(Stroke. 2001;32:2439.)
© 2001 American Heart Association, Inc.
Letters to the Editor |
Racism and tPA Use in African-Americans
Guy’s, King’s, and St Thomas’ School of Medicine, London, United Kingdom
To the Editor:
The investigation of Johnston et al1 into the influence of ethnicity on thrombolysis raises the spectre of racism in health service provision. However, as shown in the case of cardiac catheterization after myocardial infarction, racism is not always the reason for differences in treatment.2
Although the authors used a simple dichotomous definition of stroke severity in their regression analysis, they did not account for stroke subtype (or National Institutes of Health Stroke Scale [NIHSS] score). The proportion of ischemic stroke due to small-vessel disease in African-Americans is 52% compared with 25% in whites.3 Lacunar strokes tend to be less severe (maximum NIHSS of 10) and have a better prognosis than cortical ischemic strokes.4 The authors’ Table 2 demonstrates that despite American Heart Association guidelines, physicians are reluctant to give tPA to patients with less-severe stroke (only 8% of all eligible patients). Furthermore, physicians may not offer thrombolysis to those with suspected small-vessel stroke on pathophysiological grounds.5 This is in spite of no differential effect found in the NINDS study6 and that initial lacunar syndromes poorly predict eventual lacunar stroke.7
White patients arrived in the emergency department sooner than African-Americans. Although the percentage arriving within 3 hours was similar, a more realistic criterion for eligibility would be 2.5 hours, given that imaging, examination, and consent to treatment must all be completed prior to administration.
Another possible explanation is mistrust of health services. Even a few minutes’ prevarication can result in the 3-hour time window being exceeded. This may not be recorded as a refusal of treatment.
As one of the few centers outside the United States offering thrombolysis to a population with a high proportion of Afro-Caribbean patients, we have encountered the above problems, which cannot be attributed to racial prejudices. Racism in medicine, whether conscious or subconscious, individual or institutional, is to be deplored. However, ethnic variation in pathophysiology and behavior should be thoroughly examined before assuming that racism is the explanation for observed differences.
References
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Johnston SC, Fung LH, Gillum LA, Smith WS, Brass LM, Lichtman JH, Brown AN. Utilization of intravenous tissue-type plasminogen activator for ischemic stroke at academic medical centers. Stroke. 2001; 32: 1061–1070.
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Chen J, Rathore SS, Radford MJ, Wang Y, Krumholz HM. Racial differences in the use of cardiac catheterization after acute myocardial infarction. N Engl J Med. 2001; 344: 1443–1449.
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Woo D, Gebel J, Miller R, Kothari R, Brott T, Khoury J, Salisbury S, Shukla R, Pancioli A, Jauch E, Broderick J. Incidence rates of first-ever ischemic stroke subtypes among blacks: a population-based study. Stroke. 1999; 30: 2517–2522.
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Bamford J, Sandercock P, Jones L, Warlow CP. The natural history of lacunar infarction: the Oxfordshire Community Stroke Project. Stroke. 1987; 18: 545–551.
[Abstract/Free Full Text] - Mohr JP. LacunesIn: Barnett HJM, Mohr JP, Stein BM, Yatsu FM, eds. Stroke: Pathophysiology, Diagnosis and Management. 3d ed. New York, NY: Churchill-Livingstone; 1998; 599–622.
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The National Institute of Neurological Disorders Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995; 333: 1581–1587.
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Toni D, Iweins F, von Kummer R, Busse O, Bogousslavsky J, Falcou A, Lesaffre E, Lenzi GL. Identification of lacunar infarcts before thrombolysis in the ECASS I study. Neurology. 2000; 54: 684–688.
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Response
The causes of disparities in healthcare delivery—including the use of tPA in ischemic stroke—are likely to be complex, as suggested by Dr Evans and colleagues. In our article, we never imply that racism is the only cause of the ethnic disparity in tPA delivery. However, we do suggest that it contributed to the disparity, and appreciate the opportunity to clarify our reasoning.
We doubt that stroke subtype contributed importantly to the disparity. We know of no evidence to suggest that small-vessel strokes are responsible for a significantly larger portion of ischemic strokes in blacks. In fact, the article1 referenced by Evans and colleagues appears to report that small-vessel strokes account for 21% of ischemic strokes in blacks and 17% in whites—a difference that is neither clinically nor significantly important. Findings were similar in Northern Manhattan.2
Stroke severity was an important predictor of tPA use in our study, and a more detailed analysis would have been interesting. However, we found no difference in the portion with severe strokes (blacks 18% versus whites 16%), and others have found that outcomes are worse after ischemic stroke in blacks.3 Timing also does not appear to account for the disparity in our study. When we limited analysis to those arriving within 2 hours, black tPA candidates were still less likely to receive tPA than white candidates (8% versus 24%; P=0.04).
We agree that mistrust of the medical system may have contributed to the disparity. Though no black patient was documented to decline tPA, it is possible that documentation was incomplete. Of course, some may postulate that mistrust itself is rooted in racism.
When are data adequate to raise the possibility that racism is contributing to a disparity in healthcare delivery? Should we require more solid proof of racism than other factors, such as age or insurance type? The answer must depend in part on the consequences of being wrong: What are the implications of suggesting that racism is a contributor to a disparity when it is not? Regardless of cause, taking greater care in offering tPA to blacks with ischemic stroke may reduce a very large disparity in its use at minimal additional cost.
References
- Woo D, Gebel J, Miller R, Kothari R, Brott T, Khoury J, Salisbury S, Shukla R, Pancioli A, Jauch E, Broderick J. Incidence rates of first-ever ischemic stroke subtypes among blacks: a population-based study. Stroke. 1999; 30: 2517–2522.
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Sacco RL, Hauser WA, Mohr JP, Foulkes MA. One-year outcome after cerebral infarction in whites, blacks, and Hispanics. Stroke. 1991; 22: 305–311.
[Abstract/Free Full Text] - Kuhlemeier KV, Stiens SA. Racial disparities in severity of cerebrovascular events. Stroke. 1994; 25: 2126–2131.[Abstract]
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