellitus, ischemic heart disease, and congestive heart failure were not independent predictors of more severe stroke.
In terms of secondary outcomes, during the acute hospitalization, blacks were more often admitted or transferred to intensive care units (23.6% versus 18.7% for whites), and they had a higher in-hospital mortality (12.7% versus 9.5% for whites). However, these differences were not statistically significant (P=0.077 and 0.116, respectively).
|
Discussion |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
The present study examines racial variation in initial stroke severity by using a geographically and racially diverse cohort of veterans suffering from acute stroke. Within an equal-access health care system, we found a small but significant increase in stroke severity among blacks. This difference persisted after controlling for other potential influences on severity, such as atrial fibrillation, stroke type, and history of prior stroke.
Although there is relatively little literature regarding this issue, available studies, such as that of Kuhlemeier and Stiens,19 suggest that there are substantial racial differences in stroke severity. Their study, though, is based on proxy indicators of severity and fails to control for confounding variables, such as socioeconomic status, access to care, and clinical factors. The present study, which directly measured severity and controlled for potential confounders, provides methodologically stronger evidence of racial variation in stroke severity. It remains less clear, however, whether the relatively small difference in initial stroke severity observed in the present study accounts for the striking racial differences in morbidity and mortality from stroke. The racial difference in stroke severity that we observed was supported by racial differences of a similar magnitude in the proportion of patients with an intensive care unit stay and those dying in the hospital, although the racial differences in these later parameters were of borderline statistical significance. Although the matter demands further study, it is likely that factors other than stroke severity contribute to the differences in stroke outcome currently documented between blacks and whites.
In an attempt to isolate the disease-specific (biological) aspects of racial variation in stroke outcome, we used a cohort of veterans that inherently lacks constraints on access to care and generally has attenuated socioeconomic differences between races. However, race is a complex entity not merely reflected in the content of one’s chromosomes but rather the interaction of such with environmental circumstance. In the US population as a whole, race is intimately associated with socioeconomic status, and socioeconomic factors are documented to contribute to the excess stroke mortality found among blacks.26 27 Thus, the racial difference we observed in initial stroke severity may be greater in other patient populations, where black race is more strongly associated with low socioeconomic status and, therefore, less access to health care.
We recognize that our results should be interpreted with caution because veterans, particularly those who use the VHA health care system, may differ from the general population in characteristics associated with stroke severity. First of all, women were excluded from our analysis. Other studies examining racial variation in stroke have described sex as an independent predictor and as having an interaction with race when considering stroke risk factors, incidence, and mortality.27 28 29 30 Thus, it may be inappropriate to generalize our findings regarding stroke severity to female stroke patients. Second, we had a slightly lower percentage of intracerebral hemorrhages than do most stroke cohorts (8% versus 10% to 15%) and did not demonstrate the previously documented black preponderance of intraparenchymal hemorrhages.17 28 31 32 33 Moreover, the in-hospital mortality rate for blacks and whites in our cohort was about half that reported for similar racial groups in the North Manhattan cohort,28 and we have a relative paucity of severe strokes in our cohort compared with severe strokes reported in a smaller study that used the CNS24 (19% versus 32%). Because patients seen at VA hospitals often travel in excess of 100 miles for their nonacute care, these patients are unlikely to travel such a distance in the event of a severe acute stroke (such as a large or rapidly expanding intracerebral hemorrhage). Given that a large proportion of patients presenting with acute intracerebral hemorrhage and other severe strokes die while hospitalized for the event, it is likely that many veterans who reside at some distance from the VA hospital may not have survived to transfer, attenuating the number of patients with severe stroke in our cohort.34 35 Previous studies have indicated that blacks are more likely to have such an event.17 36 Thus, our findings may represent a conservative estimate of the actual racial difference in stroke severity. Third, our findings of a significant racial difference in stroke severity held only when we considered the continuous measure of severity; within clinically defined categories, the proportion of blacks was slightly greater in the moderate and severe categories but not significantly so. Whereas this may reflect the loss of information that occurs with the use of categories versus actual scores, it also may indicate the lack of a clinically relevant difference in stroke severity.
However, with respect to other important characteristics associated
with stroke severity, our cohort of veterans was similar to nonveteran
cohorts. In terms of comorbidity, 10% to 15% of our patients had
atrial fibrillation, 10% had congestive heart failure, 35% had
diabetes mellitus, and 50% to 60% had a diagnosis of hypertension.
This comorbidity profile is similar to that reported for patients in
the North Manhattan Stroke Study and the cohort derived from the
University of California at San Diego Stroke Data
Bank.11 37 Moreover, whereas time from onset of symptoms
to presentation may also affect stroke severity, 76% of
our cohort versus 70% of a community-based nonveteran cohort (adjusted
to match our enrollment restriction of presentation within
7 days) presented within 48 hours of ictus.38
In summary, we found evidence of a small but significant racial difference in initial stroke severity, with blacks having more severe strokes. This difference persisted in a model controlling for other important characteristics. The explanatory importance of this difference in stroke outcomes (eg, residual disability and death) remains to be determined. Moreover, the antecedent factors that account for the difference have yet to be ascertained but could include poorer control of known risk factors, greater susceptibility to disease given similar risk factor profiles, and the greater presence of undefined risk factors among blacks. These possibilities suggest a number of interventions, including more aggressive risk factor control for blacks and greater patient education to emphasize health-promoting behaviors, thereby reducing the likelihood of a severe neurological lesion.
|
Acknowledgments |
|---|
This study was supported by a grant from the VA Health Services Research and Development Service (SDR 93-003). Dr Horner was supported, in part, by a grant from the VA Cooperative Studies/Epidemiologic Research and Information Center Programs (VA CSP/ERIC 602).
Received October 18, 1999; revision received December 9, 1999; accepted December 9, 1999.
|
References |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
1. Anderson RN. United States Abridged Life Tables, 1996: National Vital Statistics Reports (NVSS). Vol 47, No. 13. Hyattsville, Md: National Center for Health Statistics; 1998.
2.
Otten M, Teutch S, Williamson D, Marks J. The effect
of known risk factors on the excess mortality of black adults in the
United States. JAMA. 1990;263:845–850.
3. Oh S. Cerebrovascular disease in negroes. J Natl Med Assoc. 1971;63:93–98.[Medline] [Order article via Infotrieve]
4. Cooper E. Clinical cerebrovascular disease in hypertensive blacks. J Clin Hypertens. 1987;3(suppl):79–84.
5. Howard G, Anderson R, Sorlie P, Andrews V, Backlund E, Burke GL. Ethnic differences in stroke mortality between non-Hispanic whites, Hispanic whites, and blacks: the National Longitudinal Mortality Study. Stroke. 1994;25:2120–2125.[Abstract]
6.
Gillum RF. Stroke in blacks. Stroke. 1988;19:1–9.
7.
Horner RD, Matchar DB, Divine GB, Feussner JR. Racial
disparities in ischemic stroke-relate physical and functional
impairments. Stroke. 1991;22:1497–1501.
8.
Heinemann AW, Roth EJ, Cichowski K, Betts HB.
Multivariate analysis of improvement and
outcome following stroke rehabilitation. Arch Neurol. 1989;44:1167–1172.
9. Oxbury JM, Greenhall RCD, Grainger KMR. Predicting the outcome of stroke: acute stage after cerebral infarction. BMJ. 1975;3:125–127.
10. Connett J, Stamler T. Responses of blacks and whites to the special intervention of MRFIT. Am Heart J. 1984;108:759–769.[Medline] [Order article via Infotrieve]
11.
Sacco RL, Kargman DE, Zamanillo MC. Race-ethnic
differences in stroke risk factors among hospitalized patients with
cerebral infarction: the North Manhattan Stroke Study.
Neurology. 1995;45:659–663.
12.
Sacco RL, Kargman DE, Gu Q, Zamanillo MC.
Race-ethnicity and determinants of intracranial atherosclerotic
cerebral infarction: the North Manhattan Stroke Study.
Stroke. 1995;26:14–20.
13.
Sacco RL, Roberts JK, Boden-Albana B, Gu Q, Lin I,
Kargmann DE, Berglund L, Hauser WA, Shea S, Paik MC. Race-ethnicity and
determinants of carotid atherosclerosis in a
multiethnic population: the North Manhattan Stroke Study.
Stroke. 1997;28:929–935.
14. Joubert J, Lemmer LB, Fourie PA, Van Gelder AL, Darazs B. Are clinical differences between black and white stroke patients caused by variations in the atherosclerotic involvement of the arterial tree? S Afr Med J. 1990;77:248–251.[Medline] [Order article via Infotrieve]
15.
Gorelick PB, Caplan LR, Hier DB, Patel D, Langenberg P,
Pessin MS, Biller J, Kornack D. Racial differences in the distribution
of posterior circulation occlusive disease. Stroke. 1985;16:785–790.
16.
Gorelick PB, Caplan LR, Hier DB, Parker SL, Patel D.
Racial differences in the distribution of anterior circulation
occlusive disease. Neurology. 1984;34:54–57.
17. Broderick JP, Brott T, Tomsick T, Huster G. The risk of subarachnoid and intracerebral hemorrhage in blacks compared to whites. N Engl J Med. 1992;326:733–736.[Abstract]
18.
Oddone EZ, Horner RD, Monger ME, Matchar DB. Racial
variations in the rates of carotid angiography and
endarterectomy in patients with stroke and
transient ischemic attack. Arch Intern Med. 1993;153:2781–2786.
19. Kuhlemeier KV, Stiens SA. Racial disparities in severity of cerebrovascular events. Stroke. 1994;25:2126–2131.[Abstract]
20.
Horner RD, Hoenig H, Sloane R, Rubinstein LV, Kahn KL.
Racial differences in the utilization of inpatient rehabilitation
services among elderly stroke patients. Stroke. 1997;28:19–25.
21. Horner RD, Matchar DB. Results of the VA Acute Stroke (VASt) Study: Final Report on VA HSR&D SDR 93–003: Clinical Management and Outcomes of Veterans with Stroke at VAMCs. Washington, DC: HSR&D Service, Veterans Health Administration, Department of Veterans Affairs; December 31, 1998.
22.
Goldstein LB, Chilukuri V. Retrospective assessment of
initial stroke severity with the Canadian neurological scale.
Stroke. 1997;28:1181–1184.
23.
Muir KW, Weir CJ, Murray GD, Povey C, Lees KR.
Comparison of neurological scales and scoring for acute stroke
prognosis. Stroke. 1996;27:1817–1820.
24.
Fiorelli M, Alperovitch A, Argentino C, Sacchetti ML,
Toni D, Sette G, Cavalletti C, Gori MC, Fieschi C. Prediction of
long-term outcome in the early hours following acute ischemic
stroke. Arch Neurol. 1995;52:250–255.
25. Fleiss JL. Statistical Methods for Rates and Proportions. 2nd ed. New York, NY: John Wiley & Sons; 1981:218.
26. Howard G, Russell GB, Anderson R, Evans GW, Morgan T, Howard VJ, Burke GL. Role of social class in excess black stroke mortality. Stroke. 1995;26:759–1763.
27. Casper ML, Barnett EB, Armstrong DL, Giles WH, Blanton CJ. Social class and race disparities in premature stroke mortality among men in North Carolina. Ann Epidemiol. 1997;7:146–153.[Medline] [Order article via Infotrieve]
28.
Sacco RL, Hauser WA, Mohr JP. Hospitalized stroke in
blacks and Hispanics in North Manhattan. Stroke. 1991;22:1491–1496.
29.
Heyman A, Karp H, Heyden S, Bartel A, Cassel J, Tyroler
H, Cornoni J, Hames C, Stuart W. Cerebrovascular disease in the
biracial population of Evans County, Georgia. Stroke. 1971;2:509–518.
30.
Stolley P, Kuller L, Nefzger M, Tonascia S, Lilienfield
A, Miller G, Diamont E. Three-area epidemiologic study of geographic
differences in stroke mortality. Stroke. 1972;8:551–557.
31. Klatsky AL, Armstrong MA, Sidney S, Friedman GD. A prospective study of predictors of subarachnoid and intracerebral hemorrhage in a large population. Circulation. 1999;99:1117. Abstract.
32. Morgenstern LB, Spears WD. A triethnic comparison of intracerebral hemorrhage mortality in Texas. Ann Neurol. 1997;42:919–923.[Medline] [Order article via Infotrieve]
33. Caplan LR. Intracerebral haemorrhage. Lancet. 1992;339:656–658.[Medline] [Order article via Infotrieve]
34. Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Intracerebral hemorrhage versus infarction: stroke severity, risk factors, and prognosis. Ann Neurol. 1995;37:45–50.
35.
Qureshi AI, Safdar K, Weil EJ, Barch C, Bliwise DL,
Colohan AR, Mackay B, Frankel MR. Predictors of early deterioration and
mortality in black Americans with spontaneous
intracerebral hemorrhage. Stroke. 1995;26:1764–1767.
36. Klatsky AL, Armstrong MA, Friedman GD. Racial differences in cerebrovascular disease hospitalizations. Stroke. 1991;22:229–304.
37.
Zweifler RM, Lyden PD, Taft B, Kelly N, Rothrock JF.
Impact of race and ethnicity on ischemic stroke: the University
of California at San Diego Stroke Data Bank. Stroke. 1995;26:245–248.
38.
Alberts MJ, Bertels C, Dawson DV. An analysis
of time of presentation after stroke. JAMA. 1990;263:65–68.
This article has been cited by other articles:
 |
|
 |
|
  C. Ellis Does Race/Ethnicity Really Matter in Adult Neurogenics? Am J Speech Lang Pathol, November 1, 2009; 18(4): 310 - 314. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Gunarathne, J. V. Patel, S. Kausar, B. Gammon, E. A. Hughes, and G. Y.H. Lip Glycemic Status Underlies Increased Arterial Stiffness and Impaired Endothelial Function in Migrant South Asian Stroke Survivors Compared to European Caucasians: Pathophysiological Insights From the West Birmingham Stroke Project Stroke, July 1, 2009; 40(7): 2298 - 2306. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Gunarathne, J. V. Patel, B. Gammon, P. S. Gill, E. A. Hughes, and G. Y.H. Lip Ischemic Stroke in South Asians: A Review of the Epidemiology, Pathophysiology, and Ethnicity-Related Clinical Features Stroke, June 1, 2009; 40(6): e415 - e423. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S J Sarker, P U Heuschmann, I Burger, C D A Wolfe, A G Rudd, N C Smeeton, and A M Toschke Predictors of survival after haemorrhagic stroke in a multi-ethnic population: the South London Stroke Register (SLSR) J. Neurol. Neurosurg. Psychiatry, March 1, 2008; 79(3): 260 - 265. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. O. Pierce Jr Ethnic and Racial Disparities in Diagnosis, Treatment, and Follow-up Care J. Am. Acad. Ortho. Surg., September 1, 2007; 15(suppl_1): S8 - S12. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Onukwugha and C. D. Mullins Racial Differences in Hospital Discharge Disposition among Stroke Patients in Maryland Med Decis Making, May 1, 2007; 27(3): 233 - 242. [Abstract] [PDF]
|
|
|
|
|
|
C. D.A. Wolfe, D. O.C. Corbin, N. C. Smeeton, G. H.E. Gay, A. G. Rudd, A. J. Hennis, R. J. Wilks, and H. S. Fraser Poststroke Survival for Black-Caribbean Populations in Barbados and South London Stroke, August 1, 2006; 37(8): 1991 - 1996. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. M. Bravata, C. K. Wells, B. Gulanski, W. N. Kernan, L. M. Brass, J. Long, and J. Concato Racial Disparities in Stroke Risk Factors: The Impact of Socioeconomic Status Stroke, July 1, 2005; 36(7): 1507 - 1511. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J.J. Kumwenda, G. Mateyu, S. Kampondeni, A.P. van Dam, L. van Lieshout, and E.E. Zijlstra Differential Diagnosis of Stroke in a Setting of High HIV Prevalence in Blantyre, Malawi Stroke, May 1, 2005; 36(5): 960 - 964. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. P. Stansbury, H. Jia, L. S. Williams, W. B. Vogel, and P. W. Duncan Ethnic Disparities in Stroke: Epidemiology, Acute Care, and Postacute Outcomes Stroke, February 1, 2005; 36(2): 374 - 386. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. B. Goldstein, G. P. Samsa, D. B. Matchar, and R. D. Horner Charlson Index Comorbidity Adjustment for Ischemic Stroke Outcome Studies Stroke, August 1, 2004; 35(8): 1941 - 1945. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L.B. Goldstein, D.B. Matchar, J. Hoff-Lindquist, G.P. Samsa, and R.D. Horner VA Stroke Study: Neurologist care is associated with increased testing but improved outcomes Neurology, September 23, 2003; 61(6): 792 - 796. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. J. Fullerton, Y. W. Wu, S. Zhao, and S. C. Johnston Risk of stroke in children: Ethnic and gender disparities Neurology, July 22, 2003; 61(2): 189 - 194. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. B. Goldstein, D. B. Matchar, J. Hoff-Lindquist, G. P. Samsa, R. D. Horner, and E. J. Kenton III Veterans Administration Acute Stroke (VASt) Study: Lack of Race/Ethnic-Based Differences in Utilization of Stroke-Related Procedures or Services * Diagnostic Disparities: Still Exist? Stroke, April 1, 2003; 34(4): 999 - 1004. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. D. Horner, J. W. Swanson, H. B. Bosworth, and D. B. Matchar Effects of Race and Poverty on the Process and Outcome of Inpatient Rehabilitation Services Among Stroke Patients Stroke, April 1, 2003; 34(4): 1027 - 1031. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H.J. Fullerton, D.M. Chetkovich, Y.W. Wu, W.S. Smith, and S.C. Johnston Deaths from stroke in US children, 1979 to 1998 Neurology, July 9, 2002; 59(1): 34 - 39. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Hassaballa, P. B. Gorelick, C. P. West, M. D. Hansen, and H. P. Adams Jr. Ischemic stroke outcome: Racial differences in the trial of danaparoid in acute stroke (TOAST) Neurology, August 28, 2001; 57(4): 691 - 697. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. S. Lawrence, C. Coshall, R. Dundas, J. Stewart, A. G. Rudd, R. Howard, and C. D. A. Wolfe Estimates of the Prevalence of Acute Stroke Impairments and Disability in a Multiethnic Population Stroke, June 1, 2001; 32(6): 1279 - 1284. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Crawley, R. Payne, J. Bolden, T. Payne, P. Washington, S. Williams, and for the Initiative to Improve Palliative and End-o Palliative and End-of-Life Care in the African American Community JAMA, November 15, 2000; 284(19): 2518 - 2521. [Full Text] [PDF]
|
|
|
|
|
|
H. B. Bosworth, R. D. Horner, L. J. Edwards, and D. B. Matchar Depression and Other Determinants of Values Placed on Current Health State by Stroke Patients : Evidence From the VA Acute Stroke (VASt) Study Stroke, November 1, 2000; 31(11): 2603 - 2609. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||